Relative risk confusion, the FDA weighs in on tweets, and what’s the right care with a new, expensive drug?
Welcome to the Right Care Weekly, a newsletter that will help you stay on top of all the important news in the ongoing quest to move the U.S. health care system toward the right care. We’ll bring you the most important stories, news articles, and opinion pieces of the week, along with our interpretation of why they’re important and what they mean for patients, doctors, and communities.
A recent BMJ article on mammography screening is being promoted as saying that mammography could reduce deaths from breast cancer by 28%.* However, as Aaron Carroll of the Incidental Economist writes, this figure is a perfect example of the difference between relative risk reduction and absolute risk reduction. While the relative risk reduction (fraction of breast cancer deaths avoided) was 28%, the fraction of women who avoided dying from breast cancer – the reduction in absolute risk – was only 0.27%! The absolute reduction was calculated from the Number Needed to Treat (NNT), which was 368. (This means that 368 women needed to be invited to the screening program for one breast cancer death to be prevented.) Carroll credits the authors of the BMJ study for calculating and reporting the NNT, but he points out, rightly, that it’s still the 28% relative risk reduction that’s getting attention. Meanwhile, there’s little discussion of the 367 women who will see no benefit from screening – and some of whom will likely be harmed.
Big news in Bloomberg this week on drug marketing in the social media era: the FDA has ruled drug companies who use social media to advertise must include the risks associated with their products, not just the benefits. Drugmakers also have to include both the brand and generic names for their products. That certainly poses a challenge for drug companies trying to fit within Twitter’s 140-character limit, but as we wrote last week about cancer centers, misleading advertising is a recurring problem in medicine. Benefits are highlighted, but risks, preventative measures, and alternatives are often ignored. If it stands, the rule might help prevent people from making serious medical decisions based on a one-sentence emotional appeal, and remind people that they need to understand all of a drug’s benefits and risks.
More news on the controversy over statins: A group of nine physicians and academics have published an open letterobjecting to the recommendation by NICE (the UK’s National Institute for Health and Care Excellence) and Health Secretary Jeremy Hunt that more adults be advised to take statins. They point out a number of problems with the recommendation and the research behind it, including that trials behind the guideline were largely funded by pharmaceutical companies, and that much of the data the researchers used to find a benefit to statins is still not publicly available. The letter calls for NICE to hold off on publishing these recommendations until the proposed guidelines can be reviewed by those without conflicts of interest.
Brown medical student Allan Joseph has been working on a series on the new hepatitis C drug, sofosbuvir (trade name Sovaldi). The drug seems like it’s a lot more effective than previous treatments, but it’s incredibly expensive, and the population of potential patients is enormous. There are genuinely difficult questions still to be answered about how the drug will be covered, and which patients will benefit. The series doesn’t come to clear conclusions, but it’s an important reminder that getting access to new technologies and treatments, when they have the ability to really help people, is an important part of getting the right care.
Finally, this week we mark the death of Dr. Bud Relman, former editor-in-chief of the New England Journal of Medicine. Dr. Relman was an early and forceful critic of the role of money in medicine, saying in an editorial: “We should not allow the medical-industrial complex to distort our health care system to its own entrepreneurial ends.” He also played a role in requiring the disclosure of researchers’ conflicts of interest in medical journals. Recently, he wrote a powerful piece in the New York Review of Books on his experiences as a patient in the health care system.
*We have writtenbefore about the effectiveness of screening mammography. As Dr. Carroll points out in his post, the data from large RCTs show that mammography screening has few, if any, benefits; observational data probably cannot override that conclusion.