False Alarms, Pseudoepidemics, and Reality: A Case Study with American College of Obstetricians and Gynecologists Practice Bulletins

Abstract

Objectives The objectives of this review are to (1) ascertain the frequency with which odd ratio (OR) and relative risk (RR) are in the zone of potential bias or interest in the American College of Obstetricians and Gynecologists (ACOG) practice bulletins (PB); (2) the likelihood that false alarms have been linked to recommendations; and (3) if there are differences in obstetric versus gynecological PB, vis-à-vis OR and RR in the zone of bias or interest.

Data Sources We reviewed all ACOG PBs published between May 1999 and March 2014.

Methods Documents were searched for statements with mention of OR and RR. When the reported ORs fell between 0.33 and 3.0, it was categorized as “zone of potential bias”; if ORs fell outside the interval 0.25 to 4.0, it was “zone of potential interest.” With RRs, the zones of bias and interest were 0.5 to 2.0 and 0.33 to 3.0, respectively.

Results Of the 79 PBs reviewed, 22% (n = 17) had 44 statements with OR, with 41% (n = 18) of the ORs being in the zone of bias and 54% (n = 24) in the zone of potential interest. Overall, 84% of the ORs did not lead to an actual recommendation by ACOG. In 28% (n = 22) of PBs, there were 67 statements with RRs, with 58% (n = 39) of them being in the zone of bias and 28% (n = 19) were in the zone of interest. In 73% of the PBs the RR citations did not lead to any recommendations. Across the 79 PBs, ACOG made 733 recommendations, and among them only 1 and 2% were linked with ORs and RRs, respectively.

Conclusions Over 70% of ACOGPBs did not cite OR and RR. To better understand the evidence, ACOG should increase citation of OR and RR; whenever applicable OR and RR should be part of graded recommendations.

Level of Evidence Level C.

Précis Less than a third of ACOG practice bulletins mention odds ratios or relative risks and over 95% of recommendations in them remain unsubstantiated.

Keywords

practice bulletins - odds ratio - relative risk - bias

Note

This article was presented at the Annual Meeting of Central Associations of Obstetricians and Gynecologists; October 8–11, 2014; Albuquerque, New Mexico.

• References

• 1 Grimes DA, Schulz KF. False alarms and pseudo-epidemics: the limitations of observational epidemiology. Obstet Gynecol 2012; 120 (4) 920-927
• 2 Grimes DA. Intrauterine devices and pelvic inflammatory disease: recent developments. Contraception 1987; 36 (1) 97-109
• 3 Boffetta P, McLaughlin JK, La Vecchia C, Tarone RE, Lipworth L, Blot WJ. False-positive results in cancer epidemiology: a plea for epistemological modesty. J Natl Cancer Inst 2008; 100 (14) 988-995
• 4 Lindefors-Harris BM, Eklund G, Adami HO, Meirik O. Response bias in a case-control study: analysis utilizing comparative data concerning legal abortions from two independent Swedish studies. Am J Epidemiol 1991; 134 (9) 1003-1008
• 5 Brent RL. Bendectin: review of the medical literature of a comprehensively studied human nonteratogen and the most prevalent tortogen-litigen. Reprod Toxicol 1995; 9 (4) 337-349
• 6 Chauhan SP, Berghella V, Sanderson M, Magann EF, Morrison JC. American College of Obstetricians and Gynecologists practice bulletins: an overview. Am J Obstet Gynecol 2006; 194 (6) 1564-1572 , discussion 1072–1075
• 7 Wright JD, Pawar N, Gonzalez JS , et al. Scientific evidence underlying the American College of Obstetricians and Gynecologists' practice bulletins. Obstet Gynecol 2011; 118 (3) 505-512
• 8 Scott JR. Practice bulletin guidelines. Obstet Gynecol 2011; 118 (3) 501-502
• 9 Bernhard KA, Siddiqui DS, Leonard KM, Chauhan SP. American College of obstetricians and gynecologists practice bulletins: ascertaining their citation, influence, and utilization. Am J Perinatol 2014; 31 (5) 373-382
• 10 Al-Niaimi A, Chauhan SP, Gupta LM, Bailet JW. Factors influencing the evolving practice of obstetricians in eastern Wisconsin: a survey. Am J Perinatol 2008; 25 (6) 321-324
• 11 Clark SL, Belfort MA, Dildy GA, Meyers JA. Reducing obstetric litigation through alterations in practice patterns. Obstet Gynecol 2008; 112 (6) 1279-1283
• 12 Ransom SB, Studdert DM, Dombrowski MP, Mello MM, Brennan TA. Reduced medicolegal risk by compliance with obstetric clinical pathways: a case—control study. Obstet Gynecol 2003; 101 (4) 751-755
• 13 Chauhan SP, Chauhan VB, Cowan BD, Hendrix NW, Magann EF, Morrison JC. Professional liability claims and Central Association of Obstetricians and Gynecologists members: myth versus reality. Am J Obstet Gynecol 2005; 192 (6) 1820-1826 , discussion 1826–1828
• 14 American College of Obstetricians and Gynecologists. Practice Bulletins. Available at: http://www.acog.org/Resources%20And%20Publications/Practice%20Bulletins%20List.aspx . Accessed March 15, 2014
• 15 American College of Obstetricians and Gynecologists. Prevention of Rh D alloimmunization. ACOG Practice Bulletin 4. Washington, DC: American College of Obstetricians and Gynecologists; 1999
• 16 American College of Obstetricians and Gynecologists. Thrombocytopenia in pregnancy. ACOG Practice Bulletin 6. Washington, DC: American College of Obstetricians and Gynecologists; 1999
• 17 American College of Obstetricians and Gynecologists. Antepartum fetal surveillance. ACOG Practice Bulletin 9. Washington, DC: American College of Obstetricians and Gynecologists; 1999
• 18 American College of Obstetricians and Gynecologists. External cephalic version. ACOG Practice Bulletin 13. Washington, DC: American College of Obstetricians and Gynecologists; 2000
• 19 American College of Obstetricians and Gynecologists. Operative vaginal delivery. ACOG Practice Bulletin 17. Washington, DC: American College of Obstetricians and Gynecologists; 2000
• 20 American College of Obstetricians and Gynecologists. Perinatal viral and parasitic infections. ACOG Practice Bulletin 20. Washington, DC: American College of Obstetricians and Gynecologists; 2000
• 21 American College of Obstetricians and Gynecologists. Fetal macrosomia. ACOG Practice Bulletin 22. Washington, DC: American College of Obstetricians and Gynecologists; 2000
• 22 American College of Obstetricians and Gynecologists. Obstetric analgesia and anesthesia. ACOG Practice Bulletin 36. Washington, DC: American College of Obstetricians and Gynecologists; 2002
• 23 American College of Obstetricians and Gynecologists. Thyroid disease in pregnancy. ACOG Practice Bulletin 37. Washington, DC: American College of Obstetricians and Gynecologists; 2002
• 24 American College of Obstetricians and Gynecologists. Perinatal care at the threshold of viability. ACOG Practice Bulletin 38. Washington, DC: American College of Obstetricians and Gynecologists; 2002
• 25 American College of Obstetricians and Gynecologists. Shoulder dystocia. ACOG Practice Bulletin 40. Washington, DC: American College of Obstetricians and Gynecologists; 2002
• 26 American College of Obstetricians and Gynecologists. Neural tube defects. ACOG Practice Bulletin 44. Washington, DC: American College of Obstetricians and Gynecologists; 2003
• 27 American College of Obstetricians and Gynecologists. Nausea and vomiting of pregnancy. ACOG Practice Bulletin 52. Washington, DC: American College of Obstetricians and Gynecologists; 2004
• 28 American College of Obstetricians and Gynecologists. Diagnosis and treatment of gestational trophoblastic disease. ACOG Practice Bulletin 53. Washington; DC: American College of Obstetricians and Gynecologists; 2004
• 29 American College of Obstetricians and Gynecologists. Multiple gestation: Complicated twin, triplet, and high-order multifetal pregnancy. ACOG Practice Bulletin 56. Washington, DC: American College of Obstetricians and Gynecologists; 2004
• 30 American College of Obstetricians and Gynecologists. Gynecologic herpes simplex virus infections. ACOG Practice Bulletin 57. Washington, DC: American College of Obstetricians and Gynecologists; 2004
• 31 American College of Obstetricians and Gynecologists. Pregestational diabetes mellitus. ACOG Practice Bulletin 60. Washington, DC: American College of Obstetricians and Gynecologists; 2005
• 32 American College of Obstetricians and Gynecologists. Urinary incontinence in women. ACOG Practice Bulletin 63. Washington, DC: American College of Obstetricians and Gynecologists; 2005
• 33 American College of Obstetricians and Gynecologists. Management of endometrial cancer. ACOG Practice Bulletin 65. Washington, DC: American College of Obstetricians and Gynecologists; 2005
• 34 American College of Obstetricians and Gynecologists. Episiotomy. ACOG Practice Bulletin 71. Washington, DC: American College of Obstetricians and Gynecologists; 2006
• 35 American College of Obstetricians and Gynecologists. Vaginitis. ACOG Practice Bulletin 72. Washington, DC: American College of Obstetricians and Gynecologists; 2006
• 36 American College of Obstetricians and Gynecologists. Use of hormonal contraception in women with coexisting medical conditions. ACOG Practice Bulletin 73. Washington, DC: American College of Obstetricians and Gynecologists; 2006
• 37 American College of Obstetricians and Gynecologists. Management of alloimmunization during pregnancy. ACOG Practice Bulletin 75. Washington, DC: American College of Obstetricians and Gynecologists; 2006
• 38 American College of Obstetricians and Gynecologists. Postpartum hemorrhage. ACOG Practice Bulletin 76. Washington, DC: American College of Obstetricians and Gynecologists; 2006
• 39 American College of Obstetricians and Gynecologists. Screening for fetal chromosomal abnormalities. ACOG Practice Bulletin 77. Washington, DC: American College of Obstetricians and Gynecologists; 2007
• 40 American College of Obstetricians and Gynecologists. Hemoglobinopathies in pregnancy. ACOG Practice Bulletin 78. Washington, DC: American College of Obstetricians and Gynecologists; 2007
• 41 American College of Obstetricians and Gynecologists. Endometrial ablation. ACOG Practice Bulletin 81. Washington, DC: American College of Obstetricians and Gynecologists; 2007
• 42 American College of Obstetricians and Gynecologists. Management of herpes in pregnancy. ACOG Practice Bulletin 82. Washington, DC: American College of Obstetricians and Gynecologists; 2007
• 43 American College of Obstetricians and Gynecologists. Management of adnexal masses. ACOG Practice Bulletin 83. Washington, DC: American College of Obstetricians and Gynecologists; 2007
• 44 American College of Obstetricians and Gynecologists. Prevention of deep vein thrombosis and pulmonary embolism. ACOG Practice Bulletin 84. Washington, DC: American College of Obstetricians and Gynecologists; 2007
• 45 American College of Obstetricians and Gynecologists. Pelvic organ prolapse. ACOG Practice Bulletin 85. Washington, DC: American College of Obstetricians and Gynecologists; 2007
• 46 American College of Obstetricians and Gynecologists. Viral hepatitis in pregnancy. ACOG Practice Bulletin 86. Washington, DC: American College of Obstetricians and Gynecologists; 2007
• 47 American College of Obstetricians and Gynecologists. Invasive prenatal testing for aneuploidy. ACOG Practice Bulletin 88. Washington, DC: American College of Obstetricians and Gynecologists; 2007
• 48 American College of Obstetricians and Gynecologists. Elective and risk-reducing salpingo-oophorectomy. ACOG Practice Bulletin 89. Washington, DC: American College of Obstetricians and Gynecologists; 2008
• 49 American College of Obstetricians and Gynecologists. Asthma in pregnancy. ACOG Practice Bulletin 90. Washington, DC: American College of Obstetricians and Gynecologists; 2008
• 50 American College of Obstetricians and Gynecologists. Treatment of urinary tract infections in nonpregnant women. ACOG Practice Bulletin 91. Washington, DC: American College of Obstetricians and Gynecologists; 2008
• 51 American College of Obstetricians and Gynecologists. Use of psychiatric medications during pregnancy and lactation. ACOG Practice Bulletin 92. Washington, DC: American College of Obstetricians and Gynecologists; 2008
• 52 American College of Obstetricians and Gynecologists. Diagnosis and management of vulvar skin disorders. ACOG Practice Bulletin 93. Washington, DC: American College of Obstetricians and Gynecologists; 2008
• 53 American College of Obstetricians and Gynecologists. Medical management of ectopic pregnancy. ACOG Practice Bulletin 94. Washington, DC: American College of Obstetricians and Gynecologists; 2008
• 54 American College of Obstetricians and Gynecologists. Anemia in pregnancy. ACOG Practice Bulletin 95. Washington, DC: American College of Obstetricians and Gynecologists; 2008
• 55 American College of Obstetricians and Gynecologists. Alternatives to hysterectomy in the management of leiomyomas. ACOG Practice Bulletin 96. Washington, DC: American College of Obstetricians and Gynecologists; 2008
• 56 American College of Obstetricians and Gynecologists. Critical care in pregnancy. ACOG Practice Bulletin 100. Washington, DC: American College of Obstetricians and Gynecologists; 2009
• 57 American College of Obstetricians and Gynecologists. Ultrasonography in pregnancy. ACOG Practice Bulletin 101. Washington, DC: American College of Obstetricians and Gynecologists; 2009
• 58 American College of Obstetricians and Gynecologists. Management of stillbirth. ACOG Practice Bulletin 102. Washington, DC: American College of Obstetricians and Gynecologists; 2009
• 59 American College of Obstetricians and Gynecologists. Hereditary breast and ovarian cancer syndrome. ACOG Practice Bulletin 103. Washington, DC: American College of Obstetricians and Gynecologists; 2009
• 60 American College of Obstetricians and Gynecologists. Antibiotic prophylaxis for gynecologic procedures. ACOG Practice Bulletin 104. Washington, DC: American College of Obstetricians and Gynecologists; 2009
• 61 American College of Obstetricians and Gynecologists. Bariatric surgery and Pregnancy. ACOG Practice Bulletin 105. Washington, DC: American College of Obstetricians and Gynecologists; 2009
• 62 American College of Obstetricians and Gynecologists. Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. ACOG Practice Bulletin 106. Washington, DC: American College of Obstetricians and Gynecologists; 2009
• 63 American College of Obstetricians and Gynecologists. Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. ACOG Practice Bulletin 107. Washington, DC: American College of Obstetricians and Gynecologists; 2009
• 64 American College of Obstetricians and Gynecologists. Polycystic ovary syndrome. ACOG Practice Bulletin 108. Washington, DC: American College of Obstetricians and Gynecologists; 2009
• 65 American College of Obstetricians and Gynecologists. Noncontraceptive uses of hormonal contraceptives. ACOG Practice Bulletin 110. Washington, DC: American College of Obstetricians and Gynecologists; 2010
• 66 American College of Obstetricians and Gynecologists. Emergency contraception. ACOG Practice Bulletin 112. Washington, DC: American College of Obstetricians and Gynecologists; 2010
• 67 American College of Obstetricians and Gynecologists. Management of endometriosis. ACOG Practice Bulletin 114. Washington, DC: American College of Obstetricians and Gynecologists; 2010
• 68 American College of Obstetricians and Gynecologists. Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin 115. Washington, DC: American College of Obstetricians and Gynecologists; 2010
• 69 American College of Obstetricians and Gynecologists. Management of intrapartum fetal heart rate tracings. ACOG Practice Bulletin 116. Washington, DC: American College of Obstetricians and Gynecologists; 2010
• 70 American College of Obstetricians and Gynecologists. Gynecologic care for women with human immunodeficiency virus. ACOG Practice Bulletin 117. Washington, DC: American College of Obstetricians and Gynecologists; 2010
• 71 American College of Obstetricians and Gynecologists. Female sexual dysfunction. ACOG Practice Bulletin 119. Washington, DC: American College of Obstetricians and Gynecologists; 2011
• 72 American College of Obstetricians and Gynecologists. Use of prophylactic antibiotics in labor and delivery. ACOG Practice Bulletin 120. Washington, DC: American College of Obstetricians and Gynecologists; 2011
• 73 American College of Obstetricians and Gynecologists. Long- acting reversible contraception: implants and intrauterine devices. ACOG Practice Bulletin 121. Washington, DC: American College of Obstetricians and Gynecologists; 2011
• 74 American College of Obstetricians and Gynecologists. Breast cancer screening. ACOG Practice Bulletin 122. Washington, DC: American College of Obstetricians and Gynecologists; 2011
• 75 American College of Obstetricians and Gynecologists. Thromboembolism in pregnancy. ACOG Practice Bulletin 123. Washington, DC: American College of Obstetricians and Gynecologists; 2011
• 76 American College of Obstetricians and Gynecologists. Management of gynecologic issues in women with breast cancer. ACOG Practice Bulletin 126. Washington, DC: American College of Obstetricians and Gynecologists; 2012
• 77 American College of Obstetricians and Gynecologists. Management of preterm labor. ACOG Practice Bulletin 127. Washington, DC: American College of Obstetricians and Gynecologists; 2012
• 78 American College of Obstetricians and Gynecologists. Diagnosis of abnormal uterine bleeding in reproductive-aged women. ACOG Practice Bulletin 128. Washington, DC: American College of Obstetricians and Gynecologists; 2012
• 79 American College of Obstetricians and Gynecologists. Osteoporosis. ACOG Practice Bulletin 129. Washington, DC: American College of Obstetricians and Gynecologists; 2012
• 80 American College of Obstetricians and Gynecologists. Prediction and prevention of preterm birth. ACOG Practice Bulletin 130. Washington, DC: American College of Obstetricians and Gynecologists; 2012
• 81 American College of Obstetricians and Gynecologists. Screening for cervical cancer. ACOG Practice Bulletin 131. Washington, DC: American College of Obstetricians and Gynecologists; 2012
• 82 American College of Obstetricians and Gynecologists. Antiphospholipid syndrome. ACOG Practice Bulletin 132. Washington, DC: American College of Obstetricians and Gynecologists; 2012
• 83 American College of Obstetricians and Gynecologists. Benefits and risks of sterilization. ACOG Practice Bulletin 133. Washington, DC: American College of Obstetricians and Gynecologists; 2013
• 84 American College of Obstetricians and Gynecologists. Fetal growth restriction. ACOG Practice Bulletin 134. Washington, DC: American College of Obstetricians and Gynecologists; 2013
• 85 American College of Obstetricians and Gynecologists. Second-trimester abortion. ACOG Practice Bulletin 135. Washington, DC: American College of Obstetricians and Gynecologists; 2013
• 86 American College of Obstetricians and Gynecologists. Management of abnormal uterine bleeding associated with ovulatory dysfunction. ACOG Practice Bulletin 136. Washington, DC: American College of Obstetricians and Gynecologists; 2013
• 87 American College of Obstetricians and Gynecologists. Gestational diabetes mellitus. ACOG Practice Bulletin 137. Washington, DC: American College of Obstetricians and Gynecologists; 2013
• 88 American College of Obstetricians and Gynecologists. Inherited thrombophilias in pregnancy. ACOG Practice Bulletin 138. Washington, DC: American College of Obstetricians and Gynecologists; 2013
• 89 American College of Obstetricians and Gynecologists. Premature rupture of membranes. ACOG Practice Bulletin 139. Washington, DC: American College of Obstetricians and Gynecologists; 2013
• 90 American College of Obstetricians and Gynecologists. Management of abnormal cervical cancer screening test results and cervical cancer precursors. ACOG Practice Bulletin 140. Washington, DC: American College of Obstetricians and Gynecologists; 2013
• 91 American College of Obstetricians and Gynecologists. Management of menopausal symptoms. ACOG Practice Bulletin 141. Washington, DC: American College of Obstetricians and Gynecologists; 2013
• 92 American College of Obstetricians and Gynecologists. Cerclage for the management of cervical insufficiency. ACOG Practice Bulletin 142. Washington, DC: American College of Obstetricians and Gynecologists; 2014
• 93 American College of Obstetricians and Gynecologists. Medical management of first-trimester abortion. ACOG Practice Bulletin 143. Washington, DC: American College of Obstetricians and Gynecologists; 2014
• 94 Vandenbroucke JP, Koster T, Briët E, Reitsma PH, Bertina RM, Rosendaal FR. Increased risk of venous thrombosis in oral-contraceptive users who are carriers of factor V Leiden mutation. Lancet 1994; 344 (8935) 1453-1457