Saturday, December 24, 2016

Why You Need Treatment Scores

When you get sick you need a list of all the possible treatments for your disease. You also need the Treatment Score for each treatment. The Treatment Score represents the "net treatment benefit" for the patient as summarized from the existing medical literature.

Why haven't Treatment Scores been done before?
Because a typical diagnosis has 10,000 variables that must be digested to create a list of Treatment Scores. My physician colleagues and I have spent years creating the mathematics and programming to do Treatment Scores.

Why is something so simple so hard?
When you do your taxes you figure out your gross income, then you figure out your net income.

When you get sick you need to know the "gross treatment benefit," and then the "net treatment benefit."

It all sounds simple, but patients have never had this kind of treatment transparency.

Patients desperately need to know the "net treatment benefit" for patients like them who have been previously treated. Once you know the net treatment benefit (the Treatment Score) as your starting point, shared decision-making and personalized medicine can actually happen.

Treatment Scores solve a lot of problems in healthcare!

The way Treatment Scores work is:

  1. You get a diagnosis
  2. You get a list of treatments with Treatment Scores
  3. When you click on the Treatment Score you can see the underlying statistics in the Treatment Score Calculator™
  4. You and your physician can now do shared decision-making, where input from the patient is used to further refine the Treatment Score to do personalized medicine.

Treatment Scores do the following: 

  1. Save time
  2. Save money
  3. Solve the healthcare illiteracy problem
  4. Solve the treatment transparency problem
  5. Allow for true informed consent
  6. Solve the previously unsolvable quality assurance problem
  7. Enable more people to get more healthcare at lower cost

The following entities desperately need Treatment Scores:

  1. physicians
  2. nurses
  3. patients
  4. medical schools
  5. residency programs
  6. medical journals
  7. health insurance companies
  8. governments around the world
  9. all businesses providing healthcare to employees
  10. reporters who report on medical news, whether web-based, television, or radio.

Treatment Scores will disrupt healthcare. They are needed by consumers, businesses, and governments. Throughout history, quantification has disrupted every industry it has touched.

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DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Tuesday, October 25, 2016

If they are doing it in the olympics, should we?

After seeing so many athletes with cupping therapy during the Olympic games, I became curious if this was actually a good therapy for muscular tension.  Of course, I wanted to know the actual Treatment Score and efficacy of cupping on muscular disorders.  I went to PubMed and initially researched cupping therapy, figuring that was too general for what I actually wanted to know.  I was anticipating that I would have to narrow down my search to at least one body part, or one injury type. I was surprised: I found few clinical observations on cupping, and no actual randomized controlled trials. I elected to review the article on cupping in relation to lumbar myofascial pain, as that seemed to be the closest study to what I was interested in.



I went to the Treatment Scores website and put in the information that I had. Unfortunately, the entire article was not available for me to view, so I had limited information to work with. Below are the initial findings I put in the StarBlocks.



The study type only got a quality score of "60", since it was a prospective, controlled study.  The overall quality of the study was given a "B" grade.  However, the actual treatment score for acupuncture with heated lamps, versus acupuncture with cupping, was different. This can be seen in the comparison of the two treatments below.


It does appear that acupuncture can mildly improve symptoms of lumbar back pain.  However, as per above, cupping in addition to acupuncture, actually significantly helps improve back pain more than just acupuncture alone. Those Olympic athletes may actually be on to something!

Source:
[Clinical observation on therapeutic effect of cupping combined with acupuncture stimulation at trigger points for lumbar myofascial pain syndrome].
http://www.ncbi.nlm.nih.gov/pubmed/?term=25219130

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DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Ouch, My Head!

Ever had a headache and medication did not work?  Ever had a migraine headache and thought, "if there was just a quick treatment for this, I'd be good and able to function the rest of the day"?  For the first time in my life, I had a migraine headache.  It was awful:  head pain, unrelentless nausea, and a full work day scheduled.  I had no idea what to do.  I thought, "gee, I wish I had medicine for this, though any medications I'm familiar with have side effects I cannot function with".  So after my headache subsided (days later), I decided to research acute migraine treatments.  I narrowed my search down to ER visits, as that seemed like the best way to actually manage an acute migraine if a person does not already have regular medical care for migraine headaches.

I found a great study comparing natural IV magnesium sulfate to commonly used migraine medications of IV dexamthasone and metoclopramide.  What this studied showed was actually very interesting.  First of all, I found that both treatments worked very well.
























As you can see above, the magnesium worked better at the 2 hour mark than did the combination therapy.  So you already assume that of course you would want the magnesium treatment, and you are right.  What you don't see from this one conclusion, however, is that at the 20 minute mark, magnesium had achieved a 35% reduction in headache pain as compared to the combination therapy, which only achieved a 9.8% reduction in headache pain.  What you also don't see are the side effects each of the therapies had.  You can see that information below:  

These two pictures further illustrate how magnesium has a Treatment Grade of an "A", while the combination therapy has a Treatment Grade of "B".   Magnesium only had a side effect rate of 4% nausea, while the combination medication had a side effect rate of 7% and included other side effects such as vomiting, lethargy and vertigo.  

It is extremely important that we have access to all of this data readily.  Had I known that I could access a single website to find out such information, I would have been able to better understand my treatment options and find adequate treatment sooner. This is not to say that all ERs would have been amenable to my own treatment suggestions, but at least Treatment Scores would have been readily disposable to them as well.  



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DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Tuesday, September 27, 2016

Where Do You Go For Sound Medical Information?

Do you search the internet in earnest to look up medical information?  Do you try to find out the best treatment for your condition, only to come across pages and pages of information that you cannot make sense of?  Or pages of useless or conflicting documents?  Well me too!  And I’m a physician! 

I spend hours and hours trying to research the newest and best treatments for my patients, only to be frustrated with the misinformation out there.  It is trying and tiring sorting out good medical information, from bad.  This is why you need Treatment Scores! 

Treatment Scores aims to acquire the vast amount of medical information there is on the web, in journals, in magazines, etc, whether true or false, and put it into a single place.  One location for all medical claims (disease, diagnoses, and treatments).  How great would that be?  Patients and physicians, alike, will be able to understand true versus false medical information.  Not only will we be able to do that, we will be able to see what the statistics say for one treatment and compare it to other treatments for similar conditions.  

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DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Monday, September 26, 2016

Natural versus Pharmaceutical Treatment for Knee Osteoarthritis

Many physicians and patients, alike, are searching for new and emerging treatments for chronic pain. One of the most debilitating areas of chronic pain can be due to knee arthritis.  Knee arthritis affects one's ability to maneuver throughout society without pain.  Depending on the degree of pain the patient is in, it will affect their ability to maintain function, exercise, and thus affect other areas of health as well.

Due to the fact that we do not know the exact cause of arthritis, it makes it difficult to treat.  We do know that with osteoarthritis, people have degeneration of their protective layers of cartilage in their joints.  Though we do not know how this happens (and just assume that it is predominately due to wear and tear over time), pharmaceutical companies have come up with ways to try to emulate the job of cartilage in the joints.  Of of those medications is called hyaluronic acid (HA).  It has been used for many years.  It works to provide increased joint lubrication, and thus decrease the friction between two bones that may be rubbing together, thereby decreasing pain.  HA is one of the most common treatments for osteoarthritis of the knee. However, it's effects only tend to last about 6 months, and multiple injections are required.

Platelet-rich plasma (PRP) is made from the patient's own blood.  It has healing properties and can be used in a variety of conditions.  It actually serves to stimulated the body's natural ability to regenerate tissues.  It is the hope of physicians presently using PRP and other regenerative forms of medicine, that they can recreate the body's natural ability to heal and grow, without the use of pharmaceuticals.

In the article that I researched, I was able to compare the use of HA, PRP and HA in combination with PRP for knee osteoarthritis.  I regularly perform PRP injections in my clinic.  PRP injections are not covered by insurance, and I wanted to make sure that the added cost of the injection, to the patient, was the best medical treatment I could offer them.  I was actually surprised to find out how effective all 3 treatments are!



Even though the HA treatment group ended up with a Treatment Grade of "D", a 37.5% improvement in physical ability a year after treatment is a good number.  However, it is pretty notable that both PRP groups still had a significantly better score than the HA group alone.

Through Treatment Scores, we can compare different treatments for a variety of diseases in a more organized manner.  In this way, we can place values on treatments.

Our goal is to make the process of treatment scores transparent so that every step can be verified and validated, and that the "rules" can be assessed as well. We are still in the early stages, and do not claim accuracy for our reviews at this time. (See the disclaimers below).

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DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Saturday, September 3, 2016

My Aching Back: Spinal Fusion & Treatment Scores

There is controversy in the medical community about the usefulness of spinal fusion surgery for chronic low back pain. If you’re a patient in an area where there are a lot of spine surgeons, you’re much more likely to get surgery than if you live in area where there are fewer surgeons.  I’ve heard from surgeons about desperate patients who have tried everything else and they do get better with surgery, but there are several reviews out there questioning the efficacy of spinal fusion for treatment of chronic low back pain. It’s time to take a look at some Treatment Scores.

To be clear, we’re talking about patients with chronic low back pain, not patients with acute low back pain, nerve compressions, or spinal stenosis. Our outcome measure will be a decrease in disability, specifically the Oswestry disability index, as this was the outcome used in the studies I found.  We are not using pain since this was not the main outcome in the studies. In most cases, if the disability index decreases so does the pain level.

I found three randomized controlled trials that compared surgical intervention (specifically spinal fusion) to non-surgical intervention. The best study would be a comparison of surgical intervention vs. sham surgery vs. placebo. As we saw from the studies on vertebroplasties, sham surgeries can have a powerful placebo effect.  However, the only studies done were comparing surgical to non-surgical groups. It is difficult to do sham surgeries, although they have been done for some procedures.  Nevertheless, the purpose of Treatment Scores is to figure out what we know and what we don’t know about a particular topic so we’ll proceed on.

In all of the studies, there was a decrease in the Oswestry disability index (ODI) in the non-surgical group and in the surgical group. The decrease was greater in the surgical group in every case.  We’ll use the percent decrease in the ODI in the surgical group minus the percent decrease in the OSI in the non surgical group. The differences in the three studies were 19%, 8%, and 8%. The non-surgical groups were not the same. In one of the studies the patients had physical therapy. In two of the studies the patients had cognitive therapy along with physical therapy. The group that did not have cognitive therapy had the largest difference in the OSI.

It should also be noted that these were intention to treat studies meaning that some of the patients assigned to the non-surgical group ended up having surgery and this was a significant number in some of the studies. For example, in one study 28% of the patients assigned to the non-surgical group did have surgery within two years and 4% assigned to the surgical group did not have surgery.
Another issue that has to be considered is the MCIC or minimal clinically important change.  This is probably around 10 to 15 for the ODI. The differences in these studies are either below or at the border of clinical significance.

Also, there was another study which should be mentioned. It was a cohort study following groups of patients who had fusion vs those who did not. Since it is a cohort study, it cannot rank as high as randomized trials, but it was a well done cohort study. They found that patients who did not have surgery were 40% more likely to return to work than patients who did have surgery.

In this essay, I won’t go into all of the details of how I calculated my Treatment score. As mentioned in other blogs, the Treatment Score is the gross treatment benefit minus side effects plus side benefits. There is subjectivity in coming up with the final Treatment Score due to some of the uncertainties in the studies and side effects that have to be taken into account. (We will decrease subjectivity with mathematics and programming as we move forward). The side effects have to be rescaled, estimated, and subtracted from the gross treatment benefit. One study listed a complication rate of 18%. Others had lower complication rates. Complications included death, wound infections, deep venous thrombosis, pulmonary embolus, tears of the dura, need for re-operation and nerve injury. It does seem apparent, that with the current data, spinal fusion cannot have a high Treatment Score compared to non-surgical groups. My Treatment Score is 6 as shown in the Treatment Score Calculator™ below:


A Treatment Score of 6 has a letter grade of E.

To sum up, here is what we know. There is a decrease in disability with spinal fusion for the treatment of chronic low back pain. However, the Treatment Score is low compared to non-surgical groups. It appears to be lower than the MCIC ( minimal clinically important change). The groups who had cognitive therapy along with physical therapy tended to do better.

Here’s what we don’t know. There is still uncertainty since spinal fusion has never been compared to sham surgery. Some of the patients who were in the non-surgical group did have surgery. We don’t know if this would have changed the outcome more in favor of spinal fusion if they did not cross over.

This is what Treatment Scores is about. We know what we know, what we don’t know and what we need to find out. There is a simple Treatment Score for each treatment that patients and medical professionals can understand. (See the disclaimers below.)

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DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Tuesday, August 30, 2016

What Can Treatment Scores Do For You?

Treatment Scores aims to provide users (both physicians and patients) with the ability to understand optimal medical treatments, without having to decipher the mass amounts of good and bad medical literature that there is out in the huge world of information and studies.  Physicians are under a lot of pressure to keep up with the latest studies in medical information.  They are not given many means to do this easily or in a timely fashion.  There are so many resources (Internet, societies, magazine, journal articles) that publish different studies on similar information. There is no way a single physician can keep up with all of this medical knowledge. This leads to physicians practicing ancient medicine, and also leads to physician burnout when they try to consolidate the most prevalent information for their patients.

From a patient standpoint, they have more access to vast amounts of information on healthcare.  One would think that this would enable them to better assess their own health. However, due to the massive amounts of information on the Internet, this actually, more often than not, leads to inaccurate information and assessment of one's own health issues.

One purpose of Treatment Scores is to compile all of the medical information in journal articles, papers, the internet, etc, and put it in one place. Additionally, we aim to make this information available to everyone, in a way that is easy to understand. This will serve to lessen the burden on physicians to search the world for new studies. This will also allow patients to access one site, to find out what treatments may serve them best for their single condition. That is not to say that patients will be able to treat themselves, but they may be able to do more accurate research on their diagnosed disease. Patients would thus be able to have an educated conversation with their physicians, about their treatment options.

The physicians at Treatment Scores are working to objectively and mathematically compile this information for the public. It will take some time, but it will be done.
(See the disclaimers below).

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DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.


Tuesday, August 23, 2016

Treatment Scores: Social Media Update

We need better treatment transparency. Patients need better treatment transparency! All medical treatments need to be quantified into Treatment Scores. Eventually, Treatment Scores will do three things for patients, physicians, and the healthcare system:

  1. improve patient care 
  2. save time 
  3. save money
You should follow Treatment Scores on social media to support our mission of quantifying all medical treatments in order to provide better treatment transparency (for all patients and doctors around the world).

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Friday, August 12, 2016

Efficacy of Bioidentical Hormone Replacement

I have been questioned by many patients whether hormone replacement therapy is safe or not.  This is a very good question, as I don't personally believe we know the true answer to that question.  Based on the Women's Health Intiative study that came out in 1996, hormone replacement therapy (HRT) is a bad thing.  That study revealed that the combination of Prover and Premarin led to things such as breast cancer, blood clots, and more.  After that time, many women were taken off of their HRT. Well, it is no surprise that women did not like to be off of their HRT, as their menopausal symptoms returned.

Bioidential hormone replacement therapy (BHRT) then came in to play.  BHRT claims to give women chemically identical hormones to the ones that naturally exist in their bodies at younger ages. These hormones are compunded in yams or soy.  The HRT study done in the 90s was based on hormones that were not biochemically identical to our naturally occurring hormones, such as horse estrogens (those found in Premarin).  Many physicians now prescribe BHRT, while other physicians continue to believe that all HRT is bad, no matter where it comes from.

There are not many studies dedicated to BHRT for women.  In fact, most physicians who prescribe BHRT claim that there are no studies with adverse effects of BHRT, and they use this as a reason to prescribe BHRT and label it as "safe"

I elected to find at least one decent study on BHRT to properly assess the actual risk versus benefit of BHRT for women.  I actually only found one study that was adequate to even consider putting it into Treatment Scores.  However, when I began to put this study into the STAR blocks, I immediately realized that this study was going to get an "F" grade.


This study compared topical BHRT to sublingual.  It claimed the "Wilcoxon signed-rank test" as the main statistic to compare menopausal symptom improvement in women.  However, the complete article was not available to read, and the abstract did not even mention results of their main statistic. Additionally, the main outcome that they measured is a way to see if 2 means differ, it does not actually evaluate and measure treatment outcomes! In order for a study to even begin to allow us to evaluate and grade it, it must be looking at treatment outcomes. The treatment outcomes in this study are things like hot flashes, night sweats, irritability, anxiety, fatigue, emotional lability, sleep disturbances, memory loss, fatigue, and libido. What they really needed to do is combine all those symptoms into a questionnaire and develop a symptom score for menopausal symptoms that is on a 100 point scale.

Again, the scientific research and it's availability to the public needs to be altered.  We need clear and concise information as physicians in order to get the best outcomes when treating our patients. Additionally, patients need to have access to the ever changing recommendations of medicine that exists today.  

Sources:
http://www.ncbi.nlm.nih.gov/pubmed/24881343

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DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Monday, July 25, 2016

Acupuncture for Chronic Low Back Pain: Treatment Score = 0

I want all medical treatments (Western, Eastern, herbal, alternative) to work all the time with 100% effectiveness. Who would not want this? That would be a great world! —where everyone got cured all the time. I want acupuncture to work, and to work all the time, for everything it is used for.

Doing science-based medicine is a lot like committing murder. There are these medical studies out there and when you first glance at them you really like them. You want to believe what they say. Then you start doing science. You take an ax and you chop off one leg, then an arm, pretty soon another leg, and then another arm. Pretty soon that study is dead. Often, it’s a very unpleasant death and emotionally unsatisfying. You wanted that treatment to work. You wanted the scientific evidence to be there! You wanted that treatment to be alive and well for the benefit of all humankind.

"Killing Your Babies"
Unbiased, objective, science-based medicine is hard. Evidence-based medicine is hard. You must be prepared to “kill your babies.” This means that you must be able to critique and destroy all those medical studies that you once thought were beautiful and deserving.

I have read many books about writing and several have given the advice that you must, “kill your babies.” To be a good writer, you must be able to take something that you have written, which you love, and delete it, because during the editing process you realize it’s not so good after all. I’m not sure who deserves credit for inventing the phrase, “kill your babies.” (If you know please let me know.)

William Faulkner, allegedly deserves credit for, “In writing, you must kill your darlings.” And, the English writer, Sir Arthur Quiller-Couch, allegedly said in a lecture at Cambridge University, “murder your darlings.”

Stephen King wrote in his book, On Writing: A Memoir of the Craft: “Kill your darlings, kill your darlings, even when it breaks your egocentric little scribbler’s heart, kill your darlings.”

When it comes to science-based medicine you must be able to kill your darlings: studies that look good at first, but do not deliver statistical certainty.

Why the Emotional Digression?
Why do I digress before writing about acupuncture? Because it can be so emotionally unsatisfying to do science-based medicine that much of the world simply ignores science. But you are not alone. Others have had to toughen up before you.

Dr. John PA Ioannides is with You
If you believe in science-based medicine, Dr. John PA Ioannidis is a hero. He
famously wrote, “Why Most Published Research Findings Are False.”
(http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0020124)

More recently he wrote, “Why Most Clinical Research Is Not Useful.”
(http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002049
2016http://dx.doi.org/10.1371/journal.pmed.1002049)

Acupuncture for Chronic Low Back Pain
Because of the emotion sometimes involved, I have given a lot of background explanation before going into the science about why the Treatment Score = 0 for acupuncture for low back pain (at least in this prototype example).

The National Institutes of Health says that: “About 80 percent of adults experience low back pain at some point in their lifetimes.”
(http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm)

If you talk to people, all kinds of treatments for chronic low back pain are bandied about without any “specifications” about how well they actually work. Today it’s different. My physician colleagues and I are on a mission to quantify all medical treatments for all diagnoses. We have invented Treatment Scores (in this form).

First Look
My goal is a simple demonstration of the concept of Treatment Scores, not to create the final product. It will take time to completely develop the Treatment Scores system into everything it needs to be.

What is the Treatment Score for acupuncture for chronic low back pain? By my calculations, the Treatment Score = 0, based on reviewing only one randomized controlled trial as an example, which is why this is a concept essay and not a final product.

The Treatment Score = the net treatment benefit for the patient.

Shared Decision-Making
Do you believe in shared decision-making? Reviewing acupuncture as a treatment for chronic low back pain creates a fantastic example of how shared decision-making should work in the real world. Medicine used to be a dictatorship (paternalistic or maternalistic). The doctor told you “the best thing to do.” With the rise of the Internet, we are starting to have transparency. You now have access to what used to be secret inside information. You and your physician can look at the data together and you, and him or her, can make decisions together. That’s shared decision-making!

The Quality of Studies
A colleague suggested a randomized controlled trial about acupuncture for chronic low back pain to me. I’m grateful, because reading the study has turned into an incredible lesson about the quality of medical studies.

At First Glance
At first glance it looked like an amazing study. It’s a randomized controlled trial! There are 1,549 patients in the acupuncture arm of the study, there are 1544 patients in the control arm of the study. Interestingly, there were 8,537 patients who did not want to be randomized, but did still want to receive acupuncture, and the authors collected data on those patients. That’s an excellent twist to the study.

The study found the “gross treatment benefit” for acupuncture for chronic low back pain at 3 months to be 9.4%.

The Study
This is the study:

"Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain." by Witt CM, Jena S, Selim D, Brinkhaus B, Reinhold T, Wruck K, Liecker B, Linde K, Wegscheider K, and Willich SN.  Am J Epidemiol. 2006 Sep 1;164(5):487-96. Epub 2006 Jun 23.
(http://www.ncbi.nlm.nih.gov/pubmed/16798792)

The full text of this study is available free online:
http://aje.oxfordjournals.org/content/164/5/487.long

The Diagnosis and Personalized Medicine
The diagnosis = chronic low back pain.

But that is not a specific enough diagnosis. Today we want personalized medicine. Therefore, we want to personalize the diagnosis as much as possible to the patient. In this particular situation, I wanted the diagnosis to align exactly with the patients in the study.

The diagnosis = chronic low back pain. However...

The diagnosis = chronic low back pain (in patients with no bulging or herniated discs, no neurologic symptoms, no previous surgery, no infection, no inflammation, no cancer, no autoimmune diseases, and no congenital deformities).

When you eliminate all these things, the diagnosis is basically common chronic low back pain in the typical adult who strained their back.

Follow-Up
The follow-up time period in this study was three months.

Treatment
The patients were treated, on average, with 10 sessions of acupuncture using acupuncture needles. The control group was not treated with acupuncture, but after three months without treatment, they were treated with acupuncture. This was another nice twist to the study.

The Outcome Measure = Main Statistic
The main outcome measure of this study is the Hannover Functional Ability Questionnaire (HFAQ), which is a symptom score to quantify the symptoms of chronic low back pain.

Rating the Study
When doing Treatment Scores, we rate studies on a 100% scale. With 100 being a perfect randomized controlled trial. Normally, randomized controlled trials are rated (in the didecile) between 81 to 100 (Grade A) depending upon how good they are.

Blinding
In a single-blind study, the patients don’t know whether they are receiving the treatment or a placebo. In a double-blind study, the patients don’t know what treatment they are receiving, and the physicians don’t know what treatment they are administering. In a triple blind study, the patients don’t know which treatment they are getting, the physicians don’t know which treatment they are administering, and the people who are doing the medical statistics to report the results for the study don’t know who received the treatment and who received the placebo. Blinding is very important because it removes bias! Without removing bias you cannot get the truth.

Placebo versus Sham
A placebo is a pill that doesn’t work. A placebo pill is also called a “dummy pill.” In the old days, it used to be a sugar pill. Today, a placebo may contain starch or saline, both of which are inactive. When it comes to things like surgery, a placebo is not ideal, because the patient can tell whether they’ve had surgery or not. Therefore, the highest quality randomized controlled trial will use “sham” surgery. An example of “sham surgery” of the knee would be where one group gets put under with anesthesia and then gets the real surgery, but the “sham surgery” group gets put under with anesthesia, but only gets a superficial incision without any actual internal surgery.

An example of “sham acupuncture” would be where one group gets real acupuncture with needles in the traditional acupuncture locations, but where another group gets needles in “sham locations” that have nothing to do with traditional acupuncture.

There is a systematic review of studies that have used sham acupuncture here: (http://www.ncbi.nlm.nih.gov/pubmed/19250001)

With sham acupuncture the needles are inserted in the “wrong points,” that is in locations that are not acupuncture points. With real acupuncture, the needles are inserted into the body in “meridians” as taught by acupuncturists. The meridians are said to correspond to certain areas of the body. You can see an example on YouTube:
https://www.youtube.com/watch?v=CAZ9sL4SMvo

Blinding and Sham Control are Extremely Important!
When I first read the abstract of the study I thought I was going to rate it 82% in quality. However, by the time I was done, I only rated the study 0%. To translate that, instead of rating this study 82 out of 100, or 82% in quality, I rated it 0%.

That’s dismal. The reason the quality rating is so low, is because this study is not blinded or sham controlled. The patients know whether they got acupuncture or not, and they are subject to the placebo effect. They are very likely to report that they received benefit from the treatment when in fact the treatment was no better than placebo.

The gross treatment benefit of 9.4% now has to be modified for lack of certainty. It could all be due to the placebo effect. Mathematically, the gross treatment benefit drops from 9.4% to 0%, because the mathematical certainty of the 9.4% being true is 0%.

All this may seem counter-intuitive. The bottom line is that for a statistic to believable it has to be without bias and without the placebo effect.

So, the gross treatment benefit that I can believe is now 0%. The placebo effect has been proven over and over again in medical studies. It has also been proven to occur with acupuncture.

It’s a shame. The authors spent a lot of time and money doing this study. In many ways, the authors did a nice study. It is randomized; it is controlled. They have a method for handling the patients who refused to be randomized. But by not using blinding and by not doing sham control, they basically turned a randomized controlled trial into a low quality case series study. The gross treatment benefit they published basically cannot be trusted, because it can easily be attributed to the placebo effect.

Emotional Distress
It hurts! I was talking to a physician colleague and we talked about the emotional distress when we review a treatment using science-based medicine and it doesn’t work nearly as well as we had been led to believe. We happened to be talking about amoxicillin for the treatment of otitis media in children. Naturally we wanted amoxicillin to be 100% effective. It’s not nearly that effective. (Stay tuned to this blog for the Treatment Score for that situation later.)

I’m unhappy acupuncture did not do better. I have a physician colleague who very much wants to believe in acupuncture. My preconceived notion was that acupuncture worked, perhaps only mildly, but that it worked. Maybe it does work for other specific diagnoses and based upon other randomized controlled trials. Eventually we will review every diagnosis and treatment using Treatment Scores. Using “big data” techniques and database technology every existing study will be able to be taken into account. This is not the last word on acupuncture, this is a demonstration about Treatment Scores in a specific situation using only one study.

Treatment Scores are still in their infancy and there is more work to do. One of the goals of Treatment Scores is to eventually get all the most objective and highest-quality statistics possible as the starting point.

The Treatment Score Calculator™
If one wanted to get more detailed, the situation may be even worse for acupuncture according to what we know right now from this one study. The Treatment Score may be less than zero. Remember, I started out with a “gross treatment benefit” of 9.4%.


Then when I took the quality of the study into account, the “gross treatment benefit” dropped to 0%, because the study was not blinded or sham controlled.


But the whole purpose of Treatment Scores is to get to the “net treatment benefit.” You can see in the expanded Treatment Score Calculator™ below, that we have a gross treatment benefit of 0%. There were some other potential “positive side benefits” to acupuncture, as there was a 7.9% improvement on the Low Back Pain Rating Scale, and a 1.8% improvement on the Quality of Life Short Form scale.


However, just like 9.4% improvement on the Hanover Functional Ability Questionnaire, those potential benefits also drop to 0%, because of the flaws of the study: no blinding and no sham controls.



That leaves us with only the negative side effects with which to adjust the Treatment Score.



The Net Treatment Benefit
This brings us back to the formula:

The Treatment Score (net treatment benefit) = gross treatment - side effects

When we take the gross treatment benefit of 0 and subtract the negative side effects, we are going to come up with a Treatment Score in the negative range.

It’s hard for people to conceptualize this, because we are dealing with different scales. The main statistic on the left is on one scale, and the secondary statistics on the right are all on an “event rate” scale, and if you look at each statistic individually they are each on their own individual scale.

It’s like gross income and net income. The main statistic on the left is in dollars, and you have to subtract the things on the right which are in different currencies: euros, pounds, francs, and pesos, to come up with the net treatment benefit, which equals the Treatment Score.


When I take the gross treatment score = 0 and subtract the negative side effects of:

54% minor bleeding or hematoma
21% other side effects (not specified)
x% pain caused by getting out and in and out of the car to travel for acupuncture
17% pain from acupuncture needling
0.2% decreased quality of life as measured on the quality of life short form
x% loss of time from undergoing 10 acupuncture sessions
8% suffering negative vegetative symptoms (vegetative functions are things like eating, sleeping, menstruation, bowel function, bladder activity, and sexual performance, that can be made worse by undergoing a painful or emotionally draining treatment)

I can easily justify a Treatment Score of -25%. That’s a negative 25%. For me, the time needed to go to acupuncture treatments is a huge negative. The effort to travel to acupuncture treatments when suffering from low back pain is a huge negative. The 54% incidence of bleeding and hematoma is a serious negative. The 21% incidence of unspecified side effects is a negative. The 17% incidence of pain from the acupuncture treatments is a negative. The 8% incidence of vegetative side effects is a negative.

It’s tricky, because the event rates for the negative side effects on the right have to be converted onto the scale on the left. And those conversions DEPEND ON YOU, THE PATIENT. Eventually, we will show all the math and logic for doing these types of conversions and everything will be transparent. There are things that will help us do such conversions mathematically such as “quality of life studies,” “quality adjusted life-years” and “disability adjusted life-years.”

Shared Decision-Making
The above Treatment Score Calculator™ gives us the ability to do shared decision-making. The patient needs to have input on how much weight to give the side effects on the right side of the Treatment Score Calculator™. For example, one of the negative side effects of acupuncture is the time it takes to undergo 10 sessions. Each session may take two hours between travel time, checking in at the clinic, getting prepared for the acupuncture session, and then undergoing the acupuncture itself. How big of a negative all that time is will vary from patient to patient. However, when you have a Treatment Score Calculator™ like this you can discuss these issues with your physician and do shared decision-making together. This will help you to determine what the Treatment Score is for you, as opposed to somebody telling you what the Treatment Score is for you without knowing your preferences. In other words, you as the patient are now more powerful and can have input into the shared decision-making process. You now have the benefit of treatment transparency.

Caveats
This is only one demonstration example to show the potential of Treatment Scores. This is not the final product of what a Treatment Score will be. In this essay, we only used one randomized controlled study, not the entire body of existing medical literature. This was proof of concept.

Conclusion
We have created a demonstration of how to do a Treatment Score. We have used one randomized controlled study to demonstrate that the Treatment Score for acupuncture for low back pain = 0 or less than zero (if we limit ourselves to the information from this one randomized controlled trial only).

What Needs to Be Done
In the future, we will review the top randomized, sham controlled trials on acupuncture for chronic low back pain. We will see if the Treatment Score moves up or down when other studies are taken into account.

A Study That Needs to Be Done
There needs to be a study that tests if “randomly” sticking acupuncture needles into the human body helps with chronic low back pain. There are theories as to why such needling might work such as:

  • endorphin release
  • the gate theory of pain (stimulating nerves with something different shuts the gate on the stimulation from pain)
  • the triggering of autonomic reflexes
  • triggering the release of neurotransmitters

It’s possible, for example, that physicians without any acupuncture training could place a few acupuncture needles into the lower back of patients with chronic low back pain and achieve all the benefits of the placebo effect, or even do better than the placebo effect. Such treatment might work just as well as acupuncture.

A Final Word
Treatment Scores are in no way against Eastern medical treatments, herbal treatments, or any other form of alternative medical treatment. In fact, we want to report that such treatments work when the science says they work. We already have positive examples. Treatment Scores are for science, they are not for or against any treatment or treatment philosophy.

Treatment Scores are about collecting the hard scientific data and figuring out the net treatment benefit according to the existing medical literature. When we do this, sometimes alternative medical treatments have positive Treatment Scores and sometimes they do not. We will follow the math and science, without bias, wherever they take us, and we will get better at this over time. (See the disclaimers below.)

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http://TreatmentScores.com

DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.

Thursday, July 14, 2016

Why You Need Treatment Scores!

When you do your taxes, you figure out your gross income and net income. Before you undergo a medical treatment, you need to figure out the “gross benefit” and the “net benefit” of that treatment.

Why is this such a big deal? It’s a big deal, because the medical system has never provided Treatment Scores before.

The Treatment Score = the net benefit of the treatment.

Treatment Scores have been a secret, a mystery, unable to be calculated, and have been hidden from you until now (because they are mathematically difficult).

To repeat, the Treatment Score represents the “net treatment benefit for the patient,” which is a long phrase so we simply call it the Treatment Score.

However in the real world:

The Treatment Score = "the net absolute treatment benefit for the patient as determined by the patient during shared decision-making with the physician.”

You can see why we simply call it the Treatment Score!

When you get sick with a disease, you need to review the medical literature for a list of treatments for that disease. In general, the more treatments that exist for a disease, the less effective the treatments are. For example, there are 130 treatments for insomnia, because most of the treatments for insomnia don’t work very well.

There are 57 treatments for an acute migraine headache, because most treatments for an acute migraine headache don’t work very well. There are only a few treatments for stage 1 testicular cancer, because those treatments DO WORK WELL.

When you get diagnosed with any disease, for each and every treatment for that disease, you need to figure out the “gross treatment benefit” for patients that have been treated in the past. Then, you need to figure out the “net treatment benefit” for those same patients, which is the Treatment Score.

Physicians Do Not Know Treatment Scores
You would think that physicians could help you with the "net treatment benefit." They can't. A randomized survey across 8 countries demonstrated that physicians do not understand treatment effects. In that study of 531 physicians, up to 80% of physicians could not correctly identify treatment effects. You have to be your own healthcare advocate. You need to ask, "What is the Treatment Score?" You need to lead the revolution for treatment transparency by asking, "What is the Treatment Score?" to every healthcare non-profit organization and every healthcare provider that you can. Call a disease-related non-profit today and ask them for the Treatment Score (the net treatment benefit) for a treatment listed on their website.
(Source: http://www.cmaj.ca/content/early/2015/10/26/cmaj.150430)

It has always been extremely difficult to produce Treatment Scores. Today, programming makes it possible to create Treatment Scores. Search engine technology makes it possible to find the statistics and database technology makes it possible to organize the statistics. Finally, new statistical methods enable us to calculate Treatment Scores. We have invented the technology you need.

What does all this mean for you? It means for the first time in your life you should ask your physician, “What’s the Treatment Score for that?”

Got breast cancer?
Ask for the Treatment Score for every treatment.

Got prostate cancer?
Ask for the Treatment Score for every treatment.

Got pancreatic cancer?
Ask for the Treatment Score for every treatment.

Got lung cancer?
Ask for the Treatment Score for every treatment.

Call a disease-related non-profit organization and ask:
"What's the Treatment Score for every treatment listed on your website?"

(See the disclaimers below.)

FOLLOW THIS BLOG:
Follow this blog by entering your email address in the box at the top right. You MUST CONFIRM your subscription VIA EMAIL. Then, you will automatically receive all new posts. If you have any problems, search for "feedburner" to make sure the confirmation email did not go into your spam folder.

Follow TREATMENT SCORES on Social Media:
Twitter:
https://Twitter.com/TreatmentScores
Facebook:
https://Facebook.com/TreatmentScores
AngelList:
https://angel.co/treatment-scores
Blog:
http://TreatmentScoresBlog.com
Website:
http://TreatmentScores.com

DISCLAIMERS:
You must consult your own licensed physician, or other licensed medical professional, for diagnosis, treatment, and for the interpretation of all medical statistics including Treatment Scores. Treatment Scores are for educational purposes only. Treatment Scores may be incomplete, inaccurate, harmful, or even cause death if used for treatment instead of consulting a licensed medical professional. No medical advice is being given. We DO NOT CLAIM to cure, treat, or prevent any illness or condition. Nor do our services provide medical advice or constitute a physician patient relationship. Contact a physician or other medical professional if you suspect that you are ill. Call emergency services (call 911 if available) or go to the nearest emergency room if an emergency is suspected. We are not responsible for any delays in care from using our website, our services, or for any other reason. We are not responsible for any consequential damages of any nature whatsoever. We make no warranties of any kind in connection with our writings or the use of TreatmentScoresBlog.com or TreatmentScores.com. Treatment Scores are about what happened to patients studied in the past; they do not predict the future.

COPYRIGHT:
Copyright © 2016 Treatment Scores, Inc.