[HN Gopher] Medical-evidence giant Cochrane battles funding cuts...
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Medical-evidence giant Cochrane battles funding cuts and closures
Author : pcrh
Score : 97 points
Date : 2023-09-04 16:50 UTC (6 hours ago)
(HTM) web link (www.nature.com)
(TXT) w3m dump (www.nature.com)
| bomewish wrote:
| Dark public choice perspective: this is incentive compatible for
| pharmaceutical companies and governments who can now give out
| their guidelines and solutions without as strong scrutiny.
|
| Too cynical??
| patel011393 wrote:
| This may seem like bad news, but as a grad student studying
| evidence synthesis I can say that there is a silver lining here.
| The quality of studies in systematic inputs is low and even
| Cochrane's reviews have been critiqued for missing things. It's a
| big factory that hasn't fundamentally innovated how research is
| synthesized. There are newer forms of synthesis like realist
| reviews, meta-modeling, and model-driven meta-analyses (those are
| just a few examples).
|
| Hopefully this results in some innovation at the conceptual and
| financial levels. For those who lost their income, they have
| transferrable skills that would be welcomed in healthtech
| companies, other governmental groups, and academic positions.
| It's really not as bad as it seems.
| TheBlight wrote:
| I don't remember hearing anything about Cochrane in mainstream
| news until they put out an unfavorable review on the
| effectiveness of mask usage during covid 19.
| ggm wrote:
| A very unfortunate, badly run meta analysis as I understand
| it which fundamentally undermined trust in their governance
| because it was so easily critiqued. I haven't seen a robust
| defence of that one.
| csours wrote:
| My opinion (feel free to have another one) is that it
| points to the need for training and more comfortable masks.
| The studies weren't WRONG per se, but they are very hard to
| interpret.
|
| My whacky opinion: human facing sciences (medicine,
| psychology, diet, sociology, economics, etc.) have a huge
| problem with solutions that require motivation to succeed.
| In other words, if you are motivated, you can make masks
| work. If you are motivated, you can make intermittent
| fasting work. Same for EVs, Solar Panels, etc.
| haldujai wrote:
| > The quality of studies in systematic inputs is low and even
| Cochrane's reviews have been critiqued for missing things.
|
| Criticism is good, expecting perfection is not.
|
| Quality issues are a problem of the underlying research rather
| than the review process. High quality reviews, like Cochrane,
| assess risk of bias which can limit the strength of conclusion
| they make where the underlying studies are poor quality.
|
| > There are newer forms of synthesis like realist reviews,
| meta-modeling, and model-driven meta-analyses (those are just a
| few examples).
|
| All of these answer different questions/have different use
| cases than a SR and are much harder to do while maintaining
| comparable quality and risk of bias.
|
| What's your gripe with high quality SRs following standards
| like PRISMA, STARD and QUADAS-2?
| aaron695 wrote:
| [dead]
| ttpphd wrote:
| Totally agree. Cochrane is a dinosaur and can do more harm than
| good.
| cyrillite wrote:
| This is an insane ask, but I would love to hear more about
| various reviewing and synthesis styles, their strengths and
| weaknesses, which are particularly promising and why, etc.
| you're welcome to link me to material, but I'd also appreciate
| a brief overview.
|
| I have nothing to offer other than thinking that this is a
| super cool area of study and I'd love to hear more
| thedailymail wrote:
| This site provides a concise description of many review
| types: https://guides.mclibrary.duke.edu/sysreview/types
| Traubenfuchs wrote:
| > Cochrane says that the lost NIHR funding -- around PS4.2
| million (US$5.3 million) -- does not affect its core income,
| which was PS8.9 million in 2022. However, a more existential
| threat looms. Around PS6.8 million of that core income came from
| subscriptions to the Cochrane Library, but Cochrane aims to make
| all its reviews open access by 2025
|
| What the actual fuck, those are peanuts for any single country or
| health care system. What a tragedy and a blow to evidence based
| medicine.
| KRAKRISMOTT wrote:
| Any of the top tier Ivies or US research schools could single
| handedly cover the cost.
| jimbob45 wrote:
| _evidence-based_
|
| What's the difference between something being scientific and
| something being evidence-based?
| SamoyedFurFluff wrote:
| Evidence-based is a subset of scientific, imo. A study of
| cells in a Petri dish is science but I wouldn't recommend a
| drug to a person from such a study.
| raincom wrote:
| As I wrote in another reply, evidence based medicine (EBM) =
| population, intervention, comparison and outcome (PICO). In
| other words, PICO = RCT Randomized Control Trials. To me, EBM
| is medical instrumentalism (as instrumentalism is one of
| philosophies of sciences): pick a treatment that works for a
| large number of people, without understanding the underlying
| mechanism. Even today, we use many drugs with unknown
| mechanisms of action (MOA).
| haldujai wrote:
| I would add that EBM took over because science-based
| medicine (at least the historical definition, how it's used
| now is more of a hybrid) didn't work out too well. Often
| the mechanism thought to be understood is incorrect or more
| complicated and the outcomes don't correlate well with
| what's expected, sometimes resulting in significant harm.
|
| Fundamentally, the mechanism of why a medical intervention
| works isn't that important if you're thoroughly evaluating
| outcome measures and controlling confounders.
| haldujai wrote:
| A simple example is (using the traditional understanding of
| these differences):
|
| Science-based: Cholesterol levels are associated with major
| adverse cardiovascular events (MACE), statins lower
| cholesterol levels and therefore statin therapy is
| recommended to reduce MACE.
|
| Evidence-based: A [specifically defined population] was given
| statin therapy or placebo. We observed lower MACE in the
| statin group, therefore statin therapy is recommended in
| [specifically defined population] to reduce MACE.
| coding123 wrote:
| > Cholesterol levels are associated with major adverse
| cardiovascular events
|
| > statins lower cholesterol levels and therefore
|
| You lost me here - because the science based one is just
| stating unproven statements to come to some conclusion. If
| you were to expand on why those two sentences are "proven"
| you'd likely come to evidence based reasons.
| haldujai wrote:
| > You lost me here - because the science based one is
| just stating unproven statements to come to some
| conclusion. If you were to expand on why those two
| sentences are "proven" you'd likely come to evidence
| based reasons.
|
| I'm not sure I'm exactly understanding what you're
| getting at. If you expand on those statements to find
| direct evidence of MACE (of which there is plenty) then
| it is an evidence based medicine decision not a science
| based one.
|
| Please disregard the specific intervention being
| discussed, it's just an example of the different thought
| processes and decision making between SBM and EBM. In
| real life there is plenty of science and evidence behind
| statins but I'm not intending on addressing reality or
| why this specific intervention is in use today.
|
| Note the "medicine" part in these refers to the clinical
| practice of medicine. Maybe this is clearer:
|
| The science based medicine approach (as traditionally
| defined) only considers the mechanisms and "indirect
| evidence" when making the clinical recommendation (i.e.
| statins are proven to lower cholesterol which are
| strongly correlated with MACE. Cholesterol reduction has
| also been proven to reduce plaque formation and artery
| stenosis, therefore we expect MACE will be reduced
| through statin use and are deciding to administer the
| intervention).
|
| In this thought process we have not directly measured the
| outcome of interest (MACE) but we are giving an
| intervention because it makes sense/through chain of
| thought, or in other words we are intervening to optimize
| a variable (serum cholesterol levels) because we have
| reason to believe this variable reduces MACE based on the
| mechanism (which may have components proven by evidence
| like reduction in plaque formation but the primary
| outcome measure we are discussing, MACE, has not been
| measured).
|
| In the evidence based medicine approach we are deciding
| to provide an intervention based on direct measurements
| of the outcome of interest in a specific population (i.e.
| less MACE was directly proven) and the decision making
| process is entirely independent of the mechanism or
| nature of the intervention (i.e. we are not considering
| plaque formation and cholesterol levels, simply that
| statins reduce MACE).
| chaxor wrote:
| Much of the scientific literature in biology is working
| off of hypotheses that don't have a huge amount of
| evidence. There are a large number of studies that
| present a molecular mechanism which, if studied in depth,
| will not always be consistent with what is presented in
| the literature. This is often dealt with by appending
| several conditions that must be met, such that the
| combinatorial space grows large enough and the _only_
| study that is done that meets the requirements is the one
| being presented. In this way, almost anything can be
| stated to fit some shiny new hypothesis.
|
| This is effectively the science based method, since it
| can be tracked to a, perhaps, 'plausible' mechanism
| (although often now lean towards more 'intriguing' than
| parsimonious, especially if published somewhere like
| Nature)
|
| Evidence based medicine has other faults. One subfield is
| meta-analysis, which looks for _very solid_ observations
| that are reproducible, but often lacks the complicated
| modeling that may be necessary to see any highly
| conditional effects. So the findings tend to be real, but
| boring and often "well-known". It is however, a good way
| to check if the "well-known" observations in the
| literature are reproducible.
| haldujai wrote:
| You're (correctly) addressing some of the issues in
| biomedical research but even the most rigorous and
| validated science does not necessarily translate into
| clinical outcomes for a laundry list of reasons.
|
| Evidence based medicine includes lab/animal studies (i.e.
| scientific literature in biology) but when we talk about
| EBM what we really mean is "outcomes based medicine"
| rather than relying on the science.
|
| EBM reduces the question to "Does intervention X change
| clinical outcome Y in population Z" to obviate many (but
| not all) of the clinical translation issues.
| cscurmudgeon wrote:
| A lot of folks are now angry that Cochrane went slightly
| against masks. There is a religious war unfortunately.
|
| There is even one comment here along that line.
|
| https://www.forbes.com/sites/brucelee/2023/03/11/cochrane-sa...
| ggm wrote:
| As I've said above it was subject to pretty hefty critique
| and I've never seen a robust defence. They meta combined
| papers which were not well grounded and it was unlike its RCT
| normal approach.
| [deleted]
| spamizbad wrote:
| The US or EU should pick up the tab. The UK is not really a
| wealthy country anymore and things critical to STEM should
| slowly be transferred out as it doesn't have the economic power
| to sustain them any longer.
| flextheruler wrote:
| Isn't the UK in the top 6 or 5 economies in the world? Are
| you saying that there are only 5 wealthy countries in
| existence? I mean the UK definitely has problems but it's a
| bit hysterical to say they're not wealthy.
| MithrilTuxedo wrote:
| >evidence based medicine
|
| They do mention that Cochrane is only accounting for 7% of
| systematic reviews these days.
|
| BTW, evidence-based medicine is not the same as science-based
| medicine. The Placebo Effect is evidence-based medicine.
| lostlogin wrote:
| Only 7%?!
| pcrh wrote:
| It's a bit more important than that number suggests. For one,
| 7% of global systematic reviews is not a trivial proportion.
|
| But more importantly Cochrane allows for the pre-registration
| of such reviews, i.e. where the methodology and goals
| (hypotheses) are stated before the review is conducted. This
| is probably the most scientifically rigorous method of
| assessing evidence, and is not performed for most systematic
| reviews.
| MostlyStable wrote:
| I'm not sure what you are trying to say. Are you implying
| that the placebo effect is magic, or in some other way non-
| scientific?
| raincom wrote:
| Evidence based medicine (EBM) = population, intervention,
| comparison and outcome (PICO). In other words, PICO = RCT
| Randomized Control Trials. To me, EBM is medical
| instrumentalism (instrumentalism is one of philosophies of
| sciences): pick a treatment that works, without
| understanding the underlying mechanism. Even today, we use
| many drugs with unknown mechanisms of action[0].
|
| Often times, you can find cures just by discovering
| mechanism of action, without PICO/RCT: for example,
| _Helicobacter pylori_ causing peptic ulcers.
|
| Placebo effect is NOT magic, but we don't understand the
| mechanism. Good relationship between doctors and patients
| help recover patients. Patients prefer to see particular
| doctors, even if the latter prescribe same medications as
| others, yet the differential effects on patients (when
| treated by preferred doctors vs others) is non-trivial.
|
| [0] https://en.wikipedia.org/wiki/Category:Drugs_with_unkno
| wn_me...
| Spooky23 wrote:
| As a comparison, New York Presbyterian hospital in NYC
| probably spent at least twice that deficit to put their logo
| on New York Mets jerseys.
|
| I'm not what 7% of reviews represents, but it seems like
| particularly dumb austerity measure.
| psychphysic wrote:
| Given in the UK doctors have taken a real terms paycut circa of
| over 25% [0] the UK is not currently fit to fund anything.
|
| [0] https://www.bma.org.uk/media/6882/bma-ia-juniors-fact-
| sheet-...
| fnordpiglet wrote:
| Except this sort of funding has multiplicative effects.
| Funding for a single doctor helps only that doctor and their
| patients. Funding for this sort of work helps all doctors and
| all patients. When austerity cannibalizes your force
| multiplying efforts, that's truly the end.
|
| Edit:
|
| For context the thing you linked says UK medical residents
| (in US language) make $36k/year, and the median household
| income is also $36k/y[0] .
|
| In the US the average non specialist income is $60k[1], and
| the median household income is $69k[2]
|
| This tells me things aren't out of whack.
|
| They also say 40% of residents in the UK want a different
| job. But residencies are temporary. In a few years they will
| have a new job - a full doctor.
|
| I'm not saying there's not a crisis, but that sheet doesn't
| explain to me what the crisis actually is. They seem to be
| doing on par with US residents.
|
| 0 https://www.ons.gov.uk/peoplepopulationandcommunity/persona
| l...
|
| 1 https://mededits.com/residency-admissions/residency-salary/
|
| 2 https://www.deptofnumbers.com/income/us/
| psychphysic wrote:
| What's the difference in pay between a "full doctor" as you
| put it consultant (UK) or attending (US)?
|
| UK a consultant earns PS100k pretax and pays approximately
| 30% net tax rate and 60% marginal rate.
|
| What about US?
|
| Apparently family medicine in the US brings in 130% more
| than the equivalent in the UK (GP which makes up half of
| all UK doctors).
|
| https://revisingrubies.com/us-vs-uk-doctors-salary/
|
| That's truly astounding.
| cabalamat wrote:
| > UK a consultant earns PS100k pretax and pays
| approximately 30% net tax rate and 60% marginal rate.
|
| According to https://www.moneysavingexpert.com/tax-
| calculator/ , someone in the UK who earns PS100k takes
| home PS67,049:
|
| >Earn PS100,000 in 2023/24 and you'll take home PS67,049.
| This means PS5,587 in your pocket a month. Over the year
| you'll pay PS27,432 income tax and PS5,519 in national
| insurance.
| robertlagrant wrote:
| Consultants also get a guaranteed pension funded by the
| net-contributing taxpayers.
| kwhitefoot wrote:
| The highest marginal tax rate in the UK is 45% [1] and
| you only pay that on income above 125 140 GBP.
|
| Where did your 60% come from?
|
| [1] https://www.gov.uk/income-tax-rates
| skissane wrote:
| > UK a consultant earns PS100k pretax
|
| While it depends on the specialty, in Australia it is not
| uncommon for consultants to be on AUD 300-400K (=
| 150-200K GBP, 200-250K USD). I don't understand why
| salaries in the UK are so low, even for highly educated
| professionals.
|
| My grandfather was a GP. He hated the NHS so much, he
| left the UK and never went back. Pay was likely a factor,
| but he also viewed the NHS as a denial of his
| professional freedom. While Australia eventually adopted
| something akin to the NHS (Medicare), I don't think he
| objected so much to that, since it involved less
| government control over the _how_ of his job.
| fnordpiglet wrote:
| https://www.salary.com/research/salary/benchmark/physicia
| n-i...
|
| $230k, which when indexed by median household income, is
| comparable to the UK at 100k (I assume you used dollars?
| If not that's $126k).
|
| Edit: I'm not making any tax statements because taxes are
| unavoidable and applied to everyone in the nation, so are
| part of the indexing. That said US taxes sound comparable
| or more in some areas (taxes in NYC for instance can
| exceed 50%)
| SoftTalker wrote:
| > taxes in NYC for instance can exceed 50%
|
| Is that a marginal rate or total tax burden?
| fnordpiglet wrote:
| Total, it's a combination of federal, state, and city
| income tax plus social security etc.
| fnordpiglet wrote:
| However the median household income is half the US. You
| can't compare nominal values.
| skissane wrote:
| My brother has lived in all three of the US, UK and
| Australia, doing non-professional jobs (construction,
| agriculture, gardening, cellar hand in the wine
| industry).
|
| He didn't last long in London - he was working as an
| unskilled labourer in the construction industry, the pay
| was terrible, and the basic necessities of life were so
| expensive, he could hardly afford to eat. He'd worked
| similar jobs in Australia and got paid a lot more, and
| found life more bearable.
|
| Some countries pay high because everything is expensive.
| Some countries pay low because everything is cheap. The
| UK seems to be a place where people get paid low because
| everything is expensive.
| fnordpiglet wrote:
| Absolutely true. But saying UK doctors are underpaid
| because they're paid half of a US doctor while ignoring
| everyone is paid half of a US person for everything is
| disingenuous. Everyone in the UK is inexplicably
| underpaid, and everything is expensive.
|
| What was your brothers take on the US?
| skissane wrote:
| > What was your brothers take on the US?
|
| He lived in a small town in Oregon with his first wife.
| While they weren't paid a lot, life wasn't expensive
| either. I think he would have stayed except the marriage
| didn't work out. Obviously that isn't an entirely fair
| comparison to London, but I still think the pay-to-
| expenses ratio would be more favourable in small-town US
| than small-town UK
| pcrh wrote:
| OECD numbers show that UK medical pay is internationally
| competitive when compared to average national income.
|
| Summary: https://i.imgur.com/DGT0d0d.png
|
| From: https://www.oecd.org/health/recent-trends-in-
| international-m...
| [deleted]
| msie wrote:
| [flagged]
| gruez wrote:
| >misleading review on mask effectiveness (with Tom Jefferson)?
|
| Can you provide more context for this? What was the study? Why
| was it misleading?
| trust_bt_verify wrote:
| As the sibling in the thread detailed:
| https://www.factcheck.org/2023/03/scicheck-what-the-
| cochrane...
|
| The misleading part was done by Tom during an interview with
| a major media organization with a similar established
| narrative.
| pcrh wrote:
| To be honest, that "factcheck" demonstrates the value of
| performing well-constructed systematic reviews, i.e. a
| clear and unbiased assessment of what the pertinent studies
| do and do not support.
| [deleted]
| scrollop wrote:
| [flagged]
| danpalmer wrote:
| Please don't just copy/paste LLM responses.
| dent9876543 wrote:
| > Therefore, the review does not imply that masks do not work
| [...]
|
| Actually, for all intents and purposes, it does imply exactly
| that.
|
| The RCTs involved sufficiently large sample sizes that they
| are representative of real-world outcomes. As such, masks, as
| we have generally deployed them, simply do not offer
| significant control over the trajectory of C-19-like
| infection at the population level.
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