Statistics and Evaluating the Elderly for Surgery
2015; Elsevier BV; Volume: 37; Issue: 12 Linguagem: Inglês
10.1016/j.clinthera.2015.11.005
ISSN1879-114X
Autores Tópico(s)Meta-analysis and systematic reviews
Resumo“He uses statistics as a drunken man uses lampposts—for support rather than illumination.” —Andrew Lang, 1844–19121Andrew Lang. https://en.wikiquote.org/wiki/Andrew_Lang. Accessed November 3, 2015.Google Scholar, 2Andrew Lang. https://en.wikipedia.org/wiki/Andrew_Lang. Accessed November 3, 2015.Google Scholar In the early years on my pathway to becoming a clinician/scientist, I did a brief stint as a laboratory assistant to a postdoctoral fellow. My assignment was to carry out an experiment in rats in which there were two conditions and two likely outcomes. I was then to apply a χ2 analysis and report the results to the postdoc. The results were just shy of statistical significance. The postdoc then told me to add data from a few more animals. The additional findings fell into the “right” boxes, and the overall results were now statistically significant. I asked myself then, and I ask you now, the reader: Was this the correct or appropriate thing to do? At that time, I knew very little about statistics. I knew about parametric and nonparametric approaches to data analysis, but I knew very little about preplanned sample sizes or power calculations. Since those early years, my knowledge of statistics has increased. It was not surprising, then, that I was disquieted to find a statistical flaw in an article published in 1974 in The New England Journal of Medicine3Coulehan J.L. Reisinger K.S. Rogers K.D. et al.Vitamin C prophylaxis in a boarding school.N Engl J Med. 1974; 290: 6-10Crossref PubMed Scopus (71) Google Scholar on vitamin C prophylaxis for colds that was intended to support claims from the late Linus Pauling. I then submitted a letter to the editor after consulting with two statistician–colleagues; we were surprised when it was politely turned down for publication. We expanded it into an article and published it that same year in another journal,4Shader R.I. Harmatz J. LaBrie R. Vitamin C prophylaxis and some problems of statistical inference.Curr Ther Res. 1974; 16: 655-658PubMed Google Scholar clearly showing that the article did not support the role of vitamin C in the prevention of colds. Over the next several decades, the claim that taking vitamin C can prevent colds has not been confirmed.5Vitamin C and the Common Cold. https://en.wikipedia.org/wiki/Vitamin_C_and_the_common_cold. Accessed November 4, 2015.Google Scholar My concern about the poor use of statistics has led me to contribute two additional papers6Shader R.I. A blueberry cocktail helps with memory loss: too good to be true?.J Clin Psychopharmacol. 2014; 34: 421-422Crossref PubMed Scopus (1) Google Scholar, 7Salzman C. Shader R.I. Benzodiazepine use and risk for Alzheimer disease.J Clin Psychopharmacol. 2015; 35: 1-3Crossref PubMed Scopus (15) Google Scholar both are now used in a few statistics classes. We make concerted efforts to hold authors who submit articles to Clinical Therapeutics to acceptable statistical standards. Following this Editor-in-Chief’s Note is a commentary from our Consulting Statistical Editor, Dr. Janet Forrester.8Forrester J. Putting meaning back into the mean: a comment on the misuse of elementary statistics in a sample of manuscripts submitted to Clinical Therapeutics.Clin Ther. 2015; 37: 2873-2877Abstract Full Text Full Text PDF Scopus (1) Google Scholar She has prepared an informative review covering the common statistical flaws in articles submitted to Clinical Therapeutics. My final point on this topic is that, in my role as Editor-in-Chief of the Journal of Clinical Psychopharmacology, I asked Dr. David L. Streiner (Professor at the Department of Psychiatry at the University of Toronto) to write an extended series of articles discussing, in very understandable language, the statistical concepts central to interpreting the findings from clinical trials. Adaptive randomization, number needed to treat, sample size and power calculations, and noninferiority trials are some examples of what he covers.9Streiner D.L. Commentary #1. Adaptive randomization.J Clin Psychopharmacol. 2014; 34: 7-8Crossref PubMed Scopus (4) Google Scholar, 10Streiner D.L. Commentary #4. Relative risk and the number needed to treat.J Clin Psychopharmacol. 2014; 34: 549-551Crossref PubMed Scopus (5) Google Scholar, 11Streiner D.L. Commentary #9. Sample size made easy (power a bit less so).J Clin Psychopharmacol. 2015; 15: 364-366Google Scholar, 12Streiner D.L. Commentary #2. Non-inferiority trials.J Clin Psychopharmacol. 2014; 34: 184-186Crossref PubMed Scopus (4) Google Scholar I recommend the series to any who want to rethink their understanding of applied statistics. Also in this issue, Dr. Kenneth Boockvar, our Topic Editor for Geriatric Therapeutics, has assembled a collection of articles under the heading “Anesthesia and Perioperative Care in Older Adults.” In his own commentary, he annotates each of them.13Boockvar K. Preserving cognition and attaining ideal surgical outcomes in older adults.Clin Ther. 2015; 37: 2631-2633Abstract Full Text Full Text PDF Scopus (1) Google Scholar Being an octogenarian who recently had a successful hip replacement, I was especially interested in this topic. Before my surgery, the anesthesia group’s representative asked me what type of anesthesia I wanted. I was shocked by the request, and said, “I want whatever my doctor feels most comfortable with.” I was asked the question again, and it finally dawned on me that this question was a part of the “patient-as-partner” approach that is gaining ground in American medicine. I was given three choices. I chose the mildest anesthesia, knowing that I do not have an easy time when I awaken from anesthetic gases. I preferred not to undergo a spinal, as the idea of hearing the bone saw was an unpleasant one. In my confusion, I forgot that I would probably still be getting something like midazolam. I wondered how many nonphysician patients would know that. I am delighted that Dr. Boockvar has decided to add information on this subject. Finally, before my surgery, I was interested in what is known (in addition to the obvious issues of anesthesia and infection) about the risks of surgery in older people. I came across several articles dealing with the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and a scale developed for assessing the risks for adverse events that may occur within 30 days of surgery, the ACS NSQIP risk calculator (RC).14Turrentine F.E. Wang H. Simpson V.B. et al.Surgical risk factors, morbidity, and mortality in elderly patients.J Am Coll Surg. 2006; 203: 865-877Abstract Full Text Full Text PDF PubMed Scopus (686) Google Scholar, 15Bilimoria K.Y. Yaoming L. Paruch J.L. et al.Development and evaluation of the Universal ACS NSQIP Surgical Risk Calculator: A decision aid and informed consent tool for patients and surgeons.J Am Coll Surg. 2013; 217 (e3): 833-842Abstract Full Text Full Text PDF PubMed Scopus (1080) Google Scholar This web-based scale was created using data collected from almost 400 hospitals. It is composed of 21 preoperative factors. Covering specific procedures and patients׳ characteristics (eg, age and comorbidities), the RC maps on to eight outcomes that include specific complications and range from any complication to death. Unfortunately, the RC is not good at predicting the occurrence of complications one month after hip arthroplasty.16Edelstein A.I. Kwasny M.J. Suleiman L.I. et al.Can the American College of Surgeons Risk Calculator predict 30-day complications after knee and hip arthroplasty?.J Arthroplasty. 2015; 30: 5-10Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar Fortunately for me, I have had no complications. Given the present emphasis on risk assessment and comparative effectiveness, this scale and others will likely be improved. Geriatric Therapeutics Specialty UpdatesGeriatric Therapeutics Specialty Updates are published annually and are available as FREE ACCESS content on the journal’s website. The previous Geriatric Therapeutics Update, entitled “Mental Health in Older Adults With Coexisting Medical and Mental Health Problems” was published in Volume 36, Number 11 of Clinical Therapeutics. To view the previous Update, see the articles below:1.Mattappalil, A and Mergenhagen, KA. Neurotoxicity with Antimicrobials in the Elderly: A Review.2.Zahradnik, EK and Grossman H. Palliative Care as a Primary Therapeutic Approach in Advanced Dementia: A Narrative Review.3.Peterson, JC et al. Depression, Coronary Artery Disease, and Physical Activity: How Much Exercise Is Enough?4.Reinhardt, JP et al. Addressing Depression in a Long-term Care Setting: A Phase II Pilot of Problem-solving Treatment.5.Linnebur, SA et al. Patient-level Medication Regimen Complexity in Older Adults With Depression.6.Garrido, MM et al. Benzodiazepine and Sedative-hypnotic Use Among Older Seriously Ill Veterans: Choosing Wisely?7.Redding, SE et al. Opioid Interruptions, Pain, and Withdrawal Symptoms in Nursing Home Residents. Geriatric Therapeutics Specialty Updates are published annually and are available as FREE ACCESS content on the journal’s website. The previous Geriatric Therapeutics Update, entitled “Mental Health in Older Adults With Coexisting Medical and Mental Health Problems” was published in Volume 36, Number 11 of Clinical Therapeutics. To view the previous Update, see the articles below:1.Mattappalil, A and Mergenhagen, KA. Neurotoxicity with Antimicrobials in the Elderly: A Review.2.Zahradnik, EK and Grossman H. Palliative Care as a Primary Therapeutic Approach in Advanced Dementia: A Narrative Review.3.Peterson, JC et al. Depression, Coronary Artery Disease, and Physical Activity: How Much Exercise Is Enough?4.Reinhardt, JP et al. Addressing Depression in a Long-term Care Setting: A Phase II Pilot of Problem-solving Treatment.5.Linnebur, SA et al. Patient-level Medication Regimen Complexity in Older Adults With Depression.6.Garrido, MM et al. Benzodiazepine and Sedative-hypnotic Use Among Older Seriously Ill Veterans: Choosing Wisely?7.Redding, SE et al. Opioid Interruptions, Pain, and Withdrawal Symptoms in Nursing Home Residents.
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