Re: Too Much Medicare "Care" Again

In article <roWOh.132411$_73.1457@xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx>,
George Conklin <georgeconklin1@xxxxxxxxxxxxx> wrote:

"Herman Rubin" <hrubin@xxxxxxxxxxxxxxxxxxxx> wrote in message
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In article <dDtOh.17453$tD2.3607@xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx>,
George Conklin <georgeconklin1@xxxxxxxxxxxxx> wrote:

"Skeptic" <bcs002b@xxxxxxxxx> wrote in message
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"George Conklin" <georgeconklin1@xxxxxxxxxxxxx> wrote in message
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"Skeptic" <bcs002b@xxxxxxxxx> wrote in message
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"George Conklin" <georgeconklin1@xxxxxxxxxxxxx> wrote in message
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"George Conklin" <georgeconklin1@xxxxxxxxxxxxx> wrote in message
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................


And one other study has been
going on for nearly 10 years now and has not published. If there
were
even
a 1% advantage to surgery, it would have been stopped and the results
published.

That is very incorrect. To stop the study early a very large and
obvious
advantage would have to have been seen.

Suppose you had 2000 in each group; you may think that
this is a large number but I do not. Then using the
usual significance tests, it would take roughly a 3%
difference to have an even chance of being detected.


Correct. So any advantage is very, very small. When you have to have
a
committee to decide what people really died of, by a vote, you sure do
have
a lot of politics involved.

Not necessarily. If the difference was between 20% and
23%, the size is almost the same. For the difference
between 10% and 12%, it is almost the same. And you
would have only a 50% chance of catching the difference.

It is to avoid issues of judgment like this that
experiments have to be blinded. If each committee
does not know which treatment is used, and judges
the same number from each treatment, the politics
you question does not particularly affect the
comparison. Otherwise, the results can change.

The vote changed on one or two cases and there
goes your "advantage."

But how do you decide the cause of death? Especially
in situations like this, the only answer is "medical
judgment".

The rate of autopsy has shrunk to nearly nothing these days. Yet about
half of all death certificates are questioned on autopsy.

Even with an autopsy, which normally finds about 10
internal medicine diseases, the cause of death can be
difficult to determine. Is there only ONE cause of
death? Maybe the weakening by something else caused
that cause; which is the real cause of death?


It is horrible how bad such research really is, and
the medical/industrial complex should be ashamed of itself for pushing
billions for treatments based on a few dozen cases. Bad research may be
what you are used to, but it is still an international scandal. Surgery
should be held to the same tests as drugs are. Unfortunately it is
income
first and results? That is left to your personal opinions. Shame.

You are assuming that income is the only reason for surgery.
You do not believe "Skeptic" when he tells you that prostate
surgery pays him less than other treatments.

I have argued for less stringent regulation of drugs with
more information available. The balance between the benefits
and risks associated with a drug should be based on the
intelligent decision of the patient with the doctor helping
the patient understand the probabilities of all risks and
benefits, including which are not overly serious for that
patient. My balance of these is not that of the FDA.

You seem to believe that we can get the answers quickly.

Well, Herman, we have waited 100 + years now for some kind of evaluation.
Is that not long enough for you to wait? What about 200 more years?

What drugs do we have which have been used for 100+ years?
I can name some, and all of these are off patent. This
means that anyone can make and market them, with the only
testing being that they meet the standards of purity and
accuracy of dosage. This would even apply to drugs which
are 30 years old.

As for statistical methods, it was only a little more than
70 years ago that the probability of detecting a difference
was even brought up for consideration. I was a pioneer in
simultaneous methods more than 60 years ago, and one of the
developers of decision theory in the next decade. But few
medical people have made use of those.

Unfortunately, we have to go largely on statistical studies;
they can be carried out much better than they are now, but
nothing like what you think is possible. Sometimes there
are obvious differences, but not always; the HRT you criticize
did have obvious advantages; that it had disadvantages was
much harder to find out.

Not true. They did not look for the problems.

They did not look "hard enough"; also, it took long
enough for the problems to develop. For low frequency
events, it is the numbers of events in the treatment
and control group which are the effective sizes, not
how many subjects there are.

Also, one cannot make an explicit search for all side
effects, and relying on those reported is dangerous.

--
This address is for information only. I do not claim that these views
are those of the Statistics Department or of Purdue University.
Herman Rubin, Department of Statistics, Purdue University
hrubin@xxxxxxxxxxxxxxx Phone: (765)494-6054 FAX: (765)494-0558
.

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