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Vermeer CJC, Groenewegen A, Hollander M, Schuring J, Looijmans-van den Akker I, Oostindjer A, van Duijn H, Nederend I, Rutten FH. Comparing the diagnostic considerations between general practitioners with a special interest in cardiovascular disease and those without in patients with symptoms suggestive of heart failure: a vignette study. BMC PRIMARY CARE 2024; 25:216. [PMID: 38877394 PMCID: PMC11177529 DOI: 10.1186/s12875-024-02466-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/04/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND General practitioners (GPs) specialized in cardiovascular disease (GPSI-CVD) may suspect heart failure (HF) more easily than GPs not specialized in CVD. We assessed whether GPSI-CVD consider investigations aimed at detecting HF more often than other GPs in two clinical scenarios of an older male person with respiratory and suggestive HF symptoms. METHODS In this vignette study, Dutch GPs evaluated two vignettes. The first involved a 72-year-old man with hypertension and a 30 pack-year smoking history who presented himself with symptoms of a common cold, but also shortness of breath, reduced exercise tolerance, and signs of fluid overload. The second vignette was similar but now the 72-year-old man was known with chronic obstructive pulmonary disease (COPD). GPs could select diagnostic tests from a multiple-choice list with answer options targeted at HF, COPD or exacerbation of COPD, or lower respiratory tract infection. With Pearson Chi-square or Fisher's exact test differences between the two GP groups were assessed regarding the chosen diagnostic tests. RESULTS Of the 148 participating GPs, 25 were GPSI-CVD and 123 were other GPs. In the first vignette, GPSI-CVD more often considered performing electrocardiography (ECG) than other GPs (64.0% vs. 32.5%, p = 0.003). In the second vignette, GPSI-CVD were more inclined to perform both ECG (36.0% vs. 12.2%, p = 0.003) and natriuretic peptide testing (56.0% vs. 32.5%, p = 0.006). CONCLUSIONS Most GPs seemed to consider multiple diagnoses, including HF, with GPSI-CVD more likely performing ECG and natriuretic peptide testing in an older male person with both respiratory and suggestive HF symptoms.
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Affiliation(s)
- Cornelia J C Vermeer
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Amy Groenewegen
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Monika Hollander
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Leidsche Rijn Julius Healthcare Centers, Utrecht, The Netherlands
| | - Janneke Schuring
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ingrid Looijmans-van den Akker
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Leidsche Rijn Julius Healthcare Centers, Utrecht, The Netherlands
| | | | | | | | - Frans H Rutten
- Department of General Practice & Nursing Science, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Barosa M, Jamrozik E, Prasad V. The Ethical Obligation for Research During Public Health Emergencies: Insights From the COVID-19 Pandemic. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2024; 27:49-70. [PMID: 38153559 PMCID: PMC10904511 DOI: 10.1007/s11019-023-10184-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 12/29/2023]
Abstract
In times of crises, public health leaders may claim that trials of public health interventions are unethical. One reason for this claim can be that equipoise-i.e. a situation of uncertainty and/or disagreement among experts about the evidence regarding an intervention-has been disturbed by a change of collective expert views. Some might claim that equipoise is disturbed if the majority of experts believe that emergency public health interventions are likely to be more beneficial than harmful. However, such beliefs are not always justified: where high quality research has not been conducted, there is often considerable residual uncertainty about whether interventions offer net benefits. In this essay we argue that high-quality research, namely by means of well-designed randomized trials, is ethically obligatory before, during, and after implementing policies in public health emergencies (PHEs). We contend that this standard applies to both pharmaceutical and non-pharmaceutical interventions, and we elaborate an account of equipoise that captures key features of debates in the recent pandemic. We build our case by analyzing research strategies employed during the COVID-19 pandemic regarding drugs, vaccines, and non-pharmaceutical interventions; and by providing responses to possible objections. Finally, we propose a public health policy reform: whenever a policy implemented during a PHE is not grounded in high-quality evidence that expected benefits outweigh harms, there should be a planned approach to generate high-quality evidence, with review of emerging data at preset time points. These preset timepoints guarantee that policymakers pause to review emerging evidence and consider ceasing ineffective or even harmful policies, thereby improving transparency and accountability, as well as permitting the redirection of resources to more effective or beneficial interventions.
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Affiliation(s)
- Mariana Barosa
- Nova Medical School, Nova University of Lisbon, Lisbon, Portugal
- Science and Technologies Studies (MSc student), University College London, London, UK
| | - Euzebiusz Jamrozik
- Ethox and Pandemic Sciences Institute, University of Oxford, Oxford, UK
- Royal Melbourne Hospital Department of Medicine, University of Melbourne, Melbourne, Australia
- Monash Bioethics Centre, Monash University, Melbourne, Australia
| | - Vinay Prasad
- University of California, San Francisco, 550 16th St, San Francisco, CA, 94158, USA.
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3
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McDonald EG, Hanula R, Lee TC. Oseltamivir May or May Not Reduce Hospitalizations-Reply. JAMA Intern Med 2024; 184:117-118. [PMID: 37983041 DOI: 10.1001/jamainternmed.2023.5769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Affiliation(s)
- Emily G McDonald
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Experimental Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ryan Hanula
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Todd C Lee
- Division of Experimental Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Infectious Diseases, McGill University Health Centre, Montreal, Quebec, Canada
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Chen D, Berona J, Olson-Kennedy J. Psychosocial Functioning in Transgender Youth after Hormones. Reply. N Engl J Med 2023; 389:1538-1539. [PMID: 37851893 DOI: 10.1056/nejmc2302030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Affiliation(s)
- Diane Chen
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Johnny Berona
- Northwestern University Feinberg School of Medicine, Chicago, IL
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Powell K, Olivier T, Prasad V. A novel trial methodology to test interventions with very large effect sizes: the case of dostarlimab in mismatch repair-deficient, locally advanced rectal cancer. Trials 2022; 23:1044. [PMID: 36564825 PMCID: PMC9789610 DOI: 10.1186/s13063-022-06988-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 12/03/2022] [Indexed: 12/25/2022] Open
Abstract
Dostarlimab (Jemperli, GlaxoSmithKline) is an anti-programmed death receptor-1 monoclonal antibody (anti-PD-1) recently tested in a non-randomized, phase II trial (NCT04165772) which included patients with mismatch repair-deficient, locally advanced rectal cancer. Among the first 12 patients treated with dostarlimab, 100% achieved a clinical complete response with no patients experiencing progression or recurrence to date. Most impressive, none required chemotherapy, radiotherapy or surgery the prevailing standard of care. In this paper, we discuss the impressive results of this trial and how they relate to cancer policy, as well as propose a novel trial methodology to assess dostarlimab.
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Affiliation(s)
- Kerrington Powell
- grid.412408.bSchool of Medicine, Texas A&M Health Science Center, Bryan, TX 77807 USA
| | - Timothée Olivier
- grid.150338.c0000 0001 0721 9812Department of Oncology, Geneva University Hospital, 4 Gabrielle-Perret-Gentil Street, 1205 Geneva, Switzerland ,grid.266102.10000 0001 2297 6811Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St, 2nd Fl, San Francisco, CA 94158 USA
| | - Vinay Prasad
- grid.266102.10000 0001 2297 6811Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th St, 2nd Fl, San Francisco, CA 94158 USA
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Browne JA. Total Hip Arthroplasty Itself May Be a Parachute, but Everything Else We Do is Not. J Arthroplasty 2022; 37:1419-1420. [PMID: 35914887 DOI: 10.1016/j.arth.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- James A Browne
- Alfred R. Shands Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia
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Andreoletti M, Bina F. A defense of surgical procedures regulation. THEORETICAL MEDICINE AND BIOETHICS 2022; 43:155-168. [PMID: 35551584 PMCID: PMC9388414 DOI: 10.1007/s11017-022-09569-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 06/15/2023]
Abstract
Since the advent of drug regulation in 1962, regulatory agencies have been in the practice of using strict standards to test the safety and efficacy of medical treatments and products. Regulatory agencies, such as the FDA, demand two full-fledged Randomized Clinical Trials demonstrating the safety and effectiveness of drugs to grant its marketing authorization. On the contrary, surgical treatments are left completely unregulated. There are several reasons explaining this difference, and all of them point to the difficulty of conducting well-designed RCTs in surgery. However, we argue that none of these arguments is decisive and that, under certain conditions, surgical RCTs can be morally justified and methodologically sound. Although ethical constraints restrict the number of testable surgical procedures, and surgical trials might not be as dependable as pharmaceutical RCTs, our analysis suggests that, in certain cases, it is possible to obtain high-quality evidence about the safety and efficacy of surgical procedures. Untested surgical treatments may prove to be ineffective and harm patients. Therefore, regulation of surgical procedures seems not only morally acceptable and able to provide reliable scientific evidence, but also desirable and justified from an ethical-political standpoint.
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Affiliation(s)
- Mattia Andreoletti
- Health Ethics and Policy Lab, Department of Health Sciences and Technology, ETH Zürich, Zürich, Switzerland
| | - Federico Bina
- Faculty of Philosophy, Vita-Salute San Raffaele University, Milan, Italy
- Department of Psychology, Harvard University, Cambridge, Massachusetts United States
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8
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Powell K, Prasad V. Where are randomized trials necessary: Are smoking and parachutes good counterexamples? Eur J Clin Invest 2022; 52:e13730. [PMID: 34913477 DOI: 10.1111/eci.13730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Kerrington Powell
- College of Medicine, Texas A&M Health Science Center, Bryan, Texas, USA
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
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Williams NR, Patrick H, Fiorentino F, Allen A, Sharma M, Milošević M, Macbeth F, Treasure T. Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) randomised controlled trial: a systematic review of published responses. Eur J Cardiothorac Surg 2022; 62:6567629. [PMID: 35415756 PMCID: PMC9257793 DOI: 10.1093/ejcts/ezac253] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/15/2022] [Accepted: 04/09/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The objective of this review was to assess the nature and tone of the published responses to the Pulmonary Metastasectomy in Colorectal Cancer (PulMiCC) randomized controlled trial. METHODS Published articles that cited the PulMiCC trial were identified from Clarivate Web of Science (©. Duplicates and self-citations were excluded and relevant text extracted. Four independent researchers rated the extracts independently using agreed scales for the representativeness of trial data and the textual tone. The ratings were aggregated and summarized. Two PulMiCC authors carried out a thematic analysis of the extracts. RESULTS Sixty-four citations were identified and relevant text was extracted and examined. The consensus rating for data inclusion was a median of 0.25 out of 6 (range 0 to 5.25, IQR 0-1.5) and for textual tone the median rating was 1.87 out of 6 (range 0 to 5.75, IQR 1-3.5). The majority of citations did not provide adequate representation of the PulMiCC data and the overall the textual tone was dismissive. Although some were supportive, many discounted the findings because the trial closed early and was underpowered to show non-inferiority. Two misinterpreted the authors' conclusions but there was acceptance that five-year survival was much higher than widely assumed. CONCLUSIONS Published comments reveal a widespread reluctance to consider seriously the results of a carefully conducted randomized trial. This may be because the results challenge accepted practice because of 'motivated reasoning'. But there is a widespread misunderstanding of the fact that though PulMiCC with 93 patients was underpowered to test non-inferiority, it still provides reliable evidence to undermine the widespread belief in a major survival benefit from metastasectomy.
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Affiliation(s)
- Norman R Williams
- Surgical and Interventional Trials Unit, University College London, UK
| | | | - Francesca Fiorentino
- Nightingale-Saunders Clinical Trials & Epidemiology Unit, King's Clinical Trials Unit, Kings College London, UK
| | | | - Manuj Sharma
- Research Department of Primary Care and Population Health, University College, London, UK
| | - Mišel Milošević
- Thoracic Surgery Clinic, Institute for Lung Diseases of Vojvodina, Sremska Kamenica, Serbia
| | | | - Tom Treasure
- Clinical Operational Research Unit, University College London, UK
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10
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Xu A, Prasad V. The use and meaning of the parachute metaphor in biomedicine: a citation analysis of a systematic review and a randomized trial of the parachute for freefall. J Comp Eff Res 2022; 11:383-390. [PMID: 35189694 DOI: 10.2217/cer-2021-0171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Numerous authors have used the 'parachute' analogy to comment on the importance of and need for randomized, controlled trials (RCTs) in the hierarchy of medical evidence. Methods: The authors completed a retrospective literature analysis examining publications citing the 2003 parachute paper by Smith and Pell and a 2018 RCT of a parachute by Yeh et al. For all of the articles that directly analogized a medical intervention to a parachute, the authors identified the desired outcome of the practice and searched PubMed for relevant RCTs. Results: Authors citing the parachute analogy are often critical of RCTs and often draw comparisons to interventions that are not parachutes.
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Affiliation(s)
- Alexander Xu
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19103, USA
| | - Vinay Prasad
- Department of Medicine, Division of Hematology/Oncology, University of California, San Francisco, CA, USA.,Department of Epidemiology & Biostatistics; San Francisco General Hospital, Hematology Oncology; University of California, San Francisco, CA, USA
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11
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Macbeth F. PulMiCC was Not ‘Unsuccessful’ and Stereotactic Ablative Body Radiotherapy is Not Like a Parachute: Comments on the Editorial by Ostler et al. Clin Oncol (R Coll Radiol) 2022; 34:e139. [DOI: 10.1016/j.clon.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/04/2022] [Indexed: 11/03/2022]
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BROWN ANDREWW, ASLIBEKYAN STELLA, BIER DENNIS, DA SILVA RAFAELFERREIRA, HOOVER ADAM, KLURFELD DAVIDM, LOKEN ERIC, MAYO-WILSON EVAN, MENACHEMI NIR, PAVELA GREG, QUINN PATRICKD, SCHOELLER DALE, TEKWE CARMEN, VALDEZ DANNY, VORLAND COLBYJ, WHIGHAM LEAHD, ALLISON DAVIDB. Toward more rigorous and informative nutritional epidemiology: The rational space between dismissal and defense of the status quo. Crit Rev Food Sci Nutr 2021; 63:3150-3167. [PMID: 34678079 PMCID: PMC9023609 DOI: 10.1080/10408398.2021.1985427] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
To date, nutritional epidemiology has relied heavily on relatively weak methods including simple observational designs and substandard measurements. Despite low internal validity and other sources of bias, claims of causality are made commonly in this literature. Nutritional epidemiology investigations can be improved through greater scientific rigor and adherence to scientific reporting commensurate with research methods used. Some commentators advocate jettisoning nutritional epidemiology entirely, perhaps believing improvements are impossible. Still others support only normative refinements. But neither abolition nor minor tweaks are appropriate. Nutritional epidemiology, in its present state, offers utility, yet also needs marked, reformational renovation. Changing the status quo will require ongoing, unflinching scrutiny of research questions, practices, and reporting-and a willingness to admit that "good enough" is no longer good enough. As such, a workshop entitled "Toward more rigorous and informative nutritional epidemiology: the rational space between dismissal and defense of the status quo" was held from July 15 to August 14, 2020. This virtual symposium focused on: (1) Stronger Designs, (2) Stronger Measurement, (3) Stronger Analyses, and (4) Stronger Execution and Reporting. Participants from several leading academic institutions explored existing, evolving, and new better practices, tools, and techniques to collaboratively advance specific recommendations for strengthening nutritional epidemiology.
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Affiliation(s)
- ANDREW W. BROWN
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | | | - DENNIS BIER
- Baylor College of Medicine, Houston, Texas, USA
| | | | - ADAM HOOVER
- Clemson University, Clemson, South Carolina, USA
| | - DAVID M. KLURFELD
- United States Department of Agriculture, Agricultural Research Service, Beltsville, Maryland, USA
| | - ERIC LOKEN
- University of Connecticut, Storrs, Connecticut, USA
| | - EVAN MAYO-WILSON
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - NIR MENACHEMI
- Indiana University Fairbanks School of Public Health at IUPUI, Indianapolis, Indiana, USA
| | - GREG PAVELA
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - PATRICK D. QUINN
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - DALE SCHOELLER
- University of Wisconsin-Madison Biotechnology Center, Madison, Wisconsin, USA
| | - CARMEN TEKWE
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - DANNY VALDEZ
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - COLBY J. VORLAND
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - LEAH D. WHIGHAM
- University of Texas Health Science Center School of Public Health, El Paso, Texas, USA
| | - DAVID B. ALLISON
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
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Escandón K, Rasmussen AL, Bogoch II, Murray EJ, Escandón K, Popescu SV, Kindrachuk J. COVID-19 false dichotomies and a comprehensive review of the evidence regarding public health, COVID-19 symptomatology, SARS-CoV-2 transmission, mask wearing, and reinfection. BMC Infect Dis 2021; 21:710. [PMID: 34315427 PMCID: PMC8314268 DOI: 10.1186/s12879-021-06357-4] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 06/24/2021] [Indexed: 02/07/2023] Open
Abstract
Scientists across disciplines, policymakers, and journalists have voiced frustration at the unprecedented polarization and misinformation around coronavirus disease 2019 (COVID-19) pandemic. Several false dichotomies have been used to polarize debates while oversimplifying complex issues. In this comprehensive narrative review, we deconstruct six common COVID-19 false dichotomies, address the evidence on these topics, identify insights relevant to effective pandemic responses, and highlight knowledge gaps and uncertainties. The topics of this review are: 1) Health and lives vs. economy and livelihoods, 2) Indefinite lockdown vs. unlimited reopening, 3) Symptomatic vs. asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, 4) Droplet vs. aerosol transmission of SARS-CoV-2, 5) Masks for all vs. no masking, and 6) SARS-CoV-2 reinfection vs. no reinfection. We discuss the importance of multidisciplinary integration (health, social, and physical sciences), multilayered approaches to reducing risk ("Emmentaler cheese model"), harm reduction, smart masking, relaxation of interventions, and context-sensitive policymaking for COVID-19 response plans. We also address the challenges in understanding the broad clinical presentation of COVID-19, SARS-CoV-2 transmission, and SARS-CoV-2 reinfection. These key issues of science and public health policy have been presented as false dichotomies during the pandemic. However, they are hardly binary, simple, or uniform, and therefore should not be framed as polar extremes. We urge a nuanced understanding of the science and caution against black-or-white messaging, all-or-nothing guidance, and one-size-fits-all approaches. There is a need for meaningful public health communication and science-informed policies that recognize shades of gray, uncertainties, local context, and social determinants of health.
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Affiliation(s)
- Kevin Escandón
- School of Medicine, Universidad del Valle, Cali, Colombia.
| | - Angela L Rasmussen
- Vaccine and Infectious Disease Organization, University of Saskatchewan, Saskatoon, Canada
- Georgetown Center for Global Health Science and Security, Georgetown University, Washington, DC, USA
| | - Isaac I Bogoch
- Division of Infectious Diseases, University of Toronto, Toronto General Hospital, Toronto, Canada
| | - Eleanor J Murray
- Department of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Karina Escandón
- Department of Anthropology, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Saskia V Popescu
- Georgetown Center for Global Health Science and Security, Georgetown University, Washington, DC, USA
- Schar School of Policy and Government, George Mason University, Fairfax, VA, USA
| | - Jason Kindrachuk
- Vaccine and Infectious Disease Organization, University of Saskatchewan, Saskatoon, Canada
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
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Dalton BR, Stewart JJ, Jorgensen SCJ. The case for 'conservative pharmacotherapy'-authors' response. J Antimicrob Chemother 2021; 76:2491-2492. [PMID: 34245268 DOI: 10.1093/jac/dkab234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Bruce R Dalton
- Pharmacy Services, Alberta Health Services, Calgary, AB, Canada
| | - Jackson J Stewart
- Pharmacy Services, University of Alberta Hospital, Edmonton, AB, Canada
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Verkooijen HM, Henke LE. Sensible Introduction of MR-Guided Radiotherapy: A Warm Plea for the RCT. Front Oncol 2021; 11:652889. [PMID: 33816308 PMCID: PMC8017276 DOI: 10.3389/fonc.2021.652889] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/04/2021] [Indexed: 01/09/2023] Open
Abstract
Magnetic resonance guided radiotherapy (MRgRT) is the newest face of technology within a field long-characterized by continual technologic advance. MRgRT may offer improvement in the therapeutic index of radiation by offering novel planning types, like online adaptation, and improved image guidance, but there is a paucity of randomized data or ongoing randomized controlled trials (RCTs) to demonstrate clinical gains. Strong clinical evidence is needed to confirm the theoretical advantages of MRgRT and for the rapid dissemination of (and reimbursement for) appropriate use. Although some future evidence for MRgRT may come from large registries and non-randomized studies, RCTs should make up the core of this future data, and should be undertaken with thoughtful preconception, endpoints that incorporate patient-reported outcomes, and warm collaboration across existing MRgRT platforms. The advance and future success of MRgRT hinges on collaborative pursuit of the RCT.
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Affiliation(s)
- Helena M Verkooijen
- Imaging and Oncology Division, University Medical Center Utrecht, Utrecht, Netherlands.,University of Utrecht, Utrecht, Netherlands.,Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St Louis, MO, United States
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St Louis, MO, United States
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17
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Large randomized controlled trials in infertility. Fertil Steril 2020; 113:1093-1099. [DOI: 10.1016/j.fertnstert.2020.04.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 01/12/2023]
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18
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When are randomized controlled trials needed to assess novel anticancer drugs? An illustration based on the development of selpercatinib, a RET inhibitor. Ann Oncol 2020; 31:328-330. [DOI: 10.1016/j.annonc.2019.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/28/2019] [Indexed: 11/21/2022] Open
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19
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Out of Control? Managing Baseline Variability in Experimental Studies with Control Groups. Handb Exp Pharmacol 2019; 257:101-117. [PMID: 31595416 DOI: 10.1007/164_2019_280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Control groups are expected to show what happens in the absence of the intervention of interest (negative control) or the effect of an intervention expected to have an effect (positive control). Although they usually give results we can anticipate, they are an essential component of all experiments, both in vitro and in vivo, and fulfil a number of important roles in any experimental design. Perhaps most importantly they help you understand the influence of variables that you cannot fully eliminate from your experiment and thus include them in your analysis of treatment effects. Because of this it is essential that they are treated as any other experimental group in terms of subjects, randomisation, blinding, etc. It also means that in almost all cases, contemporaneous control groups are required. Historical and baseline control groups serve a slightly different role and cannot fully replace control groups run as an integral part of the experiment. When used correctly, a good control group not only validates your experiment; it provides the basis for evaluating the effect of your treatments.
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Sturmberg JP. Evidence-based medicine-Not a panacea for the problems of a complex adaptive world. J Eval Clin Pract 2019; 25:706-716. [PMID: 30887648 DOI: 10.1111/jep.13122] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 02/13/2019] [Indexed: 12/26/2022]
Abstract
The recent sacking of Peter Gøtzsche from the Cochrane Collaboration Board raised strong responses and highlights the neglected issue about priorities-maintaining the reputation of the organization or vigorously debating the merits of scientific approaches to find answers to complex problems? The Cochrane approach hales the randomized trial (RCT) as the gold standard research approach and affirms that meta-analysis provides the ultimate proof (or platinum standard) to settle contentious issues confronting the clinician. However, most published medical research is wrong, and critics coined the acronym GIGO (garbage in, garbage out) as a meme to highlight the risks of blind faith in the hyped-up procedures of the EBM movement. This paper firstly explores the differences between the prevailing scientific method arising from the linear cause-and-effect assumption and the complex adaptive systems science methods arising from observations that most phenomena emerge from nonlinearity in networked systems. Most medical conditions are characterized by necessary features that by themselves are not sufficient to explain their nature and behaviour. Such nonlinear phenomena require modelling approaches rather than linear statistical and/or meta-analysis approaches to be understood. These considerations also highlight that research is largely stuck at the data and information levels of understanding which fails clinicians who depend on knowledge-the synthesis of information-to apply in an adaptive way in the clinical encounter. Clinicians are constantly confronted with the linked challenges of doing things right and doing the right thing for their patients. EBM and Cochrane with their restrictive approaches are the antithesis to a practice of medicine that is responsive to constantly changing patient needs. As such, the EBM/Cochrane crisis opens a window of opportunity to re-examine the nature of health, illness and disease, and the nature of health care and its systems for the benefits of its professionals and their patients. We are at the cusp of a paradigmatic shift towards an understanding a praxis of health care that takes account of its complexities.
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Affiliation(s)
- Joachim P Sturmberg
- School of Medicine and Public Health, University of Newcastle, Wamberal, NSW, Australia
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21
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Kunnumakkara AB, Bordoloi D, Sailo BL, Roy NK, Thakur KK, Banik K, Shakibaei M, Gupta SC, Aggarwal BB. Cancer drug development: The missing links. Exp Biol Med (Maywood) 2019; 244:663-689. [PMID: 30961357 PMCID: PMC6552400 DOI: 10.1177/1535370219839163] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPACT STATEMENT The success rate for cancer drugs which enter into phase 1 clinical trials is utterly less. Why the vast majority of drugs fail is not understood but suggests that pre-clinical studies are not adequate for human diseases. In 1975, as per the Tufts Center for the Study of Drug Development, pharmaceutical industries expended 100 million dollars for research and development of the average FDA approved drug. By 2005, this figure had more than quadrupled, to $1.3 billion. In order to recover their high and risky investment cost, pharmaceutical companies charge more for their products. However, there exists no correlation between drug development cost and actual sale of the drug. This high drug development cost could be due to the reason that all patients might not respond to the drug. Hence, a given drug has to be tested in large number of patients to show drug benefits and obtain significant results.
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Affiliation(s)
- Ajaikumar B Kunnumakkara
- Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Devivasha Bordoloi
- Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Bethsebie Lalduhsaki Sailo
- Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Nand Kishor Roy
- Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Krishan Kumar Thakur
- Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Kishore Banik
- Cancer Biology Laboratory, DBT-AIST International Laboratory for Advanced Biomedicine (DAILAB), Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati 781039, India
| | - Mehdi Shakibaei
- Faculty of Medicine, Institute of Anatomy, Ludwig Maximilian University of Munich, Munich D-80336, Germany
| | - Subash C Gupta
- Department of Biochemistry, Institute of Science, Banaras Hindu University, Varanasi 221005, India
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22
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Radecki RP, Spiegel RJ. Adventures With Andexanet Alfa in Efficacy, Effectiveness, and One-Armed Studies: May 2019 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2019; 73:545-547. [PMID: 31029291 DOI: 10.1016/j.annemergmed.2019.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ryan P Radecki
- Northwest Permanente, Portland, OR; The University of Texas Health Science Center at Houston, Houston, TX
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23
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Yeh RW, Valsdottir LR, Yeh MW, Shen C, Kramer DB, Strom JB, Secemsky EA, Healy JL, Domeier RM, Kazi DS, Nallamothu BK. Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial. BMJ 2018; 363:k5094. [PMID: 30545967 PMCID: PMC6298200 DOI: 10.1136/bmj.k5094] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To determine if using a parachute prevents death or major traumatic injury when jumping from an aircraft. DESIGN Randomized controlled trial. SETTING Private or commercial aircraft between September 2017 and August 2018. PARTICIPANTS 92 aircraft passengers aged 18 and over were screened for participation. 23 agreed to be enrolled and were randomized. INTERVENTION Jumping from an aircraft (airplane or helicopter) with a parachute versus an empty backpack (unblinded). MAIN OUTCOME MEASURES Composite of death or major traumatic injury (defined by an Injury Severity Score over 15) upon impact with the ground measured immediately after landing. RESULTS Parachute use did not significantly reduce death or major injury (0% for parachute v 0% for control; P>0.9). This finding was consistent across multiple subgroups. Compared with individuals screened but not enrolled, participants included in the study were on aircraft at significantly lower altitude (mean of 0.6 m for participants v mean of 9146 m for non-participants; P<0.001) and lower velocity (mean of 0 km/h v mean of 800 km/h; P<0.001). CONCLUSIONS Parachute use did not reduce death or major traumatic injury when jumping from aircraft in the first randomized evaluation of this intervention. However, the trial was only able to enroll participants on small stationary aircraft on the ground, suggesting cautious extrapolation to high altitude jumps. When beliefs regarding the effectiveness of an intervention exist in the community, randomized trials might selectively enroll individuals with a lower perceived likelihood of benefit, thus diminishing the applicability of the results to clinical practice.
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Affiliation(s)
- Robert W Yeh
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Avenue, Boston, MA 02215, USA
| | - Linda R Valsdottir
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Avenue, Boston, MA 02215, USA
| | - Michael W Yeh
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Changyu Shen
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Avenue, Boston, MA 02215, USA
| | - Daniel B Kramer
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Avenue, Boston, MA 02215, USA
| | - Jordan B Strom
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Avenue, Boston, MA 02215, USA
| | - Eric A Secemsky
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Avenue, Boston, MA 02215, USA
| | - Joanne L Healy
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Avenue, Boston, MA 02215, USA
| | - Robert M Domeier
- Department of Emergency Medicine, University of Michigan and Saint Joseph Hospital, Ann Arbor, MI, USA
| | - Dhruv S Kazi
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Avenue, Boston, MA 02215, USA
| | - Brahmajee K Nallamothu
- Michigan Integrated Center for Health Analytics and Medical Prediction, Department of Internal Medicine and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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Lynch HF, Nicholls S, Meyer MN, Taylor HA. Of Parachutes and Participant Protection: Moving Beyond Quality to Advance Effective Research Ethics Oversight. J Empir Res Hum Res Ethics 2018; 14:190-196. [PMID: 30541368 DOI: 10.1177/1556264618812625] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
There are several reasons to believe that Institutional Review Boards (IRBs) and Human Research Protection Programs (HRPPs) contribute to ethical research and the protection of research participants, but there are also important reasons to interrogate this belief. Determining whether IRBs and HRPPs "work" requires empirical evaluation of whether and how well they actually achieve what they were designed to do. In other words, it is critical to examine their outcomes and not only their procedures and structures. In this response to Tsan, we argue that the concept of IRB and HRPP quality entails three dimensions: (1) effectiveness, (2) procedures and structures likely to promote effectiveness, and (3) features unrelated to effectiveness but nonetheless essential, such as efficiency, fairness, and proportionality. Because not all types of quality necessarily guarantee or entail effectiveness, we suggest that broad quality assessments, including such features as regulatory compliance and other procedural measures suggested by Tsan, are unhelpful as the first step in evaluating IRBs and HRPPs. Instead, we must start with outcomes relevant to effectiveness. To do this, we launched the Consortium to Advance Effective Research Ethics Oversight (AEREO), with a mission to define and specify ways to measure relevant outcomes for research ethics oversight, empirically evaluate whether those outcomes are achieved, test new approaches to achieving them, and ultimately, develop and implement empirically-based policy and practice to advance IRB and HRPP effectiveness. We describe several anticipated AEREO projects and call for collaboration between various stakeholders to more meaningfully evaluate IRB and HRPPs.
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Affiliation(s)
| | | | | | - Holly A Taylor
- 4 Johns Hopkins University Berman Institute of Bioethics, Baltimore, MD, USA
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- The following AEREO Consortium Members endorse this article in their individual capacities and not necessarily on behalf of any institutions of which they are a part: Angela Bain, Barbara E. Bierer, Justin Clapp, Anne K. Clark, Carl Coleman, Whitney Eriksen, Jonathan Green, Sarah Greene, Elisa A. Hurley, Steven Joffe, Susan Kornetsky, Lisa M. Lee, Lindsay McNair, Linda Parreco, Suzanne M. Rivera, Stephen Rosenfeld, Michele Russell-Einhorn, Megan Singleton, David H. Strauss, Emma Tumilty, and Tracy Ziolek. This publication represents the views of the authors and does not reflect the official position or policy of the National Cancer Institute, the National Institutes of Health, or the Department of Health and Human Services
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Wordsworth S, Doble B, Payne K, Buchanan J, Marshall DA, McCabe C, Regier DA. Using "Big Data" in the Cost-Effectiveness Analysis of Next-Generation Sequencing Technologies: Challenges and Potential Solutions. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1048-1053. [PMID: 30224108 DOI: 10.1016/j.jval.2018.06.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 06/27/2018] [Indexed: 05/27/2023]
Abstract
Next-generation sequencing (NGS) is considered to be a prominent example of "big data" because of the quantity and complexity of data it produces and because it presents an opportunity to use powerful information sources that could reduce clinical and health economic uncertainty at a patient level. One obstacle to translating NGS into routine health care has been a lack of clinical trials evaluating NGS technologies, which could be used to populate cost-effectiveness analyses (CEAs). A key question is whether big data can be used to partially support CEAs of NGS. This question has been brought into sharp focus with the creation of large national sequencing initiatives. In this article we summarize the main methodological and practical challenges of using big data as an input into CEAs of NGS. Our focus is on the challenges of using large observational datasets and cohort studies and linking these data to the genomic information obtained from NGS, as is being pursued in the conduct of large genomic sequencing initiatives. We propose potential solutions to these key challenges. We conclude that the use of genomic big data to support and inform CEAs of NGS technologies holds great promise. Nevertheless, health economists face substantial challenges when using these data and must be cognizant of them before big data can be confidently used to produce evidence on the cost-effectiveness of NGS.
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Affiliation(s)
- Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Oxford National Institute for Health Research, Biomedical Research Centre, Oxford, UK.
| | - Brett Doble
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Oxford National Institute for Health Research, Biomedical Research Centre, Oxford, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, The University of Manchester, Manchester, UK
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Oxford National Institute for Health Research, Biomedical Research Centre, Oxford, UK
| | | | - Christopher McCabe
- Institute of Health Economics, Alberta, Canada; Faculty of Medicine and Dentistry, University of Alberta, Alberta, Canada
| | - Dean A Regier
- Canadian Centre for Applied Research in Cancer Control (ARCC), Cancer Control Research, BC Cancer, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada
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