Panelists gathered in a session at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) to help find ways to contribute to the evidence and sift through it to find quality. “It’s difficult to keep up; it’s hard to know what to trust,” said Kara Davis, MD, at the University of Pittsburgh. For instance, publications of human papillomavirus-related studies in head and neck cancer have increased from about 125 in 1985 to more than 400 in 2014, she said.
Private Practitioners Must Publish, Too
Sujana Chandrasekhar, MD, director of New York Otology and president of the AAO-HNS, said that it might seem too difficult, or even unnecessary, to contribute to the literature if you’re in private practice. But that’s where the greatest need for good data lies, she said, because more than half of patients get their care from private practice, compared to just 27% at academic centers.
It’s vital for the literature to include data from the “people who are in the trenches and are actually seeing large numbers of patients,” Dr. Chandrasekhar said. “We see the more common things in private practice, and the common things are what we need information about.”
Dr. Chandrasekhar has actually produced more research in private practice—22 publications over 10 years—than she did in academia—11 over nine years. “I think there is much more time in private practice to publish than you might think is available,” she said, adding that one advantage is that there isn’t nearly as much demand to attend time-consuming meetings.
She acknowledged that time, energy, inexperience, independent review boards, and less support from statisticians and librarians can be hurdles. But resources such as the CHEER Network, designed to help otolaryngologists clear common research hurdles, can help. Working on clinical practice guideline committees and collaborating with nearby academic centers can also help, she said.
Short on Time? Read a Summary
Martin Burton, DM, director of the UK Cochrane Center, said that when you are trying to determine whether reading a paper is worth the time, you should ask yourself three questions.
Can you believe the study you’re looking at? “It’s about asking yourself, How well is this study being done?” Dr. Burton said.
What are the results? Dr. Burton suggested looking at the effect size to determine how confident you can be about the results.
Will these results help me in my practice? “Only you know the answer to that question,” Dr. Burton said.
He continued, “You also need to know something about the harms and the costs of the treatment that’s being evaluated in the paper. Sometimes you get that from the paper, and sometimes you have to dig a little deeper.”
Dr. Burton gave one answer to those questions: systematic reviews. These are studies that use “a particular disciplined, transparent, scientific process for locating, appraising, and synthesizing the evidence.”
He added, “You might go to systematic reviews at the top of the evidence tree if you’re short of time.”
Don’t Be Afraid to Tromp Over to the Library
Robert Ferris, MD, PhD, chief of head and neck surgery at the University of Pittsburgh, cautioned that, when you are reading the literature, it’s important to do so skeptically and to keep up with the issues even after they seem to have been fairly settled.
If you don’t keep up, you do so at your own peril, he said. In 2003, a study in the New England Journal of Medicine seemed to establish that concurrent radiation therapy and chemotherapy were best in laryngeal cancer, but what was missed at the time was that the endpoint of the study—laryngeal preservation—was not the most important endpoint; rather, laryngectomy-free survival was. When the same authors reexamined the data 10 years later, looking at the more appropriate endpoint, they determined that radiation therapy before chemotherapy actually produced better results.
“You had to monitor that data were shifting,” Dr. Ferris said. “The field had already switched. We were treating people with one regimen, and this got reversed and a different conclusion arose. And I think it’s important for people to realize that that occasionally happens.”
He suggested that physicians read and know the data, be critical, and talk to colleagues and hear presentations on how others apply the data and the results. “With PubMed, it’s almost too easy,” he said. “You can just look at the abstract and move on. In the old days, we had to tromp over to the library and get the whole paper. So go to the methods, look at the data, look at the figures.”
Guidelines for Guidance
Richard Rosenfeld, MD, MPH, former chair of the AAO-HNS Guideline Development Task Force and chair of otolaryngology at SUNY Downstate Medical Center in Brooklyn, N.Y., said that he needs to look no further than his own practice to know that these guidelines—recommendations meant to optimize patient care resulting from systematic reviews of the evidence—can change care.
He said he used to give peri-operative antibiotics as a matter of course for tonsillectomy but no longer does so after his participation in reviewing evidence and issuing guidelines that recommend against doing so unless there are overriding reasons for antibiotics. “They don’t make a significant difference,” he said. “That, I thought, was an insight that was very helpful to me in practice.”
Another guideline involved pain control after tonsillectomy. The rule of thumb was that using nonsteroidal antiinflammatory drugs was too risky. After a review, the clinical practice guideline suggested using NSAIDS, Dr. Rosenfeld said.
Another found almost no value in home sleep studies for children, which he used to rely on.
Dr. Rosenfeld said, “I thought I was really practicing great medicine, and I learned very quickly in this guideline that only overnight sleep studies are truly accurate.”
He also said he’s learned—and implemented—the concept of using water to dissolve earwax and discovered that adenoidectomy doesn’t have an effect on otitis media with effusion for patients younger than four years old. “So I’d encourage you to look at the guidelines,” he said, adding, with some understatement, “Occasionally, there’s some useful information in there.”
Thomas Collins is a freelance medical writer based in Florida.