Industry effects on evidence: a case study of long-acting injectable antipsychotics

A vigorously debated issue in the psychiatric literature is whether long-acting injectable antipsychotics (LAIs) show clinical benefit over antipsychotics taken orally. In addressing this question, it is critical that systematic reviews incorporate risk of bias assessments of trial data in a robust way and are free of undue industry influence. In this paper, we present a case analysis in which we identify some of the design problems in a recent systematic review on LAIs vs oral formulations. This case illustrates how evidence syntheses that are shaped by commercial interests may undermine patient-centered models of recovery and care. We offer recommendations that address both the bioethical and research design issues that arise in the systematic review process when researchers have financial conflicts of interest.

[Top 4 Research Studies of the month for Italian Primary Care Physicians: April 2024.]

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) In children and adults with acute conjunctivitis, antibiotic drops increase the likelihood that a patient will experience clinical recovery. Damage appears to be minimal for all agents other than fusidic acid (therefore, fusidic acid should be avoided). Since most patients improve without antibiotics, the benefit is modest, and there is a risk of antibiotic resistance, we would avoid them for patients with milder symptoms, especially immunocompetent adults. 2) A high quality randomized controlled trial was recently conducted on more than 4000 adult patients with recurrent episodes of subclinical atrial fibrillation. Trialists found that there was approximately 1 fewer ischemic stroke and 1 more major bleed for every 250 persons treated with apixaban instead of aspirin, but in people treated with apixaban major bleeding was also significantly more likely. This seems like a decision that requires an informed patient and shared decision-making. 3) In an intriguing but somewhat limited network meta-analysis, probiotics were equally or more effective than treatment with any antidepressant except escitalopram. Given the low advantage of standard treatments over placebo, probiotic treatment might be offered to patients who are reluctant to use antidepressants. 4) A recent meta-analysis showed that amyloid-targeting monoclonal antibodies do not provide any clinical meaningful benefits for patients with Alzheimer disease. Instead, they are associated with concerning risks of harm, most notably cerebral hemorrhage identified on imaging studies. The balance of risk versus benefit demonstrated thus far doesn't justify the use of these costly (over US$ 20,000 annually) drugs.

[Top 5 Research Studies of the month for Italian Primary Care Physicians: March 2024.]

This monthly article provides a collection of summaries of the most relevant studies identified as POEMs (patient-oriented evidence that matters) for Italian primary care physicians. 1) A simple, well-validated risk score can help clinicians counsel patients with atrial fibrillation regarding the use of DOACs to prevent stroke. The score shares its name with the drug class (the "DOAC" score). 2) Presumably by perturbing the intestinal microbiome, antibiotic treatment is associated with an increase in the likelihood of the development of irritable bowel disease; this is especially true with multiple courses of antibiotics. 3) Patients with uncomplicated gallstones can be managed over time with analgesia and monitoring, though approximately 25% will eventually undergo cholecystectomy over the next 18 months. Still, there appears to be no need to rush to surgery without evidence of common bile duct blockage or acute pancreatitis. 4) Delivering bad news (e.g. a cancer diagnosis) by telephone does not affect levels of anxiety, depression, or satisfaction with care as compared with delivering the news in person. 5) An updated high quality systematic review found that, in conjunction with psychosocial interventions, oral naltrexone (50 mg/day) and oral acamprosate have the strongest evidence for being effective in the treatment of alcohol use disorder.

Implementing Whole Person Primary Care: Results from a Year-Long Learning Collaborative

PURPOSE

The National Academies of Medicine report on Implementing High-Quality Primary Care calls for a transformation of the primary care to a "whole person" model that is person-centered, relationship-based and takes into account the social, spiritual, emotional and behavioral aspects of health. However, our current delivery tools, such as the SOAP Note, do not sufficiently capture and organize the delivery of these elements in practice. To explore how to remedy this, an Integrative Health Learning Collaborative (IHLC) was established to implement and test new tools for changing primary care practices toward whole person care.

METHODS

The IHLC comprised primary care practices committed to changing to a whole person care model of care along with a panel of experts in integrative health and change management. The IHLC met virtually monthly. Representatives from each practice and an assigned expert met to strategize and adapt the tools to their environment and practice. The practices used previously developed tools (the HOPE Note toolkit), change management tools, and quality improvement techniques to introduce, implement, and evaluate the changes.

RESULTS

Sixteen clinics completed the process after 1 year. Overall, practices used the HOPE Note tools in 942 patients. Participants reported changes on the effectiveness of the collaborative (1) on clinical practice, (2) on the skills and attitudes of participants; and (3) the support in change management.

CONCLUSIONS

This online learning collaborative supported practices implementing a whole person care model in primary care and improved the understanding, skills, and delivery ability of whole person care in all clinics completing the program.

Becoming a Phronimos: Evidence-Based Medicine, Clinical Decision Making, and the Role of Practical Wisdom in Primary Care

There has been much discussion about the overmedicalization of human experience and the problems incurred by overzealous action-oriented medical care. In this paper we describe the Aristotelean virtue of phronesis, or practical wisdom, and discuss how it can be developed by interested clinicians. We argue that becoming a phronimos requires conscious attention to one's practice by using feedback to continually improve. But there must also be judicious adherence to clinical practice guidelines and advocacy for people-as-patients at individual, community, and national levels.

Indicators of the dimensions of trust (and mistrust) in early primary care practice: a qualitative study

BACKGROUND

Trust occurs when persons feel they can be vulnerable to others because of the sincerity, benevolence, truthfulness and sometimes the competence they perceive. This project examines the various types of trust expressed in written reflections of developing healthcare clinicians. Our goal is to understand the roles trust plays in residents' self-examination and to offer insight from relationship science to inform the teaching and clinical work for better trust in healthcare.

METHODS

We analyzed 767 reflective writings of 33 residents submitted anonymously, to identify explicit or implicit indicators attention to trust or relationship development. Two authors independently coded the entries based on inductively identified dimensions. Three authors developed a final coding structure that was checked against the entries. These codes were sorted into final dimensions.

RESULTS

We identified 114 written reflections that contained one or more indicators of trust. These codes were compiled into five code categories: Trust of self/trust as the basis for confidence in decision making; Trust of others in the medical community; Trust of the patient and its effect on clinician; Assessment of the trust of them exhibited by the patient; and Assessment of the effect of the patient's trust on the patient's behavior.

DISCUSSION

Broadly, trust is both relationship-centered and institutionally situated. Trust is a process, built on reciprocity. There is tacit acknowledgement of the interplay among what the residents do is good for the patient, good for themselves, and good for the medical institution. An exclusive focus on moments in which trust is experienced or missed, as well as only on selected types of trust, misses this complexity.

CONCLUSION

A greater awareness of how trust is present or absent could lead to a greater understanding and healthcare education for beneficial effects on clinicians' performance, personal and professional satisfaction, and improved quality in patients' interactions.

Evidence reversals in primary care research: a study of randomized controlled trials

BACKGROUND

Evidence-Based Medicine is built on the premise that clinicians can be more confident when their decisions are grounded in high-quality evidence. Furthermore, evidence from studies involving patient-oriented outcomes is preferred when making decisions about tests or treatments. Ideally, the findings of relevant and valid trials should be stable over time, that is, unlikely to be reversed in subsequent research.

OBJECTIVE

To evaluate the stability of evidence from trials relevant to primary healthcare and to identify study characteristics associated with their reversal.

METHODS

We studied synopses of randomized controlled trials (RCTs) published from 2002 to 2005 as "Daily POEMs" (Patient Oriented Evidence that Matters). The initial evidence (E1) from these POEMs (2002-2005) was compared with the updated evidence (E2) on that same topic in a summary resource (DynaMed 2019). Two physician-raters independently categorized each POEM-RCT as (i) reversed when E1 ≠ E2, or as (ii) not reversed, when E1 = E2. For all "Evidence Reversals" (E1 ≠ E2), we assessed the direction of change in the evidence.

RESULTS

We evaluated 408 POEMs on RCTs. Of those, 35 (9%; 95% confidence interval [6-12]) were identified as reversed, 359 (88%) were identified as not reversed, and 14 (3%) were indeterminate. On average, this represents about 2 evidence reversals per annum for POEMs about RCTs.

CONCLUSIONS

Over 12-17 years, 9% of RCTs summarized as POEMs are reversed. Information alerting services that apply strict criteria for relevance and validity of clinical information are likely to identify RCTs whose findings are stable over time.

Conflicts of Interest in Psychopharmacology Textbooks

While most medical journals require disclosures of industry payments to authors and editors, there is no requirement for textbooks. In this study we evaluated nine well-known psychopharmacology textbooks to identify payments to their writers and editors. Two-thirds of the textbooks had at least one editor or author who received personal payments from one or more pharmaceutical companies, for a total of 11,021,409 USD paid to 11 of 21 editors/authors over a seven-year period. Much of this money was paid to a single author but 24% of the writers received over 75,000 USD each over this time period. There are several psychopharmacology textbooks authored by writers without apparent financial conflicts of interest. Just as with medical journals, medical textbooks should be transparent about payments made to their authors and editors.

The science of education: using learning theory to solve teaching problems in medical education

Although theories do not play a major role in clinical medicine, the application of established theories of education can improve medical teaching. By understanding and harnessing learning theories, clinician educators can solve common teaching problems, thoughtfully craft their teaching sessions, determine whether learners or residents have achieved the intended learning objectives, and even earn higher course ratings. Key theories to be aware of include cognitive load theory, social learning theory, experiential learning, constructivism, humanism, behaviourism and connectivism. Various teaching problems are presented, along with explanations rooted in educational theory and possible solutions for use in the clinical educational setting.

Reducing overuse by recognising the unintended harms of good intentions

Overdiagnosis and overtreatment-overuse-is gaining wide acceptance as a leading nosocomial intervention in medicine. Not only does overuse create anxiety and diminish patients' quality of life, in some cases it causes harm to both patients and others not directly involved in clinical care. Reducing overuse begins with the recognition and acceptance of the potential for unintended harm of our best intentions. In this paper, we introduce five cases to illustrate where harm can occur as the result of well-intended healthcare interventions. With this insight, clinicians can learn to appreciate the critical role of probability-based, evidence-informed decision-making in medicine and the need to consider the outcomes for all who may be affected by their actions. Likewise, educators need to evolve medical education and medical decision-making so that it focuses on the hierarchy of evidence and that what 'ought to work', based on traditional pathophysiological, disease-focused reasoning, should be subordinate to what 'does work'.