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Discussion in 'Pain Medicine' started by Tenesma, Aug 25, 2015.
SIS has a publication pending for LESI.
I eagerly await the day when that guy has an acute, florid radic. Then I would sell my soul to be the one with the authority to say, sorry pal, you can't have an injection. Here is your prescription for Motrin 800mg and physical therapy three times a week for six weeks. Buh Bye.
Why is anyone giving this guy the time of day? He is an internist. Does he even have true pain training? Why doesn't he study something like spinal fusion, which is horribly expensive and shows almost equal results as epidurals, PT and psych counseling combined?
I wish more people would listen to Deyo about spine surgery outcomes.
do you remember when he presented 3-4 years ago at one of our meetings - cna't remember if it was ASIPP or ISIS - still think he was pretty brave for doing that. Although his logic was flawed at multiple steps of his presentation.
He is not a pain doc - but has found a niche where he looks at the literature, writes reviews of the data (with his twist) and resells this to work. comp, to occ health - he is getting paid to do this....
How hard would it be to start preaching to internists how their patients keep dying of heart disease, hypertension, diabetes and from eating themselves to death, from all the futile attempts they make to prevent such outcomes?
As if all the crap they're doing is curing a damn thing. After all, they take a diabetes pill and guess what? It wears off and they need to take another. Is that reason to stop prescribing them?
The internists can see all the chronic pain patients and fix them, with all those great treatments internists have to cure these patients unlike ours.
This is a joke.
"...benefits (of ESI) were small and not sustained, and there was no effect on long-term surgery risk" could be rewritten as:
"...benefits (of surgery) were small and not sustained, and there was no effect on long-term ESI risk".
In his world, spine surgery seems to be above questioning.
Here is how it works : research changes policy, policy changes payment, payment changes practice.
I honestly feel that this is can be used as an advantage for pain management. Who amongst us really feel that epidurals provide long term benefit(over 3 months)? He is noting that there is short term benefit...
What we need is a comparison of the risks/costs/benefits of intermittent ESI over a 3 month and 10 year course vs initiation of COT and SSD.
That's called "Garbage-In/Garbage Out" (GIGO) research.
"But advances in spine surgery have made it easier than ever to treat pinched nerves caused by herniated discs, Chou added. These days it’s performed as a day procedure, and requires only a small incision.
“People recover quickly, and it usually works pretty well,” he said. “Most people, if they are told about the expected benefits of corticosteroid shots compared with surgery, I believe would choose not to receive the injections.”
He needs to spend a day in my office to see how well it usually works.
Multi-society letter already done and sent to Berliner.
I don't think a SISy can help. Integrated health systems are chasing bundled and capitated payments.
Payment drives research, payment changes policy. Research changes nothing.
Henceforth, perpetually, and for all time, that shall be known as the Lobel Axiom...
I like Lobel Doctrine....
In anycase its up to cms to decide what to do with this data. Medicare determines policy, payment, and practice....
I wonder why anyone would think that ESI provides long term benefit. Obviously the body creates a condition and steroid - however it does it - temporarily changes this condition that causes pain relief. Sometimes the condition returns, sometimes it doesn't.
What is strange is that someone like Chou would want to publish an article that says "Hey guys, epidurally placed steroid isn't permanent!"
If I give someone a pill of gabapentin, it lasts 4 hours. An ESI lasts 3-12 months.
Based on what i just looked up, about 10 days of gabapentin costs ~$50. So 30 days is ~$150.
What are the side effects of an ESI? what about gabapentin?
What is the cost of physical therapy?
I think Roger is looking at the cost of the service, the total # performed, and the paltry ROI.
It's hard to argue with his analysis from my experience.
Several fixes: change criteria in selection of studies reviewed. He used only RCT. He had all comers lumped in with back or leg pain, no specific dx. The upcoming SIS review adresses all of this.
Change the procedure: mandate no series of 3, flhoro and contrast only. Send pictures and not note for payment. No ESI unless concordant imaging, history, exam. Back pain gets no esi. Stenosis with claudication and acute/subacute radic are only right answers.
Is it? Compare it to a months supply of low dose narcotic - 4 to 6 a day - with the previously mentioned very poor return to work data when back pain patients use COT.
By that cost analysis, opioids run roughly $250 for one month supply. That's $750/3 month, combined with low rate of RTW. Vs $600-1200/3 month depending on the ESI...
Btw I was not able to read the full article. Was there analysis for quality of life markers? Functioning he mentions shows short term improvement. Are we getting that from COT?
Nothing has good ROI in what we do. MAYBE rfa
Outcome measures: Pain, Function, and subsequent surgery.
You are presenting a false dicotomy: ESI or COT.
"Whether our judgments are motivated by fatigue, hunger, institutional norms, the diagnosis of the last patient we saw, or a memory of a patient who died, we are all biased in countless subtle ways. Teasing out the relative effects of any of these other biases is nearly impossible. You can’t exactly randomly assign some physicians to being motivated by the pursuit of tenure, others by ideology, others by the possibility of future stock returns, and others by just wanting to be really good doctors. The difficulty of measuring these other motivations, however, creates the problem that plagues many quality-improvement efforts: we go after only what we can count. It is easy to count the dollars industry pays doctors, but this ease of measurement obscures two key questions: Does the money introduce a bias that undermines scientific integrity? And by focusing on these pecuniary biases, are we overlooking others that are equally powerful?"
I wonder what kind of biases are contained in these kind of meta-analyses?
Chou's statement on spine surgery proves he is either disingenuous, a moron, or a disingenuous moron. Now that we know spinal fusion results in subsequent disc degeneration at adjacent level and with all the data showing the results of fusion in spinal stenosis, lumbar DDD, etc without instability are marginal at best; it's shocking that he said what was quoted above. He must not know the difference between a microdiscectomy and a multilevel fusion, or the true indications for these procedures. Maybe someone should point out the success of fusions in workers comp patients.
No I'm not. Part 1 of EBM is of course whether an intervention is clinically effective. Chou is stating that there is short term benefit.
The next phase is to compare this therapy with existing or alternative therapies to determine clinical risk/benefit.
If Chou is going to propose that ESI is ineffective long term, then someone else less short sighted needs to postulate what should be done for these patients.
No epidurals... Then what? The easy answer is PT/CBT. People wont - in our society - buy that. So COT rears its ugly head... Is that better than ESI?
I would prefer Medicare and insurance stop paying for esis so I can bill cash for them.
Large ACO's, academic health centers, and integrated health centers are under pressure to reduce "revenue leak" from bundled and capitated payment. Keeping surgeons busy in the OR is good for business and provides the internal grant money to offset productivity losses from reduced clinical work--as long as the message is congruent with the larger needs of the organization.
And in a similar vein: Guys & gals that do too many ESIs are upset that Roger is calling them out.
I wonder what the data are on the NNT or the NNH for ESI's? I wonder if that data are deduced, imputed, or politically determined...
Here's the way it works : Payment drives research, payment changes policy. Research changes nothing.
man you lost me with this one...
Seriously? How can you say this when currently fusion rates are at historical highs and most surgeries cost between 75,000 and 150K. Not including loss of work time, cost of post op care/PT. and for what? To have a second or third operation in 5 years? You could do ESIs q4 weeks for 20 years and not reach the level of waste of a typical spinal fusion patient.
http://www.improvingmedicalstatistics.com/Meta Beware gifts.htm
"Human nature dictates that each of us tends to find it more satisfying to confirm a previously held opinion, particularly a published opinion, rather than create an analysis that refutes our own prior conclusions. Hence, interpretive bias is even more likely to occur when a meta-analysis is conducted by an author with a strong particular viewpoint in an area of controversy. When the meta-analysis is conducted by a strong advocate of a particular position, it is more likely to be biased in concordance with the author's previously advocated opinion."
No one should defend GIGO science...especially if a meta-analytician's primary source of income is soft-money from grants...
And spend a day treating failed back surgery syndrome from all these so-called "day surgeries" requiring "only a small incision" and then be aquatinted with the fusion-industrial-complex and how curative it is. Talk about detached from reality.
Also, because some negligent hacks are doing 25 esi's per year in patients and need to lose their licenses, doesn't mean we need to get coverage for esi's denied by every insurance company, and denied for every patient in the land because of it. Yes, reign in the abusers. But what the hell is wrong with doing a procedure that works, that authors admit works, for short term relief, which the authors admit they provide, when they have a spike in pain a few times a year?
In fact, there's everything RIGHT with it.
Chou (and by extension Paul) are being intentionally disingenuous. One of Chou's co-author have already demonstrated that esi's are not effective for spinal stenosis. To then include that group in this study sets it up for failure. But when your underlying agenda is to show esi's are ineffective? It makes perfect sense.
Bad science, but great headlines.
Also, while I realize the details aren't important when u already have ur mind made up, several of the studies used in the meta-analysis include blind epidurals.
Science is never agenda-driven. To me, it seems like the authors started with the notion that "too many epidurals are given". His analysis doesn't refute, but also don't justify his conclusion.
Everyone expects academic "freedom" to be balanced by academic responsibility--or, at the very least, intellectual honesty. Still, Deans, Department Chairs and politically appointed policymakers need faculty to stick with a particular message for institutional purposes. Meta-analysis is a tempting way to build a career and get promoted: No messy IRB's, no human subject committee, no lengthy follow-up, etc. In fact, no real scientific expertise in a subject matter required. The typical reader of the medical literature is blind to these dynamics, blind to the politics of policy, and blind to the publish or perish realities of an academic career. Some people walk away from it all with disgust. Others "adapt" to survive and take their marching orders.
It's interesting in Europe , where epidurals are not paid by the single payer system due to limited data, but the commercial supplementary plans cover this benefit no problem. Irrespective of which country you reside, money and higher end plans will always offer better access to care, independent of the literature... Sad state of affairs. The NIH tried to limit mammography, prostate screening, Pap smear screening, all for cost savings no other reason( ie reduce breast biopsies, turp, cervical biopsies)... That hasn't sat well
I try to tell all my residents and anyone that will listen that meta-analysis is about the most sneaky lie possible.
In fact, I have mentioned that on here and people have criticized me - somehow believing that meta-analysis is the highest quality of evidence - when in fact that isn't true at all. The highest quality as deemed by many societies is "Multiple, large, high quality, randomized controlled trials" which is a world apart from a meta-anlaysis - which tries to take data from all the RCT's and combine them somehow.
Why anyone ever even started doing meta-analysis is beyond me.
I agree. Especially, considering there's a huge amount of non-published research, negative studies that don't show the predetermined and desired results the investigators were trying show, that is never published, therefore never shows up in meta-analyses and severely skews these compiled results.
a meta analysis is the perfect way for a pseudo scientist to get published using a statistics grad student to compile research done by others...
i have seen some professors climb their way to the top of academia on the backs of primarily meta-analysis studies --- they never broke a sweat...
bunch of clowns.
As my mentor, a leading public health critic of meta-analysis misuse and abuse, "meta-analysis is like crack cocaine for uninspired academics."
Who is the quote from. Post his name, let's see if he'll stand by it pubically.
I have no doubt that Gil will set *ANYONE* straight on what meta-analysis can and can't do. Stand-up guy; a scholar and a gentleman...
Just to be clear, you are defending meta-analysis as a high quality evidence based medicine technique?
No. Paul has become a nihilist. He is defending the proposition that nothing works. Lousy methodology? No problem. Dare to oppose his position? You are an evil human being, and your views should be discounted as a result.
Chou's science is indefensible. Paul likes the conclusion, as it confirms his overarching principle. When confronted with a factually superior argument he will attack the people opposing him personally.
No one should put a political agenda ahead of bonafide science. When GIGO science simply becomes a rhetorical weapon for the advancement of a bad public policies, it's patients who lose. All evidence-based practitioners should stand against methodological misuse of meta-analysis and ridicule its proponents. Get involved, and stay involved, in CAC's, licensing boards, etc. You won't grab the headlines, but you'll help make a difference in the personalized care of patients.
i did an epidural today. think it worked. im gonna publish that.