What philosophy should be taught to the future medical professionals?

Medicine, Health Care and Philosophy - The presence of philosophy, amidst other humanities,within the body of medical education seems to raise no doubt nowadays. There are, however, some questions...     

How should interventions to reduce inequalities in health be evaluated?

OBJECTIVE: The effectiveness of interventions which have been proposed or are currently in progress to reduce socioeconomic inequalities in health is largely unknown. This paper aims to develop guidelines for evaluating these interventions. APPROACH: Starting from a set of general guidelines which was recently proposed by a group of experts reporting to the national Programme Committee on Socioeconomic Inequalities in Health in The Netherlands, an analysis was made of the appropriateness of different study designs which could be used to assess the effectiveness of interventions to reduce inequalities in health. RESULTS: A "full" study design requires the measurement, in one or more experimental populations and one or more control populations, of changes over time in the magnitude of socioeconomic inequalities in health. This will usually imply a community intervention trial. Five alternative study designs are distinguished which require less complex measurements but also require more assumptions to be made. Several examples are given. CONCLUSIONS: Building up a systematic knowledge base on the effectiveness of interventions to reduce socioeconomic inequalities in health will be a major enterprise. Elements of a strategy to increase learning speed are discussed. Although the guidelines and design recommendations developed in this paper apply to the evaluation of specific interventions where rigorous evaluation methods can often be used, they may also be useful for the interpretation of the results of less rigorous evaluation studies, for example of broader policies to reduce socioeconomic inequalities in health.     

How should patients' utilities be incorporated into clinical decisions? 2008 SESPAS Report

There are many clinical situations in which there is no "right" decision from a technical point of view. An example of this is elective surgery, in which patients' preferences are critical. One way to integrate patients' preferences within clinical practice is the application of decision analysis. According to this approach, preferences (utilities) are assessed and are then combined with physicians' knowledge. This combination of evidence and utilities leads to the so-called shared decision-making (SDM) model. The overview provided in the present article indicates that: a) The SDM model, if systematically applied, could improve treatment effectiveness and patients well being; b) clinical practice, nevertheless, faces barriers in the form of time and resource constraints, limiting the application of such a model; c) discrepancies between patients' and doctors' preferences could be narrowed if patients' utilities were included in clinical practice guidelines; d) the application of this kind of analysis seems to be scarce in Spain. Moreover, information provided to patients is probably insufficient; and e) patient decision aids, even though their use is rapidly growing, are subject to certain problems.     

How should vasectomy be promoted in Guatemala?

In the article "Evaluation of a Communications Program to Increase Adoption of Vasectomy in Guatemala" by J.T. Bertrand et al (Stud Fam Plann 1987 Nov/Dec), the authors conclude that the use of a male promoter alone was 4 times more cost-effective in increasing the number of vasectomies than the use of radio alone because the costs of the radio program were 4 times higher. This conclusion is questionable for several reasons. 1) The district where the promoter was used alone was twice as large as the radio-only district. 2) In one of the promoter-only districts the same promoter worked throughout the program, but in the other, 3 different promoters had to be recruited and trained, due to high personnel turnover. 3) The initial costs of a radio program may be higher, but 1 program can be broadcast in all districts with little or no extra cost, whereas the costs of a promoter would have to be multiplied by the number of districts. 4) Although the promoter and the radio program produced approximately equal numbers of vasectomies, the radio messages reached over 70% of the people surveyed. Thus, on a national basis, radio broadcasts would be far more cost-effective than the use of salaried promoters in each district.     

How should risk adjustment data be collected?

Risk adjustment has broad general application and is a key part of the Patient Protection and Affordable Care Act (ACA). Yet, little has been written on how data required to support risk adjustment should be collected. This paper offers analytical support for a distributed approach, in which insurers retain possession of claims but pass on summary statistics to the risk adjustment authority as needed. It shows that distributed approaches function as well as or better than centralized ones-where insurers submit raw claims data to the risk adjustment authority-in terms of the goals of risk adjustment. In particular, it shows how distributed data analysis can be used to calibrate risk adjustment models and calculate payments, both in theory and in practice--drawing on the experience of distributed models in other contexts. In addition, it explains how distributed methods support other goals of the ACA, and can support projects requiring data aggregation more generally. It concludes that states should seriously consider distributed methods to implement their risk adjustment programs.     

How should patients with Barrett's esophagus be monitored?

Some patients who have been diagnosed with Barrett's esophagus will develop dysplasia and, in some cases, esophageal carcinoma (strength of recommendation [SOR]: A, based on consistent cohort studies). Endoscopic surveillance is recommended for all patients with Barrett's esophagus as it is superior to other methods for detecting esophageal cancer (SOR: B, based on systematic review). The degree of dysplasia noted on biopsy specimens correlates with the risk of esophageal carcinoma development and should guide the frequency of subsequent evaluations (SOR: B, based on consistent cohort studies). The optimal frequency of endoscopy has yet to be determined in any randomized trial. Recommendations from the 2002 American College of Gastroenterology (ACG) Practice Guideline provide guidance as to the frequency of endoscopy surveillance but were not based on an explicit systematic review of the literature (SOR: C, based on expert opinion).     

How should low-density lipoprotein cholesterol concentration be determined?

The National Cholesterol Education Program Adult Treatment Panel III Report (NCEP-ATP III) has identified low-density lipoprotein cholesterol (LDLC) as the primary target of therapy and has recommended using the Friedewald calculated LDL-C (CLDL- C). The present study compared a direct LDLC (D-LDL-C) method with the C-LDL-C and determined the possible impact on treatment decisions. C-LDL-C and D-LDL-C were compared in 464 consecutive patients. The D-LDL-C was 18% higher than the C-LDL-C at 100 mg/dL, an important level for medical decision making. This can result in inappropriate drug therapy (usually overtreatment) if the NCEP-ATP III treatment guidelines are followed with the D-LDL-C rather than the C-LDL-C. The C-LDL-C is preferred because this assay has been used in clinical trials documenting the benefits of cholesterol-lowering therapy.     

How should meta-regression analyses be undertaken and interpreted?

Appropriate methods for meta-regression applied to a set of clinical trials, and the limitations and pitfalls in interpretation, are insufficiently recognized. Here we summarize recent research focusing on these issues, and consider three published examples of meta-regression in the light of this work. One principal methodological issue is that meta-regression should be weighted to take account of both within-trial variances of treatment effects and the residual between-trial heterogeneity (that is, heterogeneity not explained by the covariates in the regression). This corresponds to random effects meta-regression. The associations derived from meta-regressions are observational, and have a weaker interpretation than the causal relationships derived from randomized comparisons. This applies particularly when averages of patient characteristics in each trial are used as covariates in the regression. Data dredging is the main pitfall in reaching reliable conclusions from meta-regression. It can only be avoided by prespecification of covariates that will be investigated as potential sources of heterogeneity. However, in practice this is not always easy to achieve. The examples considered in this paper show the tension between the scientific rationale for using meta-regression and the difficult interpretative problems to which such analyses are prone.