- Email: [email protected]
Evidence-based obstetrics and gynecology: still a marathon to run
Letters to the Editors
www.AJOG.org
REPLY We agree with Volny and Powers that, given our finding that physician recommendations of contraceptive methods vary by patients’ race/ethnicity and socioeconomic status, it is important to consider how these differences may impact women’s contraceptive use. We have limited understanding of how contraceptive counseling affects contraceptive use generally,1 and even less understanding of the effect of counseling on disparities in contraceptive use. Further research is needed to determine how clinician behaviors influence women’s use of contraception. As Volny and Powers state, this effort is of particular value for low income and minority populations, in whom there is a disproportionately high rate of unintended pregnancy.2 In considering the role of contraceptive counseling and interventions to improve counseling, it is important for clinicians and public health advocates to not solely focus on the efficacy of contraceptive methods. The choice of a method is a singularly personal decision, and multiple factors influence the appropriateness of a specific method for each individual woman, including mode of administration, side effect profile, and previous experience with contraceptives. As women’s continuation of a contraceptive method is strongly influenced by whether she receives her preferred method,3 achieving the Healthy People 2020 goal of decreasing the high rate of unintended pregnancy in the United States will be facilitated by family planning providers assisting patients to select the method most acceptable to the patients, rather than placing an inordinate emphasis on the efficacy of a specific method, such as intrauterine contraception, at preventing pregnancy. This respect for patient preference and autonomy is likely of particular importance for populations that have been previously impacted by discriminatory and coercive family planning programs.4
Overall, as Volny and Powers point out, our findings that clinician recommendations for intrauterine contraception are influenced by the clinician’s perceptions of a patient’s race/ ethnicity and socioeconomic status indicate the need for selfexamination by family planning providers. Being aware of the potential for our subconscious biases to impact the care we provide is a powerful first step in combating the effect of such biases.5 f Christine Dehlendorf, MD University of California-San Francisco Family and Community Medicine 995 Potrero Ave. Ward 83 San Francisco, CA 94110 [email protected] REFERENCES 1. Moos MK, Bartholomew NE, Lohr KN. Counseling in the clinical setting to prevent unintended pregnancy: an evidence-based research agenda. Contraception 2003;67:115-32. 2. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006; 38:90-6. 3. Pariani S, Heer DM, Van Arsdol MD Jr. Does choice make a difference to contraceptive use? evidence from east Java. Stud Fam Plann 1991; 22:384-90. 4. Stern AM. Sterilized in the name of public health: race, immigration, and reproductive control in modern California. Am J Public Health 2005; 95:1128-38. 5. Wegener DT, Dunn M, Tokusato D. The flexible correction model: phenomenology and the use of naive theories in avoiding or removing bias. In: Moskowitz G, ed. Cognitive social psychology: the Princeton symposium on the legacy and future of social cognition. Mahwah, NJ: Lawrence Erlbaum; 2001:277-90. © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.01.017
Evidence-based obstetrics and gynecology: still a marathon to run TO THE EDITORS: We read with great interest the article by Brandt et al on the 100 most frequently cited papers in obstetrics and gynecology journals during the last 50 years.1 Surprisingly, only 7 RCTs were included, whereas the rational increase in influential RCTs percentage after 1980 was rather disappointing. As the authors admit, the exclusion of articles published in general medicine and surgery journals may have underestimated the reported impact of obstetrics and gynecology related RCTs. Moreover, the poor quality of the reporting RCTs conducted before mid 1990s may have undermined their use as references.2 However, these findings should launch an indepth debate: are we still in lack of high-quality evidence driving the fundamental aspects of our clinical practice? Apart from ethical issues– occasionally, one major problem of RCTs, especially in perinatal medicine, hides in the recruitment of the targeted sample size, resulting in either underpow-
ered or time-consuming and costly studies. Barriers pertaining to the patient, the health provider, the institution involved, and the study design usually take the blame for that.3 In contrast, as Vintzileos heretically states “in obstetrics, the best evidence should not be restricted to RCTs, because it could be found in real-life observational studies”; based on specific examples, his personal perspective emphasizes the problem and merits special consideration.2 Evidence-based medicine incorporates the physician’s experience, the current best of knowledge and the needs of an individual patient.2,4 Until robust evidence fails to prove the improvement of patient care because of the RCTs conclusionsguided clinical practice, if ever, RCTs should be considered as the best tool to judge the effectiveness of a medical intervention.4 In this context, obstetrics and gynecology leaders should leave no stone unturned in their effort to promote RCTs imJULY 2011 American Journal of Obstetrics & Gynecology
e21
Letters to the Editors plementation. Assessing different/suitable recruitment strategies may optimize the patients’ enrollment.3 The worldwide introduction–and function– of “the basic principles of research methodology” even in medical students’ curriculum may help them better evaluate the scientific value of published articles and cautiously choose those they should rely on in the future. Finally, changing the journals policy regarding the references of each submitted paper might be an additional option: why should the authors prefer citing exclusively an observational study when an RCT with inherently better level of evidence on the same topic exists? It is probably time to offer further acknowledgement to research pioneers and a strong f incentive to all others. Vasileios D. Sioulas, MD, PhD 1 Rimini St. GR-12462, Haidari Athens, Greece [email protected] Charalampos S. Siristatidis, MD, PhD Dimitrios P. Kassanos, MD, PhD Third Department of Obstetrics and Gynecology University of Athens Attikon Hospital Haidari, Athens, Greece REFERENCES 1. Brandt JS, Downing AC, Howard DL, Kofinas JD, Chasen ST. Citation classics in obstetrics and gynecology: the 100 most frequently cited journal articles in the last 50 years. Am J Obstet Gynecol 2010;203:355.e1-7. 2. Vintzileos AM. Evidence-based compared with reality-based medicine in obstetrics. Obstet Gynecol 2009;113:1335-40. 3. Tooher RL, Middleton PF, Crowther CA. A thematic analysis of factors influencing recruitment to maternal and perinatal trials. BMC Pregnancy Childbirth 2008;8:36. 4. Scott JR. Evidence-based medicine under attack. Obstet Gynecol 2009;113:1202-3. © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.01.018
REPLY We welcome the interest and comments by Dr Sioulas et al1 concerning our recent publication. Dr Sioulas et al1 pose several questions about the quality of contemporary research in obstetrics and gynecology. In our paper, we characterized the 100 most frequently cited papers in obstetrics and gynecology journals during the last 50
e22
American Journal of Obstetrics & Gynecology JULY 2011
www.AJOG.org years.2 We demonstrated that the proportion of randomized controlled trials (RCTs) published before and after 1980 was similar. We restricted our review to journals of obstetrics and gynecology, excluding general medicine journals such as the New England Journal of Medicine. We acknowledge in our discussion that the exclusion of these journals may have “underestimated the reported impact of obstetrics and gynecology related RCTs.” Nevertheless, Dr Sioulas et al1 pose an important question about the quality of evidence that informs the clinical decision making of obstetrician-gynecologists. They ask: “are we still in lack of high quality evidence driving the fundamental aspects of our clinical practice?” Studies that have recently evaluated the quality of clinical trials in obstetrics and gynecology would suggest that post-1990s RCTs are better than earlier trials, but that there is still room for improvement. The recent update of CONSORT guidelines, which were revised this year, demonstrates that there still remains a long way to go.3 We agree with Dr Sioulas that RCTs remain the best tool to judge the effectiveness of medical interventions and to inform (and not replace) common sense and sound clinical judgment. We are happy that our paper may draw some attention to these issues. f Justin S. Brandt, MD Department of Obstetrics and Gynecology New York Presbyterian Hospital–Weill Cornell Medical Center New York, NY 10021 [email protected] Stephen T. Chasen, MD Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology New York Presbyterian Hospital–Weill Cornell Medical Center New York, NY 10021 REFERENCES 1. Sioulas VD, Siristatidis CS, Kassanos D. Evidence-based obstetrics and gynecology: still a marathon to run. Am J Obstet Gynecol 2011: 204:eX. 2. Brandt JS, Downing AC, Howard DL, Kofinas JD, Chasen ST. Citation classics in obstetrics and gynecology: the 100 most frequently cited journal articles in the last 50 years. Am J Obstet Gynecol 2010:203:355.e1-7. 3. Grimes DA. The CONSORT guidelines: sound advice, spotting compliance. Obstet Gynecol 2010;115:892-3. © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.01.019
www.AJOG.org
REPLY We agree with Volny and Powers that, given our finding that physician recommendations of contraceptive methods vary by patients’ race/ethnicity and socioeconomic status, it is important to consider how these differences may impact women’s contraceptive use. We have limited understanding of how contraceptive counseling affects contraceptive use generally,1 and even less understanding of the effect of counseling on disparities in contraceptive use. Further research is needed to determine how clinician behaviors influence women’s use of contraception. As Volny and Powers state, this effort is of particular value for low income and minority populations, in whom there is a disproportionately high rate of unintended pregnancy.2 In considering the role of contraceptive counseling and interventions to improve counseling, it is important for clinicians and public health advocates to not solely focus on the efficacy of contraceptive methods. The choice of a method is a singularly personal decision, and multiple factors influence the appropriateness of a specific method for each individual woman, including mode of administration, side effect profile, and previous experience with contraceptives. As women’s continuation of a contraceptive method is strongly influenced by whether she receives her preferred method,3 achieving the Healthy People 2020 goal of decreasing the high rate of unintended pregnancy in the United States will be facilitated by family planning providers assisting patients to select the method most acceptable to the patients, rather than placing an inordinate emphasis on the efficacy of a specific method, such as intrauterine contraception, at preventing pregnancy. This respect for patient preference and autonomy is likely of particular importance for populations that have been previously impacted by discriminatory and coercive family planning programs.4
Overall, as Volny and Powers point out, our findings that clinician recommendations for intrauterine contraception are influenced by the clinician’s perceptions of a patient’s race/ ethnicity and socioeconomic status indicate the need for selfexamination by family planning providers. Being aware of the potential for our subconscious biases to impact the care we provide is a powerful first step in combating the effect of such biases.5 f Christine Dehlendorf, MD University of California-San Francisco Family and Community Medicine 995 Potrero Ave. Ward 83 San Francisco, CA 94110 [email protected] REFERENCES 1. Moos MK, Bartholomew NE, Lohr KN. Counseling in the clinical setting to prevent unintended pregnancy: an evidence-based research agenda. Contraception 2003;67:115-32. 2. Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health 2006; 38:90-6. 3. Pariani S, Heer DM, Van Arsdol MD Jr. Does choice make a difference to contraceptive use? evidence from east Java. Stud Fam Plann 1991; 22:384-90. 4. Stern AM. Sterilized in the name of public health: race, immigration, and reproductive control in modern California. Am J Public Health 2005; 95:1128-38. 5. Wegener DT, Dunn M, Tokusato D. The flexible correction model: phenomenology and the use of naive theories in avoiding or removing bias. In: Moskowitz G, ed. Cognitive social psychology: the Princeton symposium on the legacy and future of social cognition. Mahwah, NJ: Lawrence Erlbaum; 2001:277-90. © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.01.017
Evidence-based obstetrics and gynecology: still a marathon to run TO THE EDITORS: We read with great interest the article by Brandt et al on the 100 most frequently cited papers in obstetrics and gynecology journals during the last 50 years.1 Surprisingly, only 7 RCTs were included, whereas the rational increase in influential RCTs percentage after 1980 was rather disappointing. As the authors admit, the exclusion of articles published in general medicine and surgery journals may have underestimated the reported impact of obstetrics and gynecology related RCTs. Moreover, the poor quality of the reporting RCTs conducted before mid 1990s may have undermined their use as references.2 However, these findings should launch an indepth debate: are we still in lack of high-quality evidence driving the fundamental aspects of our clinical practice? Apart from ethical issues– occasionally, one major problem of RCTs, especially in perinatal medicine, hides in the recruitment of the targeted sample size, resulting in either underpow-
ered or time-consuming and costly studies. Barriers pertaining to the patient, the health provider, the institution involved, and the study design usually take the blame for that.3 In contrast, as Vintzileos heretically states “in obstetrics, the best evidence should not be restricted to RCTs, because it could be found in real-life observational studies”; based on specific examples, his personal perspective emphasizes the problem and merits special consideration.2 Evidence-based medicine incorporates the physician’s experience, the current best of knowledge and the needs of an individual patient.2,4 Until robust evidence fails to prove the improvement of patient care because of the RCTs conclusionsguided clinical practice, if ever, RCTs should be considered as the best tool to judge the effectiveness of a medical intervention.4 In this context, obstetrics and gynecology leaders should leave no stone unturned in their effort to promote RCTs imJULY 2011 American Journal of Obstetrics & Gynecology
e21
Letters to the Editors plementation. Assessing different/suitable recruitment strategies may optimize the patients’ enrollment.3 The worldwide introduction–and function– of “the basic principles of research methodology” even in medical students’ curriculum may help them better evaluate the scientific value of published articles and cautiously choose those they should rely on in the future. Finally, changing the journals policy regarding the references of each submitted paper might be an additional option: why should the authors prefer citing exclusively an observational study when an RCT with inherently better level of evidence on the same topic exists? It is probably time to offer further acknowledgement to research pioneers and a strong f incentive to all others. Vasileios D. Sioulas, MD, PhD 1 Rimini St. GR-12462, Haidari Athens, Greece [email protected] Charalampos S. Siristatidis, MD, PhD Dimitrios P. Kassanos, MD, PhD Third Department of Obstetrics and Gynecology University of Athens Attikon Hospital Haidari, Athens, Greece REFERENCES 1. Brandt JS, Downing AC, Howard DL, Kofinas JD, Chasen ST. Citation classics in obstetrics and gynecology: the 100 most frequently cited journal articles in the last 50 years. Am J Obstet Gynecol 2010;203:355.e1-7. 2. Vintzileos AM. Evidence-based compared with reality-based medicine in obstetrics. Obstet Gynecol 2009;113:1335-40. 3. Tooher RL, Middleton PF, Crowther CA. A thematic analysis of factors influencing recruitment to maternal and perinatal trials. BMC Pregnancy Childbirth 2008;8:36. 4. Scott JR. Evidence-based medicine under attack. Obstet Gynecol 2009;113:1202-3. © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.01.018
REPLY We welcome the interest and comments by Dr Sioulas et al1 concerning our recent publication. Dr Sioulas et al1 pose several questions about the quality of contemporary research in obstetrics and gynecology. In our paper, we characterized the 100 most frequently cited papers in obstetrics and gynecology journals during the last 50
e22
American Journal of Obstetrics & Gynecology JULY 2011
www.AJOG.org years.2 We demonstrated that the proportion of randomized controlled trials (RCTs) published before and after 1980 was similar. We restricted our review to journals of obstetrics and gynecology, excluding general medicine journals such as the New England Journal of Medicine. We acknowledge in our discussion that the exclusion of these journals may have “underestimated the reported impact of obstetrics and gynecology related RCTs.” Nevertheless, Dr Sioulas et al1 pose an important question about the quality of evidence that informs the clinical decision making of obstetrician-gynecologists. They ask: “are we still in lack of high quality evidence driving the fundamental aspects of our clinical practice?” Studies that have recently evaluated the quality of clinical trials in obstetrics and gynecology would suggest that post-1990s RCTs are better than earlier trials, but that there is still room for improvement. The recent update of CONSORT guidelines, which were revised this year, demonstrates that there still remains a long way to go.3 We agree with Dr Sioulas that RCTs remain the best tool to judge the effectiveness of medical interventions and to inform (and not replace) common sense and sound clinical judgment. We are happy that our paper may draw some attention to these issues. f Justin S. Brandt, MD Department of Obstetrics and Gynecology New York Presbyterian Hospital–Weill Cornell Medical Center New York, NY 10021 [email protected] Stephen T. Chasen, MD Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology New York Presbyterian Hospital–Weill Cornell Medical Center New York, NY 10021 REFERENCES 1. Sioulas VD, Siristatidis CS, Kassanos D. Evidence-based obstetrics and gynecology: still a marathon to run. Am J Obstet Gynecol 2011: 204:eX. 2. Brandt JS, Downing AC, Howard DL, Kofinas JD, Chasen ST. Citation classics in obstetrics and gynecology: the 100 most frequently cited journal articles in the last 50 years. Am J Obstet Gynecol 2010:203:355.e1-7. 3. Grimes DA. The CONSORT guidelines: sound advice, spotting compliance. Obstet Gynecol 2010;115:892-3. © 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2011.01.019