12:00

tobacco cessation or mental health

12:02

planning or whatever it is, knowing that those

12:04

types of interventions are easy to tick

12:06

but kind of probably

12:08

low impact because they're sort of

12:11

quickly sussed over in the course of a visit.

12:14

But instead, can we use

12:16

data to identify patients who I

12:18

like to think of as like falling through the cracks, people

12:20

who are completely missing from from the system, like

12:23

whether their blood pressure is, you know, 148

12:25

over 88 versus 152 over 92 is less important than

12:30

identifying the people who are completely untreated,

12:32

have known hypertension, they've been diagnosed with

12:35

it, and they're not coming back for care

12:37

for whatever other reason. Maybe it's,

12:39

you know, the burden of care, maybe they're taking

12:41

care of another individual, maybe they can't

12:44

afford to take the day off from work, right,

12:46

these are the people that we need to reach as a health system

12:48

if we're gonna improve population health.

12:51

Indeed, and there was a nice editorial that,

12:53

going back to your research paper that we started this

12:56

discussion with, there was a nice editorial that goes

12:58

with it by Kath Cheklund, a

13:00

professor of health policy and primary

13:02

care in Manchester. And that gives a nice

13:04

overview, I think, of that whole quaff

13:07

endeavor, where it is

13:09

sort of a bit historical, where it came from. And

13:12

she summarizes the extensive

13:15

evaluations that happened, concluding

13:18

that the benefits were modest

13:20

at best. There was a lot of attainment

13:23

and achievement of these goals but that

13:25

the evidence suggested that the scheme, although

13:27

it had narrowed some inequalities in

13:29

care quality, the longer term evaluation

13:32

wasn't as good as was imagined. And 10

13:35

years after its inception,

13:39

there was a decision that it hadn't really been associated

13:41

with the kind of improvements in mortality

13:45

and modelling suggested that it wasn't cost effective,

13:47

so things have kind of moved on. So

13:49

it will be interesting to see what comes next. And

13:52

maybe something which feels much more suitable

13:55

for 2023 and onwards, something

13:57

that's much more patient-centered. and

14:00

focused around the priorities that people have,

14:03

rather than the priorities that were

14:05

decided for them. By the powers

14:08

that be. The administrators. Exactly,

14:11

exactly.

14:17

You'll forgive

14:17

me for being a little bit UK-centric

14:20

on this item, but there was an announcement by

14:22

Chancellor Jeremy Hunt here on the 15th

14:25

of March about

14:27

drug and, well, medicines and

14:29

technology regulation in the UK. And

14:32

he said there was going to be near automatic sign-off

14:35

for medicines and technologies already approved

14:37

by trusted regulators. And this is

14:39

part of setting out after

14:41

Brexit what's going to happen in

14:44

this space. Recently, I spoke

14:46

with Husain Naji

14:47

to tell us a bit more.

14:52

Hi, Husain, thank you so much for joining me.

14:54

Can you just begin by introducing yourself

14:57

and giving a sense to our listeners

15:00

of why you are a man who knows stuff about this issue?

15:02

Thanks, Ellen, thanks so much for having

15:04

me. I'm Hussein Najee, I'm an Associate Professor

15:06

of Health Policy at the London School of Economics and

15:09

Political Science, and my research

15:11

is on pharmaceutical policy and regulation, and

15:14

specifically I look at the quantity and the quality

15:16

of evidence that supports regulatory

15:18

approvals of new medicines.

15:20

Okay, so I think just

15:22

for any listeners who are less familiar with the

15:24

regulatory environment. Just give us a swift

15:27

rundown on the key players. Can you just tell

15:29

us who the regulators are and

15:31

then who the health technology appraisers

15:33

are? Because I think that's gonna put this conversation

15:36

in context for them.

15:38

Right, so traditionally we would

15:40

have

15:41

private companies developing their products and then

15:43

seeking an approval by a regulatory

15:45

agency. And this can be an organization

15:48

like the US Food and Drug Administration in the US

15:50

or the European Medicines Agency within

15:52

the European Union, or in the case of the UK,

15:55

the Medicines and Healthcare Products Regulatory

15:57

Agency, the MHRA. once

15:59

product

16:00

products are approved by the regulatory agencies, they're

16:02

then appraised by, usually,

16:04

not in all countries, but usually they're appraised

16:06

by health technology assessment bodies. And in

16:08

the UK, this is nationally suited for

16:11

health and care excellence or NICE, that

16:13

looks at not only the efficacy of the product, but also

16:15

its cost effectiveness to see if it's good

16:18

value for money for the NHS.

16:20

So the regulators in effect answer,

16:23

might it work sufficiently well to

16:25

have a license to sell this thing

16:27

and the healthcare, sorry, and the health

16:29

technology appraisers are saying,

16:31

is it really worth it? That's exactly

16:33

right. Okay. So what does this announcement

16:36

change? So this announcement

16:38

essentially means that the MHRA

16:40

will be looking at other international

16:43

regulators and it's going

16:45

to be increasing its reliance on other regulatory

16:47

agencies for approving new medicines.

16:51

And why would it do that? So

16:54

much of the kind of the

16:56

announcement can be or the motivation for the

16:58

announcement can be traced back to Brexit,

17:01

which is of course the UK's departure

17:03

from the European Union a few years ago.

17:06

Until Brexit, the UK was part

17:08

of the European regulatory framework, and

17:11

it was working under the auspices

17:13

of the European Medicines Agency. And

17:16

it was really a crucial kind of member

17:18

of the European Medicines Agency in that it was

17:21

responsible for over 30% of drug

17:23

reviews done by

17:24

the EMA. And in turn,

17:26

it benefited from collaboration

17:28

with other regulatory agencies within the European Union.

17:32

And this also had a benefit for the industry

17:34

in that once a product was approved

17:36

by the European Medicines Agency, it could

17:38

be launched in all of the EU countries subsequently.

17:42

Since Brexit, the MHRA has become

17:44

the independent, the sole regulator for

17:47

the UK market. And what that means is

17:49

companies now have to seek

17:52

authorization from the MHRA before they can launch

17:54

their products in the UK. Now,

17:56

what this means is that there's a bit of

17:58

a concern from the government. a very

18:01

explicit concern from the government that UK

18:04

being a relatively small market, it only accounts

18:06

for 3% or 4% of

18:08

the global pharmaceutical market, companies

18:11

may not launch their products here or they may delay

18:13

launching their products here. So this announcement

18:16

is essentially sending a signal to

18:18

companies that the UK remains

18:20

an attractive, reliable market for companies

18:23

to launch their products in the UK.

18:24

And so what do you see as

18:27

the potential benefits and

18:29

harms of this announcement?

18:30

So it does have some

18:32

benefits in theory. Anytime

18:35

we have more kind of coordination or collaboration

18:38

or harmonisation of regulatory processes,

18:41

that's in theory a good thing. We

18:43

saw that with COVID-19 when there was

18:45

a bit of a lack of

18:47

a collaboration between regulatory agencies.

18:51

couldn't agree on efficacy thresholds for vaccines,

18:53

for example. Some countries approved

18:57

the AstraZeneca vaccine, whereas others didn't.

19:00

So we could see, you know, benefits of better

19:02

collaboration. So that's

19:04

a positive thing about this announcement

19:07

that the MHRA will work closely with other regulators.

19:10

The other

19:11

potential benefits of this is that the MHRA is

19:13

going to get quite a bit of a funding boost over

19:16

the next few years. Okay. How's that work?

19:18

And it's going to receive

19:20

approximately 10 million pounds for the next two years.

19:23

And that's really good because the MHRA suffered

19:25

really big budget cuts following

19:28

Brexit. And this led to staff

19:30

redundancies and some senior

19:33

staff members have really voiced concern

19:35

over what this may mean for the ability

19:38

of the organization to really deliver on its

19:40

objectives. So that's

19:42

a positive. But on the flip side of this,

19:45

this additional funding is contingent

19:47

on speeding

19:48

up the approval

19:50

processes for the MHRA. So

19:53

MHRA is getting more money, but it's conditional

19:56

on it speeding up its processes. And it's this

19:58

speed, this emphasis.

20:00

on speed that is potentially

20:02

a problem as it can lead to all sorts

20:04

of unintended consequences for patients.

20:06

Tell us a bit about those. So

20:08

we know, for example, from the

20:11

US, which historically has had

20:13

a lot of experience

20:15

with speedy

20:17

drug review processes, when

20:20

regulators work under pressure and they work

20:22

under strict arbitrary rigid deadlines,

20:25

those approvals that happen immediately

20:28

before the deadline tend to have more

20:30

safety concerns that emerge during the

20:32

post-marketing period. So that's something that the

20:34

MHRA will need to really pay attention

20:36

to and monitor. In

20:39

terms of efficacy, there are some unintended consequences

20:41

as well because when we

20:43

look at a drug early

20:45

on, then we may get a wrong

20:48

sense of how good this drug actually works if

20:50

we were to wait longer and get more mature data

20:52

about the drug. And one recent

20:55

example of this is the MHRA's

20:58

approval of Molynepyravir

21:00

for high-risk COVID-19 patients.

21:04

The MHRA was the first regulator in the world to

21:06

approve this medicine, and it was based on

21:09

interim data from a clinical trial.

21:12

And that interim data made the drug look really impressive

21:14

in terms of reducing the risk of hospitalizations

21:17

and other severe outcomes. But

21:19

when more mature

21:22

data appeared from

21:24

the same clinical trial, the drug no longer

21:26

looked as effective as it initially appeared

21:28

on the basis of the interim data. So by looking at

21:30

drugs,

21:32

possibly prematurely, we may be

21:35

actually making suboptimal decisions

21:38

in terms of appraising the efficacy of products.

21:40

What if there's disagreement between the international

21:43

regulators? So FDA maybe said yes,

21:45

and EMA said no, or vice versa?

21:48

I think it's yet to figure out, but again,

21:52

it sounds like, again, this is trying

21:54

to read between the lines because there's no clear kind

21:56

of policy documents yet.

22:00

go for the speediest. So whichever one is

22:02

the first approval, we would adopt that

22:04

one because in Jeremy Hunt's words, I

22:06

mean, this is what he said and I quote,

22:09

this will put in place the quickest, simplest

22:11

regulatory approval in the world. So

22:15

if they approve it first, MHR is

22:17

going to adopt that decision is what it sounds like at

22:19

the moment, but it's unclear how it's going to be implemented

22:21

in practice.

22:22

And what are the external regulator gets it

22:24

wrong? Well, that's precisely

22:27

the concern. When

22:30

the MHRA looks

22:33

to other regulators for their decisions

22:35

and almost automatically signs

22:37

off on them, then we may be subjecting

22:41

the NHS to really questionable decisions

22:43

from other regulators. And one recent example

22:45

of this is Adrucanumab, which

22:47

was approved by the US FDA in 2021

22:51

for the treatment of Alzheimer's disease. And

22:53

This was a very controversial decision because

22:55

the FDA gave the green light to this

22:58

product on the basis of a surrogate endpoint, which

23:00

according to established literature is

23:02

not really predictable, predicting

23:05

delays in cognitive impairment. Other

23:07

regulatory agencies actually refused approval

23:10

for this particular medicine, those in

23:12

Canada, Japan, and the European Union.

23:15

It's unclear at the moment what safeguards

23:18

the UK has in mind to implement

23:20

to prevent these types of questionable

23:22

approvals from getting an automatic sign

23:25

off in the UK.

23:29

So if you were in charge of the MRHA

23:31

and you were thinking how can I take

23:34

this forward in a way where we might

23:36

get,

23:37

maximize some of those benefits that

23:39

you mentioned, but minimize

23:42

the potential for harm, what

23:44

do they need to be thinking about or doing? I

23:46

think it would be really important to put as

23:49

much emphasis on the post-marketing

23:51

obligations or responsibilities of the regulator,

23:54

not only pre-market responsibilities.

23:56

There has been a lot of emphasis, as I mentioned, on

23:59

speeding up the approved.

24:00

of products, but this actually can really

24:02

backfire and it can have unintended consequences

24:04

because when you

24:07

get products onto the market quite early on

24:09

in their life cycle on the base of quite limited

24:11

or uncertain evidence, then you need to

24:13

really boost the resources available for

24:16

post-marketing responsibilities to make sure that

24:18

those drugs that appeared efficacious

24:20

initially, they continue to really

24:23

deliver benefits for patients in the

24:25

NHS or that they don't have post-marketing

24:27

safety concerns. And if they do emerge, then

24:29

these can be quickly spotted, and then products

24:32

can be withdrawn if necessary. And without

24:35

that type

24:37

of a more holistic approach

24:39

to drug regulation, and putting all of the emphasis

24:41

on this early market access aspect

24:44

of it, I think this is the aspect

24:47

of the proposal or the move

24:49

that is potentially problematic.

24:51

So they need to keep an eye on what happens afterwards,

24:54

and they need to be prepared then to change

24:56

their mind, or adapt their position

24:58

as new evidence emerges.

24:59

Right.

25:03

So what do you two think of what Hussein had

25:05

to say? I thought

25:08

it was fascinating. It's obviously an interesting

25:10

and probably deliberately provocative

25:13

new policy from the MHRA,

25:15

this kind of concept of the SWIFT approval.

25:18

There's been a whole host of

25:20

research that's looked at

25:23

the issues around faster approval and

25:25

risk that Hussein alludes

25:28

to demonstrating that when

25:30

products are approved right near the deadlines, there

25:33

does seem to be a greater risk that they had safety

25:36

issues identified later on.

25:38

Do you have a little interest to declare there, Joe?

25:41

Oh, well, that did come from a paper that

25:43

my group published. It was built

25:45

on a seminal paper that Dan Carpenter published

25:48

two decades ago. And it's actually,

25:51

you know, it's interesting. We just published

25:53

a paper in BMJ, Evidence-Based Medicine

25:55

that looked at this issue, where

25:58

kind of gets at why the this

26:00

may happen because what we identified is when

26:02

there were disagreements among the medical

26:04

officers, the reviewers at the FDA,

26:07

those applications take longer to decide upon,

26:10

but they are less likely to then have

26:12

a safety issue identified later on. And it could be

26:14

because they're sort of pressure checking and looking

26:16

at information. I mean, I'm speculating about why that

26:18

might be as opposed to the sort of rubber

26:20

stamp, everyone gets it out because it's got to make that

26:22

deadline. Obviously these

26:25

regulators will all benefit

26:27

from cooperation and there's a tremendous

26:29

amount of cooperation between the major

26:31

kind of high-income regulators like the

26:34

US, Canada, EMA,

26:36

MHRA,

26:37

Japan and Australia already.

26:40

But this idea of kind of reciprocal approval,

26:42

kind of farming it out and allowing another

26:45

regulator to make the decision for your kind

26:47

of, you know, nation state is—it's

26:50

interesting. I mean, I think the biggest question

26:52

will be how does—what position does

26:54

this put nice it because there's

26:56

a step of approval, regulatory approval,

26:58

demonstrating safety and effectiveness, and then there's a step

27:00

of, you know, are we going to pay for it at the cost, right?

27:03

In the US, right, we don't really have

27:05

that second step. So you know,

27:07

generally, approval means it's on

27:09

the market. And, you know, Hussein was

27:11

sort of getting at some of the challenges and

27:13

like what happened with Adjucana map.

27:16

But it's, it's provocative. I don't know, Juan,

27:18

what do you think?

27:19

Yeah, that

27:21

was a shameless plug, wasn't it? Since

27:23

you mentioned BMJ, we'll forgive

27:26

you. No,

27:28

it's a great paper, actually. It's

27:30

a great paper. But it was

27:32

fascinating to listen to Hussein, analysis

27:36

of the situation. I guess for me, it

27:38

wasn't that shocking, because many countries

27:40

in Latin America use

27:43

this process to sort of triangulate

27:48

the approval

27:49

in other stringent regulatory

27:52

agencies to fast track products

27:55

for many reasons the market

28:00

being not so attractive for companies to

28:02

place their products is one that Hussein already

28:04

mentioned and the situation in the UK seems

28:07

to be signaling that way. Another

28:10

perspective has to do with the reduction in

28:12

costs that relates to the

28:14

approval and most of these costs are usually

28:16

bared by the public

28:20

administration. So perhaps

28:23

I'm not so skeptical in that regard

28:26

and perhaps I would also like to add another

28:29

dimension that perhaps

28:30

time, when

28:32

we talk about bureaucracy and

28:35

processes, time, I'm

28:37

less concerned about time but consider

28:40

that one of the main concerns that we have been having

28:42

in the last few years is the changing criteria

28:45

for approval. So one of the

28:47

concerns that was that the

28:49

FDA has been relaxing the criteria

28:51

to approve drugs. So whether

28:54

we could do that more efficiently or not

28:57

in time? I think

28:59

it's great. But I

29:01

think that we need

29:02

to also keep a

29:04

close look as to what is

29:06

the, where are the criteria that

29:08

all of the agencies are using and whether

29:11

there's a systemic relaxation

29:13

of criteria across agencies that

29:15

would also

29:16

impact the UK. That is quite

29:19

interesting Juan, that over time

29:21

it's like there's a difference in terms

29:23

of what it means to be a drug which

29:25

has

29:26

been allowed access to the market. How

29:29

much certainty or uncertainty

29:32

do we still have about the benefit

29:34

and harm of the drug? And

29:36

maybe the ability of regulators,

29:38

Hussein was talking about there, to

29:40

go to place greater

29:43

emphasis on the post-marketing, not

29:45

just studies, but just sort of information and

29:48

willingness to fine-tune

29:50

the approval or even sometimes to

29:52

change what they said in light

29:54

of new information. and you

29:56

don't have that sort of necessary

29:58

sense of circularity. about them coming

30:01

back to review something. It

30:03

feels a bit linear, doesn't it? You get through

30:05

that stage, it's a tick, and you're off to the next

30:07

stage.

30:08

Yeah, this has been a growing challenge

30:11

on the FDA side with the greater

30:14

use of the expedited regulatory

30:16

pathways. Right, the accelerated approval

30:18

program, the breakthrough designation program,

30:21

all of which essentially

30:24

use slightly different evidentiary standards

30:26

to allow drugs to come to market more quickly, but

30:31

then put more incentives or requirements

30:33

on the post-market side to verify or confirm

30:35

clinical benefit. And whether or not it's

30:37

working, some of us think

30:40

that the standards aren't strong enough

30:42

on the post-marketing side, recognizing that,

30:44

particularly in the US, there's always

30:46

going to be the sort of motivation to bring products to market

30:49

more quickly. But it's challenging

30:51

to think about how to do this. And now what are the implications going

30:53

to be on the UK side

30:56

if they're going to abide by a sort of

30:58

a reciprocal approval made by the FDA. And

31:02

so now if the US is saying,

31:04

okay, we'll approve it, but you're going to have to do this post-marketing

31:06

requirement study, where does that leave

31:08

NICE? If there are sort of the approvals based

31:10

on surrogate markers, right? So we don't

31:12

really understand if there's actually a clinical benefit

31:14

yet associated with the treatment or it hasn't

31:17

been verified. If

31:19

it's allowing quote unquote

31:21

speedy or a swifter approval,

31:23

but NICE still isn't going to pay for it.

31:25

Is the policy effective? Is it

31:28

worthwhile? Was it a good use of funds?

31:32

Well, we will have to watch this space,

31:34

I think. So

31:40

from

31:41

drug regulation, which feels rather abstract

31:43

to many jobbing doctors, to

31:46

something which feels perhaps more in your

31:48

control, and Juan, another

31:51

shameless plug from you for EBM journal

31:53

content here, a systematic

31:56

review looking at how good

31:58

point of care

32:00

reference tools or textbooks

32:04

are. Tell us about it.

32:06

Well this article was published

32:08

at the UVM Journal

32:11

and it's very interesting because when

32:13

we talk about point of care apps,

32:16

of course when I was trained in medical school

32:18

we didn't have those, and

32:20

I'm not that old, But and

32:23

then in residency we did started

32:25

using all of this and

32:28

doing our patient's

32:31

encounters. We had that

32:33

we couldn't remember some criteria for some

32:35

disease. You turn

32:36

to your phone and you look at one of these

32:38

apps and and they they've

32:41

grown exponentially. So

32:44

what this group of authors did is provided

32:46

a thorough assessment of how these apps

32:49

that provide information

32:53

for clinical

32:55

content that is useful at point of care for

32:57

clinicians, what is the

32:59

rigor of their development, how evidence-based

33:02

they are, and

33:04

they looked at apps for Android

33:07

and iPhone, and

33:09

they included eight apps, up-to-date,

33:12

Dynamo, BMJ best practice, therapeutic

33:14

guidelines, medscape, five minute clinical

33:17

consults, pathway medical knowledge,

33:19

and AMBOS medical knowledge.

33:22

The

33:24

assessment is quite thorough and they looked at

33:27

different aspects. One had to do with a

33:29

tutorial quality and how evidence-based

33:31

they are. And one

33:34

of the top rated apps

33:36

were up-to-date, up-to-date dynamite and

33:39

BMJ best practice in terms of editorial

33:41

quality and evidence-based methodology. Go

33:43

BMJ! This

33:47

is an independent evaluation. But it's very

33:50

interesting the differences.

33:52

For

33:57

example, up to today had a greater

34:00

coverage, so for example, that

34:02

is very interesting for the internists

34:04

who are always looking for the rare disease,

34:06

well, okay, well, on the

34:08

bedside of the patient.

34:12

But for example, DINAMED

34:15

included a more structured

34:18

way of grading the certainty

34:20

of evidence, which is sort of

34:22

relates to this concept of grade and so on.

34:25

So each of them have pros

34:28

and cons. And I think

34:30

that it'd be useful to think about how

34:33

this market is growing and

34:35

what's the regulatory framework

34:37

for this in terms of these

34:40

apps are influencing

34:42

the decision that doctors are making, so we need

34:45

to make sure that they're evidence-based.

34:47

Jo, you were whooping in a

34:49

very US style there in the

34:51

middle. Did you want to pitch in first?

34:54

Well, I'm proud that

34:57

the BMJ best practice comes off

35:00

in this objective measurement as not

35:02

being terrible. It's actually considered pretty

35:04

good and reliable and of good quality.

35:07

I mean, I'll just say, a

35:09

couple of times a year I'm on the wards with

35:12

house staff and then I'm also in clinics

35:15

working as a preceptor. It's amazing.

35:18

These point of care resources,

35:20

either access through a computer or through your

35:22

smartphone,

35:24

They've completely changed the way medicine

35:27

works. It used to be, I mean, even I'm even

35:29

older than Juan. I

35:31

think up to date was just being developed

35:34

when I was a resident and you'd have to, there

35:36

was one computer on the

35:38

floor

35:40

of the whole hospital ward that had

35:42

it, because you had to have an individual subscription.

35:44

And so people would kind of line up to

35:47

look up things, but really we were all still using big textbooks.

35:50

We would lug around or that would be in the sort

35:52

of team room that you would sort

35:54

of look through. And now, you

35:57

know, you don't have to memorize as much, right because

35:59

you can just kind of remind yourself

36:02

of all these things you've learned by looking it up, you

36:04

know, either on the internet or you know through the app

36:07

and you know, that's that's probably really

36:09

good so long as they're reliable accurate

36:11

and objective and evidence-based and so

36:13

it's actually quite important to have

36:16

these kinds of assessments

36:18

it is quite an interesting issue to consider

36:20

isn't it because Do you imagine

36:23

that if you rewound back to

36:25

the era of the textbook? we would have evaluated

36:28

how evidence-based textbooks were.

36:30

Well, let's just say evidence

36:33

is very different now. I mean, right, you

36:36

know, there's so much more evidence.

36:38

There's better trials. There's many

36:40

more trials, some of which are not better. There's

36:43

just more observational studies. There's more

36:45

surveys. There's more of everything, which, you

36:47

know, enable, it's created a far

36:50

bigger, you

36:51

know, basis of evidence to

36:53

guide decision making, right? I mean, back

36:56

in the era of the, you know, the 80s,

36:59

even into the 90s, right? You know, there

37:01

weren't there, there just wasn't as much research. It

37:03

moved more slowly. So as things, as things

37:06

have sped up, we

37:08

need resources like this to help synthesize

37:11

and aggregate in my opinion.

37:13

Yes. No, I totally agree. I totally

37:15

agree. You have to have that. But it's interesting

37:18

to think going forwards, if,

37:20

if you're,

37:21

if we collectively are our

37:24

EBM nerds. We care about this thing and we

37:26

care that what people are doing is evidence-based.

37:29

It's interesting to think how you can more

37:31

clearly communicate that information so that

37:33

you're sharing what amounts to sort

37:35

of received wisdom or things that we sort

37:37

of do, as opposed

37:40

to things which through

37:42

some clear evidence framework

37:44

we understand are maybe worthwhile

37:47

or clearly you

37:49

need to do this thing based on best evidence.

37:51

And I still don't think I don't think we've quite got that right. I don't

37:53

think we've quite got the conversation about what

37:57

you're reading, what information that's based

37:59

on. as clear as

38:01

it could or should

38:02

be. I see exactly what you mean now, and

38:04

I totally agree, right? Because when UpToDate puts out

38:07

a sort of a recommendation or

38:09

a guidance, right, that doesn't necessarily

38:11

mean that it applies equally to any individual

38:13

patient, that the evidence that it was based

38:16

on, you know, is

38:18

relevant to older adults versus younger adults,

38:20

right? And so people with certain comorbid

38:22

diseases. And sometimes that does get lost,

38:25

right? Because you're not going to the source study, You're

38:27

just reading the synthesis of it.

38:30

So it's not to say that

38:32

that's not important. It just kinda,

38:35

I think it provides

38:37

a starting point, particularly

38:39

for those clinicians who wanna follow

38:41

out the trail of evidence through links

38:44

embedded right within that point of source, point

38:46

of care source material. It's much easier

38:49

than of course sitting down and doing

38:51

a big PubMed search and then trying to manage that.

38:54

I think we all know that's

38:55

not gonna happen. It's the middle

38:57

of a clinical day. Right,

39:04

that's about all we have time for this

39:06

week. You can subscribe and

39:08

rate us wherever you get your podcast from.

39:10

And we'll be back next

39:12

month

39:12

with more from the world of evidence. Until

39:15

then, it's goodbye from me.

39:17

Goodbye from me. And

39:19

goodbye from me. Take care

39:21

out there.