The devil is in the details- overstating the results of the effects of corticosteroids in patients with pneumonia

This blog post will tie in nicely with what I blogged on earlier today about composite endpoints. Read that post first before reading this.

Today I received my e-table of contents from JAMA and read a study on the of Effect of Corticosteroids on Treatment Failure Among Hospitalized Patients With Severe Community-Acquired Pneumonia and High Inflammatory Response. The primary outcome of the study was “treatment failure (composite outcome of early treatment failure defined as [1] clinical deterioration indicated by development of shock, [2] need for invasive mechanical ventilation not present at baseline, or [3] death within 72 hours of treatment; or composite outcome of late treatment failure defined as [1] radiographic progression, [2] persistence of severe respiratory failure, [3] development of shock, [4] need for invasive mechanical ventilation not present at baseline, or [5] death between 72 hours and 120 hours after treatment initiation; or both early and late treatment failure).”

The authors make a bold statement:

The results demonstrated that the acute administration of methylprednisolone was associated with less treatment failure…”

I find this statement (from the 1st sentence in the discussion section) to be a vast overstatement of what they in fact found in this study.  Examine the table below (I trimmed out the per-protocol analysis results) and see just what was actually reduced by steroids.

From JAMA 2015;313(7):677-686

From JAMA 2015;313(7):677-686

Steroids had no effect on “early treatment failure”. They significantly reduced “late treatment failure” but this was all driven by one outcome. The only thing steroids did was reduce radiographic progression. They didn’t help any other outcomes of this large composite but yet the authors make this sweeping statement of steroids being associated with less treatment failure. This demonstrates the importance of looking at the individual components of the composite and not just focusing on the overall composite result.

It also demonstrates why I don’t like to read the discussion section of a paper nor the conclusions from an abstract- you will be misled. The reviewers and editors should have toned down these conclusions as they are a gross overstatement of what was actually found.

What’s The Evidence For That? A new series I am starting

One thing I have noticed is that current residents don’t seem to know the evidence supporting a lot of the treatments they use, especially if the studies were done before they started med school.  I also don’t think they really want to read articles from the past when there is so many new things that excite them more. So I came up with a new series of data summaries I am going to make for teaching purposes during rounds to remind the residents and students that there is evidence behind some of what we do.  I designed them to be one pagers and answer what I feel are the key questions on the particular topic I am covering. I also try to follow the Hayne’s 6 S Hierarchy and focus on evidence higher up the pyramid (that isn’t UpToDate or Dynamed). I want to hit the less sexy topics that we encounter a lot on the inpatient medicine service like COPD exacerbation, hepatic encephalopathy, etc.

So here’s the first one I made: What’s The Evidence For That: Steroids for COPD Exacerbation. (Steroids for AECOPD) This took about 1.5-2 hours to make… mostly because I had to figure out how to make the template in Publisher do what I wanted it to do (and it fought me all the way).

Feel free to copy it and use it in your clinical teaching. Let me know if it is useful and how it could be made better. If you make any share them with me.

As I make more of these I will publish them here. I also plan to make Touchcasts of them and will post that here when I do.