Changing stroke rehab and research worldwide now.Time is Brain!Just think of all the trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 493 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It lays out what needs to be done to get stroke survivors closer to 100% recovery. It's quite disgusting that this information is not available from every stroke association and doctors group.
My back ground story is here:http://oc1dean.blogspot.com/2010/11/my-background-story_8.html

Friday, November 23, 2018

Research waste is still a scandal—an essay by Paul Glasziou and Iain Chalmers

I would expect our fucking failures of stroke associations to go thru all stroke research and identify the wasted ones. Then boycott those senior researchers and mentors from further grants.

Research waste is still a scandal—an essay by Paul Glasziou and Iain Chalmers

BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4645 (Published 12 November 2018) Cite this as: BMJ 2018;363:k4645



  1. Paul Glasziou, director1,
  2. Iain Chalmers, coordinator2
    Author affiliations
  1. Correspondence to: P Glasziou Paul_Glasziou@bond.edu.au
Progress has been made towards reducing the 85% of wasted effort in medical research—and the huge amounts of money misspent and harm caused to patients—but there’s still a long way to go, say Paul Glasziou and Iain Chalmers
In their history of the evolution of guidelines for reporting medical research, Doug Altman and Iveta Simera showed that poor design, conduct, and reporting of medical research have been concerns for over a century: “The quality of published papers is a fair reflection of the deficiencies of what is still the common type of clinical evidence. A little thought suffices to show that the greater part cannot be taken as serious evidence at all.”1
Indeed, more than 250 years ago, the Scottish doctor James Lind declared in the introduction to his review of reports on treating scurvy: “Before this subject could be set in a clear and proper light it was necessary to remove a great deal of rubbish.”2
Quantifying the extent of poor reporting of medical research seems not to have begun until 1966 (box). After assessing 295 publications in 10 “most frequently read” medical journals, Schor (a statistician) and Karten (a medical student) concluded: “In almost 73% of the reports . . . conclusions were drawn when the justification for these conclusions was invalid.”3
However, the title of their article, “Statistical evaluation of medical journal manuscripts,” was unlikely to ignite action among clinicians to deal with a situation that threatened their patients’ wellbeing.
The wake-up call came 30 years later, in 1994, with an editorial in The BMJ by the journal’s chief statistical adviser, Doug Altman. He described as a scandal4 that “huge sums of money are spent annually on research that is seriously flawed through the use of inappropriate designs, unrepresentative samples, small samples, incorrect methods of analysis, and faulty interpretation.” In 2015, the journal’s readers rated the article the most important in The BMJ in the previous 20 years.5 It has been cited over 700 times.

Milestones in the recognition and reduction of avoidable research waste

  • 1966: Schor and Karten find 73% of research conclusions not justified
  • 1986: Simes shows impact of non-publication; call for universal registration
  • 1994: Altman declares “scandal of poor medical research” in The BMJ
  • 1996: CONSORT statement published
  • 1997, 2000: ClinicalTrials.gov founded, made internet accessible
  • 2006: Altman founds EQUATOR Centre in Oxford
  • 2009: Chalmers and Glasziou publish “Avoidable waste in research” in Lancet
  • 2010: National Institute for Health Research initiates adding value in research programme
  • 2012: Begg and Ellis fail to replicate key preclinical studies
  • 2013: AllTrials campaign launched
  • 2014: Lancet series of five papers on avoidable waste
  • 2015: Conference in Edinburgh and the REWARD statement
  • 2015: Ensuring Value in Research (EVIR) Funders’ Forum founded
  • 2017: Cochrane-REWARD prizes to NIHR, SYRCLE, and COMET
  • 2018: Cochrane-REWARD Prizes to EQUATOR, TrialsTracker, and James Lind Alliance
Altman was blunt: “What should we think about researchers who use the wrong techniques, use the right techniques wrongly, misinterpret their results, report their results selectively, cite the literature selectively, and draw unjustified conclusions? We should be appalled. Yet numerous studies have shown that all of the above phenomena are common. This is surely a scandal”4
Altman’s conclusion was that we needed “less research, better research, and research done for the right reasons.”

Responses to Altman’s challenge

Altman’s challenge contributed to two important developments. Drummond Rennie, a senior editor of JAMA, was influential in both. Firstly, in 1989, Rennie initiated a series of congresses on peer review in biomedical publication, an international forum in which these problems could be identified and confronted. Secondly, he suggested that clinical trial reporting was so poor that a reporting guideline was needed. The resulting CONSORT (Consolidated Standards of Reporting Trials) statement6 prompted the development of other reporting guidelines. In 2006, recognising the need to compile, improve, and disseminate these guidelines, Altman established the first EQUATOR centre for enhancing the quality and transparency of health research.7
Unfortunately, medical journals’ efforts to improve reporting do not tackle fundamental deficiencies in the design and conduct of research. Another Altman article8 suggested that journals could help to prevent poor research by promoting electronic publication of research protocols; this could occur within the emerging framework of registering trials at their inception. Subsequent reports of the registered research could be linked electronically, through to deposition of whole datasets.
Better trial registration has made it possible to assess the extent of biased under-reporting of whole studies, first shown in medicine in 1986 with comparisons of analyses based on all trials registered with all those that had been reported in public showing that the reported trials overestimated benefit by between 10% and 15%.9 Other studies showed biased reporting of outcomes within studies.1011
Commenting on the practical consequences of these reporting biases, Alessandro Liberati, a health services researcher and patient, complained about the waste and suffering caused by the biased under-reporting of research.12 To tackle that concern, the AllTrials campaign was launched in 2013, calling for all past and present clinical trials to be registered, and their results reported.

How much money is wasted?

To try to quantify Altman’s “huge sums of money” wasted, we estimated in 2009 that 85% of the more than $100bn a year spent on medical research globally was being wasted avoidably.13 This waste arises from the multiplicative effects at different stages of research: over 50% of research is not published; over 50% has avoidable design flaws; and over 50% is unusable or incompletely reported, or both.14
This staggering sum brought attention to Altman’s scandal. One of England’s principal research funders, the National Institute for Health Research, soon established the “Adding value in research” programme to monitor and tackle the problems. The Lancet commissioned five articles with over 40 authors, including Altman and his former students, giving more detail about sources of, solutions to, and recommendations for reducing avoidable research waste (www.thelancet.com/series/research).
Altman’s observations and critique were largely in applied clinical research, but similar problems have become apparent in preclinical research. Most notably, a 2012 study failed to replicate the findings of 47 of 53 “key” preclinical studies, even though the attempted replications had mostly been done by the original authors.15
This finding challenged researchers to reconsider whether the research enterprise was working. The causes can largely be found in the issues Altman had raised in 1994: “inappropriate designs, unrepresentative samples, small samples, incorrect methods of analysis, and faulty interpretation,” together with pervasive biased under-reporting of research.
What have been the drivers that led us to this waste? The lack of motivation to tackle research waste has been driven by the lack of awareness: funders and researchers often express surprise, or even disbelief, at the scale of the problem. Instead, academic and commercial incentives in the research system reward poor research practices such as reanalysing data until statistical significance is found (P hacking), spin, incomplete reporting, and withholding protocols and data. Fortunately, both awareness and incentives seem to be changing.

Where are we now?

At Edinburgh’s 2015 conference on research waste, Altman’s keynote address began, “It is my great pleasure to be here and make you feel quite sad about how bad things are.”16 He proceeded to enthral and sadden us with a catalogue of editorials and research which had pointed out the extensive and ongoing problems in medical research. However, in 2016, a report by the journalology researcher David Moher and his colleagues promoted some optimism that practical steps could be taken to reduce waste.17 They documented the global response to the 2014 Lancet series using examples of individual initiatives to reduce research waste in different stakeholder groups.
Among the responses has been the establishment of the Evidence-Based Research Network (www.EBRNetwork.com) in 2016 to lobby for all proposals for new research to be supported by references to systematic reviews of relevant existing research.18 This is supported by the call from nine influentially placed coauthors, including former and current chief scientific advisers to the British government, for information syntheses that are inclusive, rigorous, transparent, and accessible for policy makers,19 a call we consider long overdue.20
But perhaps most notable and potentially influential development is the Ensuring Value In Research (EVIR) Funders’ Forum, established by the National Institute for Health Research in England, ZonMw in the Netherlands, and the Patient-Centred Outcomes Research Institute in the United States.21 The forum now includes over 30 research funders internationally, working together to reduce research waste and improve value. Given their influence through funding decisions and regulation, research funders have a pivotal role in fostering improvements. However, their potential influence remains underexploited: an audit of the adoption by funders of relevant recommendations in the Lancet series showed low levels of uptake, with a few influential outliers.22

Cochrane-REWARD prize

At the 2015 Edinburgh conference, the REWARD (Reduce Research Waste and Reward Diligence) Alliance was founded to facilitate work on the recommendations from the Lancet series. It has established the Cochrane-REWARD prize to recognise and disseminate scalable initiatives aimed at reducing avoidable waste in research. At the 2017 World Congress on Research Integrity in Amsterdam, the first prize was awarded to NIHR for its initial response and ongoing work in monitoring and reducing research waste. The second prize was shared by the Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE), based in Nijmegen, the Netherlands, for reducing waste in animal research through systematic reviews and better regulation; and the Core Outcome Measures for Effectiveness Trials (COMET) Initiative, which promotes the agreement and adoption of core outcome measures for assessing the effects of interventions, as pioneered in the 1990s by the rheumatologists who created the Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) Group.
The 2018 Cochrane-REWARD prize was awarded to the EQUATOR Network for Good Reports, and in recognition of the considerable work of Altman’s Oxford Centre for Medical Statistics in improving research reporting and reducing research waste more generally.23 Second prize went jointly to the James Lind Alliance for its extensive and innovative efforts to improve research prioritisation and to the Trials Tracker established by Ben Goldacre and his colleagues at the Oxford Centre for Evidence Based Medicine. The tracker exposes the institutions and people who are acquiescing in under-reporting of research (it has shown that academia is now more culpable than industry).

What needs to happen now?

Initiatives such as those recognised by the REWARD prize are heartening, but their work is poorly supported by funders and institutions. So, although the pace of change in reporting guidance has been rapid, change in improving practice has remained slow, with overall publication rates remaining at about 50%, and vast other areas of medical research unobserved and unimproved.
The recent evidence based medicine manifesto, citing Altman’s 1994 “scandal” paper, proposes nine steps towards “better evidence for better healthcare.”24 It links the problems of poor research to poor information for clinical decision making. For Altman, these decision making consequences were central. As a statistician, he was appalled by the poor quality of the design, conduct, and reporting of research, not just for its deleterious effects on the medical knowledge base but, more importantly, for its “serious consequences for clinical practice, research, policy making, and ultimately for patients.”
Given Doug Altman’s pivotal role in raising awareness of the scandal of poor medical research and in establishing the EQUATOR centres, it is unsurprising that he received a Lifetime Achievement Award from The BMJ in 2016. To realise the full value of his legacy, research funders, research regulators, research organisations, journals, and the many people Doug taught and inspired must act together to design, conduct, and report better research done for the right reasons. The continuing ethical, scientific, and economic deficiencies of medical research remain scandalous.

Biography

Paul Glasziou is a GP researcher and the founding director of the Centre for Research in Evidence-Based Practice at Bond University. He is also chair of the REWARD Alliance.
Iain Chalmers has a longstanding interest in biased under-reporting of research. He is coordinator of the James Lind Initiative.

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