Another Example of Medicine Getting It Wrong with Deadly Effects — Contrary to Previously Accepted Medical Practice, Young African-American Patients Do Significantly Worse than Whites on Kidney Dialysis — the Power of Asking the Right Questions

10 August 2011

I’m repeatedly struck by the unscientific nature of most medical thinking and practice — and how physicians’ status-derived authority can lead to undesirable medical outcomes

I have addressed the avoidable and unavoidable limitations of medical knowledge before.

I do so again, after undergoing a medical review in which I found myself arguing against an accepted protocol on scientific grounds — even though the medical practice guideline was fully supported by my highly intelligent and competent physician.

The discussion that he and I had, and my self-questioning afterward, reminded me just how disadvantaged patients are, when they lack scientific or medical training.

If I doubted my analysis — even after this physician volunteered that I knew more about the science and statistics underlying the protocol than he did — what chance do less knowledgeable patients have in confidently charting their medical courses?

For most of us, I think, it is overwhelmingly tempting to go with what white-coated authority tells us to do — even when we know that the scientific basis for their diagnosis/treatment is questionable, lacking, or contraindicated.

In such stressful circumstances is helpful to remind ourselves how often established medicine gets diagnosis and treatment wrong. Often in a profoundly harmful ways.

For example, a new study demonstrates that that accepted medical practice has the facts backwards in regard to recommending kidney dialysis for below age-50 African-Americans

Johns Hopkins Medicine reported today that accepted kidney dialysis advice for young African-Americans has been badly wrong:

For years, medical studies have reached the same conclusion: African-American patients do better on kidney dialysis than their white counterparts.

But new Johns Hopkins research, published in the Journal of the American Medical Association, shows that younger blacks — those under the age of 50 — actually do much worse on dialysis than equally sick whites who undergo the same blood-filtering process.

The findings — called “surprising” by the research team — could have a serious impact on long-held practices guiding who gets referred for lifesaving kidney transplantation and who remains on dialysis indefinitely.

Previous research on this issue, according to the Hopkins team, has been based on analysis of racial differences in dialysis outcomes for all patients with end-stage kidney disease, a majority of whom are over the age of 50.

Specifically, results of the new study of 1.3 million patients with end-stage kidney disease, led by Dorry L. Segev, M.D., Ph.D., an associate professor of surgery at the Johns Hopkins University School of Medicine, show that black patients between the ages of 18 and 30 are twice as likely to die on dialysis than their white counterparts; and those ages 31 to 40 are 1.5 times as likely to die.

A not so small “oops”

Dr. Segev made the obvious inferences. Physicians have been counseling their black patients incorrectly in regard to the risks of dialysis. And they have been referring black patients for transplants less often than almost certainly warranted:

“This new study shows that, actually, young blacks have a substantially higher risk of dying on dialysis, and we should instead be counseling them based on this surprising new evidence.”

In patients ages 18 to 30, the study found that 55 percent of white patients got new kidneys during the study period of 1995 to 2009, while only 32 percent of comparable black patients got transplants.

Meanwhile, 28 percent of young black patients died on dialysis during the study period and only 14 percent of white patients died.

Segev thought it possible that some of the medical outcome disparity in outcome could be attributed to lower socioeconomic status. Many young African-Americans have less generous (or no) medical insurance.

And part of the higher death rate might also be due to the higher prevalence of hypertension (high blood pressure) among African-Americans.

Citation

Lauren M. Kucirka, Morgan E. Grams, Justin Lessler, Erin Carlyle Hall, Nathan James, Allan B. Massie, Robert A. Montgomery, and Dorry L. Segev, Association of Race and Age With Survival Among Patients Undergoing Dialysis, Journal of the American Medical Association [JAMA] 306(6): 620-626 (10 August 2011)

This study is probably reasonably accurate

It involved observing a cohort of 1,330,007 end-stage renal disease patients in the U.S. Renal Data System from 01 January 1995 to 28 September 2009.

There is statistical power in a sample that size, over that duration — even with all the problems that observational cohort studies bring with them.

The hidden lesson — When research gets it wrong, small sample size, bad methodology, bias, and inadequate statistical analysis are often the culprits

Who knows what mysteries lurk inside agglomerated data that researchers have made no methodological or statistical effort to detect.

A medical study that makes (or attempts to make) little or no comparison between age groups is questionable. One that treats varying genetic heritages (and the two sexes) as “likes” is misguided.

Segev’s numerically impressive dialysis cohort dialysis study uncovered nuances apparently hidden in earlier work.

From its abstract, and in more detail than the Johns Hopkins overview:

Similar to previous studies, black patients undergoing dialysis had a lower death rate compared with white patients (232 361 deaths [57.1% mortality] vs 585 792 deaths [63.5% mortality], respectively; adjusted hazard ratio [aHR], 0.84. . . .

However, when stratifying by age and treating kidney transplantation as a competing risk, black patients had significantly higher mortality than their white counterparts at ages

18 to 30 years (27.6% mortality vs 14.2%; aHR, 1.93 . . .

31 to 40 years (37.4% mortality vs 26.8%; aHR, 1.46 . . .

41 to 50 years (44.8% mortality vs 38.0%; aHR, 1.12 . . .

as opposed to patients aged

51 to 60 years (51.5% vs 50.9%; aHR, 0.93 . . .

61 to 70 years (64.9% vs 67.2%; aHR, 0.87 . . .

71 to 80 years (76.1% vs 79.7%; aHR, 0.85 . . .

and older than 80 years (82.4% vs 83.6%; aHR,

0.87 . . . .

© 2011 Lauren M. Kucirka, Morgan E. Grams, Justin Lessler, Erin Carlyle Hall, Nathan James, Allan B. Massie, Robert A. Montgomery, and Dorry L. Segev, Association of Race and Age With Survival Among Patients Undergoing Dialysis, Journal of the American Medical Association [JAMA] 306(6): 620-626 (10 August 2011) (from the abstract’s “results” paragraph) (paragraph split)

Notice the downward sloping adjusted hazard ratio (for African-Americans) trend line. That is curious, and it demands more inquiry. Is physiology or some other variable at work?

Notice, too, that previous dialysis investigators apparently did not think to ferret out younger patients’ experiences. That oversight may be an example of poor research design, lackluster analysis, or taking too much for granted.

If we don’t ask the right questions, we are destined to get wrong (or obscure) answers.

Why good science methodology and analysis matter

Depending on inadequate studies in clinical medical practice is difficult to defend.

Medicine uses low-power studies because they are “there” and, presumably, better than pure ignorance. But in our dialysis example, confessed ignorance would actually have been better for many patients than providing them with the ultimately harmful guidance based on badly done or poorly interpreted studies.

And that’s the crux of my observation — medical practitioners, and the organizations that guide them, often don’t think in thoroughly scientific terms. If clinical practice were to demand better-designed and better-analyzed research, such would appear, even if properly doing the investigations proves to be more expensive.

At present, medical inquiry is mostly done by self-interested parties, many of whom attempt to camouflage unsubstantiated findings inside pseudo-scientific packages.

The average (busy) practitioner can’t penetrate the ruses the industry, including researchers bent on making a name for themselves, use to hide biased or ignorant tracks.

And a small, but noticeable, proportion of practitioners don’t care to uncover deceptions or voids because they, too, financially benefit from performing worthless or misguided interventions.

The caring majority of physicians and surgeons are trapped in an infrastructure increasingly based on avarice and sloppy science — which they have little power to correct and perhaps even less to correctly interpret.

The moral? — Learn as much as you can about your ailments and ask questions

Persuasive science-based medicine is not here yet, no matter what the establishment community thinks. More questions from patients and medical practitioners might lead to scientifically sounder research and more rigorously well-founded practice guidelines.

As a patient, be curious and skeptical. Consciously collaborate with your doctors. Almost all of them have our well-being at heart, even when they are cognitively trapped in a substantially flawed system.

Regularly thinking about what we know, and how we know it, is arguably beneficial in all aspects of human endeavor.

PeteFree.com

Another Example of Medicine Getting It Wrong with Deadly Effects — Contrary to Previously Accepted Medical Practice, Young African-American Patients Do Significantly Worse than Whites on Kidney Dialysis — the Power of Asking the Right Questions