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    Saturday, July 13, 2002

    Lies, Damned Lies, and Statistics: Ian Murray, at The Edge of England’s Sword is skeptical about the recent study of hormone replacement therapy. He also has this link to a critique of the statistics used in the study.

    They’re both a little hard on the study and on the media. Most of the media reports I read were careful to say that the increase in cancer and heart disease in the users of estrogen were small, but significant. They were also careful to point out that the study only pertained to those using estrogen and progesterone. Still, there is a tendency, both in the media and in the medical community, to take this kind of data and communicate it in terms of relative risk, which always makes the danger seem much more ominous than it is. Physicians aren't any better at statistical analysis than the general public, so we get sucked into the exaggeration, too. It's quite conceivable that people, including doctors (and more ominously, malpractice lawyers), will interpret the findings to mean that no one should take estrogen replacement therapy. That would be wrong. (For the raw results of the study click here.)

    The biggest issue here, is that patients need to be allowed more of a voice in selecting preventive treatments. By and large, women weren’t given much of a choice when it came to hormone replacement therapy. They may have been told of the potential risks and the benefits, but if the physician believed the benefits outweighed the risks, he would emphasize the benefits. In many cases, though, especially ten or twenty years ago, women were just told to take it because it was the belief of the medical community that estrogen was good for them. Too often, the patients weren’t given any say in the matter at all. This is especially egregious considering that, with the exception of treating hot flashes and vaginal dryness, the purpose in taking the medication was to prevent a condition that might develop (heart disease, osteoporosis) rather than a disease that already exists.

    The same thing happens with cholesterol-lowering medication. This is medication that, in most cases, must be taken for the rest of one’s life to maintain cholesterol at acceptable levels. The sole purpose of taking it is to reduce the risk of developing disease. Taking it all of your life doesn’t mean that you won’t some day end up with a heart attack, it only means that you have less of a chance to end up with one. Most of the time, that distinction isn’t communicated to patients. Instead, they are told that they have a certain cholesterol level and that medicine is indicated to bring the cholesterol down to the acceptable standard. Like estrogen replacement therapy, we do this because it is the accepted belief of the medical community that lowering cholesterol is good. In this case, though, it goes even further than that. We know this is good care because we have been given guidelines that tell us so. Insurance companies and hospitals know this is good care because they read the guidelines, too. They use them to monitor the quality of care that physicians deliver. The result is that there is pressure on the physician to get those cholesterol levels down to acceptable levels. Cholesterol becomes a disease rather than a risk factor. Patient preferences are taken completely out of the equation.

    Statistics have played a role here, too. Take a look at some of the studies that influenced the guidelines (here, here, here, here, and here.) They all have a fondness for expressing their results in terms of relative risks and risk reductions. It sounds so much more impressive to say that heart attacks were reduced by 31%. But, in terms of pure numbers, the differences in the number of heart attacks is only a few percentage points. How many people would take cholesterol medication if they knew that it really only gave a benefit of 3 or 5 fewer heart attacks per 100 people taking the medication? What are we going to tell our patients when, after twenty or thirty years experience with them, we discover their long-term side effects and consequences?

    We should exercise more care when counseling patients on taking preventive medicine. It’s become too common to prescribe preventive medication as if we were treating disease itself. They aren't the same at all. Patients should be given the straight facts and a chance to make their own decisions when it comes these issues.

    posted by Sydney on 7/13/2002 05:29:00 PM 0 comments


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