Dear Dr. Roach: In a recent column discussing the use of aspirin, you made reference to the results of a study that were neither “statistically significant” nor “clinically meaningful.” While I am quite familiar with the concept of statistical significance and believe it is very helpful in interpreting the results of a study, I am not familiar with the latter concept. Are you referring to a poorly designed study or one with too small of a sample? I am wondering whether “clinically meaningful” adds any benefit to the scientifically accepted concept of statistical significance.
P.J.B.
Statistical significance is a concept central to understanding medical or other scientific studies. Often, one group (an experimental group, who may get a new treatment, for example) is compared with another group (the control group, who got some other treatment, usually the standard treatment or, if there is no standard treatment, a placebo). The difference in the outcome is looked at between the two groups.
A statistician employs one of several methods to calculate the likelihood that the difference between the two groups could have happened by chance, called the p-value. If the p-value is less than five per cent, then that is usually considered statistically significant. The lower the p-value, the less the likelihood that the observed difference between the two groups could have happened by chance if the two treatments were identically effective.
Clinical significance, or clinical meaningfulness, refers to the real-world usefulness of the intervention. While the term “clinical significance” is subjective and therefore an opinion, the term nevertheless is useful. For example, with a very large trial, a small difference in effectiveness between the two treatments could have a very significant p-value, as low as 0.0001, with only a 1 in 10,000 chance that the two treatments are equivalent. However, the effectiveness may be 50.1 per cent in one group and 49.9 per cent in the other group. Although statistically significant, the clinical significance is marginal.
If a result is not statistically significant, it cannot be considered clinically meaningful, even if the difference is large, because there is not enough evidence to reject the hypothesis that the difference could have occurred by chance.
It is logically impossible to prove the absence of a difference between two treatments. All we can do is show that it is unlikely that the two treatments are identically effective. Unfortunately, this means that concepts long regarded as true sometimes can be upended by new information. Medicine is not mathematics: Mathematicians can be sure that once a concept is proved, it will stay proved. That is not the case for clinical trials in medicine.
Dear Dr. Roach: Have you ever heard of a gallbladder being stuck to the intestines? That’s what the surgeon found when I went to have mine removed. Two days later, I went home with my gallbladder still in. I am worried about what might happen if I need it removed one day. The surgeon stated that it could be complicated.
M.P.
It’s called an adhesion when different parts of the abdominal contents stick to one another, and adhesions can come from previous surgery, occasionally from birth, or in your case, possibly from an attack of acute cholecystitis, an inflamed gallbladder, usually due to a stone.
Adhesions do make the surgery more difficult, but I am a little surprised the surgeon decided against surgery entirely. The adhesions aren’t going to get better, and operating on the gallbladder when things are quiet is generally best.
The surgeon needs to painstakingly remove the adhesions, taking great care not to damage either the intestines or the gallbladder.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu
