This study could have easily been reported as a clear case of new technology besting the old way of doing things. Thankfully, this story avoided that simplistic narrative by reaching out to an independent expert, who explained that the traditional approach is still the preferred option for certain patient groups who aren’t good candidates for general anesthesia. We thought the story could have delved deeper into certain issues that are relevant to patients — like how quickly people were able to return to work after undergoing each procedure, and whether everyone with this type of hernia even needs surgery.The story also would have done well to examine some other studies that don’t support the conclusions reached by these researchers.
Innovation in medicine almost always means higher costs, but sometimes it doesn’t lead to higher quality or better outcomes. Good studies are needed to confirm the benefits of new approaches compared with the existing standard.
Most surgical studies comparing treatment options compare outcomes over short periods of time. This study presents results over an average of 5 years and addresses important longer-term outcomes of common surgical procedures used to repair groin hernias. Studies have shown that short-term outcomes of laparoscopic and standard surgical repair have similar outcomes though recovery with the laparoscopic is associated with less pain and potentially quicker return to usual activities. This article presents rates of recurrence and persistent pain after an average of about 5 years after surgery. Recurrence rates overall were low for both procedures and appeared to be influenced by the experience of the surgeon performing the laparoscopic procedure. Interestingly, more patients having the traditional procedure reported persistent pain. As the story correctly concludes, this doesn’t mean that one procedure is preferred over the other, but rather provides important data that patients may want to know when considering the options for elective surgical repair of groin hernias.
We’ll give credit to the story for attempting to compare the relative costs of the two procedures, but we thought the language used was just too vague to support a satisfactory rating. The story says the costs of the two procedures are “comparable,” but that “the laparoscopic procedure may cost more.” Unfortunately, it’s difficult to tell from this description if the procedures cost about the same or whether the laparoscopic procedure is, in fact, more expensive. Attaching a specific dollar figure to each procedure would have made the meaning more explicit. Given the nature of the long-term follow-up presented, one could have discussed both the short-term medical costs of the two procedures and then whether there were differences in care over the ensuing 5 years that may have changed the short-term comparison.
The story quantified how often the hernias recurred in each group and how many patients had chronic pain at follow-up. It noted that “the vast majority of patients do well, regardless of the approach.” This is enough for a satisfactory, though the story could have provided data about how quickly patients were able to return to work with each procedure, and how satisfied they were overall with their results.
The story explained that the less invasive surgery might not be appropriate for patients who face increased risk from general anesthesia, including the elderly or those with multiple health problems. We’ll rule this satisfactory, but the story could also have noted that the less invasive procedure produced a higher rate of operative complications than the standard procedure (6% vs. 2%).
The story gave a reasonable account of the study design, and it noted that better outcomes were seen with more experienced surgeons — an important wrinkle. However, it didn’t really communicate just how critical the surgeon’s experience level is to the success of the laparoscopic procedure. According the Medscape’s coverage, there was a 25% recurrence rate for inexperienced surgeons using this approach, compared to just 0.5% for experienced surgeons. That’s an important detail for patients to keep in mind when deciding on a treatment plan.
In addition, the story didn’t make any attempt to square these findings with those of a much larger multicenter study that reported much higher recurrence rates with the laparoscopic procedure compared with the traditional procedure. Omitting this important research from the discussion may give readers a warped view of the evidence on this question.
An independent source provided useful context about the important continuing role of the traditional “open” procedure.
The study compared two major surgical approaches and the story mentioned the existence of a third approach that wasn’t tested. However, it didn’t mention nonsurgical management or “watchful waiting,” which may be an appropriate strategy for patients with minimal symptoms or who are asymptomatic. Since almost all hernia repairs are elective – meaning that they are designed to minimize pain and bulging rather than preventing a potentially serious medical problem (such as bowel obstruction or incarceration in the hernia) – it is appropriate to mention that for many patients part of the decision making process is whether to have surgery or not. Once one decides to have surgery, then the question of what is the best procedure becomes relevant. Some patients make the decision about whether to have surgery on not based upon the risks and benefits of the procedure, so that is why mentioning not having surgery is part of the comparison of treatment options.
Both approaches seem to be widely available, so the fact that the story didn’t discuss this shouldn’t be held against it. We’ll rule it not applicable.
The story notes that the laparoscopic approach has been around since the 1990s and that the traditional approach is older.
This story wasn’t based on a press release.
Systematic, Criteria-Driven
Monday at #ADA2021, an infectious disease epidemiologist, a journalist, and a researcher shared perspectives on communication of risk in the era of COVID-19: http://ow.ly/ROfR30rMeE7 @AstleyCM @garyschwitzer @berthahidalgo @ADA_DiabetesPro
Shoutouts to @susan_bewley @drkevinknopf @MichaelBaum11 in this call for more than fawning coverage from press releases for these kinds of stories.
Also, linked history inside goes back 5 years just on Grail apparently trying to become Holy Grail. https://twitter.com/garyschwitzer/status/1408849696416841731
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