Questions about healthcare

I may not have seen a pharmaceutical rep for over five years, but still the branded pens they gift to medics continue to infiltrate my house and my handbag. I conciously throw out the drug company pens I find, but they just seep back in: every time I lose my own plain biro, there is another pen somewhere near, in a ravishing colour or with streamlined design, beckoning to take its place.

The reasons why I don’t like seeing drug reps are several. But mainly they come down to this: time is precious, and unbiased appraisals of evidence are better delivered elsewhere. Reps are there to sell, and fair evidence should not need ‘sold’.

But this may not be quite enough. An interesting paper in the Archives of Internal Medicine has examined the effect of exposing medical students exposure to brand logos on equipment – stickers on clipboards or branded notepaper – prior to being asked about the implicit attitudes towards these drugs. The students who had been exposed to the promotional material held higher implicit values for the promoted drug compared with the control group.

There are obvious limitations to this study - it is a single study performed with one cohort of students, and it does not necessarily mean that prescribing is going to vary with the presence of promotional gifts. Yet we don’t know that it doesn’t. Here is a report in Pharmaceutical Field magazine calling on reps to find those ‘rare but lovely creatures’ – GPs who see reps daily. We now have the internet and excellent sources of information. I do not think that pharmaceutical sales reps are needed, or advantageous to patient care. 

A couple of other potential harms bother me. First, pharmaceutical reps are usually highly qualified and very able individuals. They are utterly wasted in being drug reps.  And second, do people seeing their doctor feel any differently for the presence of branded goods in the consulting room?

The ritual of weekly baby weighing clinics is unlikely to end anytime soon, and so I am delighted to learn that – at last- the old World Health Organisation baby weight charts are being ditched in favour of more evidence-based ones.  Previously, the charts “smoothed over” the differences in normal childrens’ weight gain in the first two weeks of life: now, the fact that “all infants show different patterns of weight gain” in these two weeks is accepted and instead the weight gain relative to birth weight is more important. Additionally, there are now charts specifically for pre-term infants.

I am sorry to say that I never knew the old infant weight charts to be contentious until I (or my child) was on the wrong side of them. The old charts were based on forumula-fed babies. Breast-fed babies, having a different pattern of weight gain, tended to look malnourished on the old charts rather than thriving.

The charts are free to download from the Royal College of Paediatrics website.

I live with an Irishman, which means that at home we drink Barry’s Tea. In my early married life I was “not allowed” this Irish brand, as apparently I did not appreciate it enough. Now, there is a supplier in Glasgow and we no longer have to import boxes of the elusive blend from Dublin. I am still not allowed to make it, however, as there is a very specific brewing time – at least five minutes, so I’m told.

This method of preparation may be a good thing, for in the process of brewing, then adding milk, the tea is never piping hot. According to a recent study in the British Medical Journal, the temperature of tea could be a risk factor for cancer. The habit of drinking of hot tea in Iran, where the study was conducted, seemed to increase the likelihood of developing oesophageal cancer.

More than 80 per cent of oesophageal cancers are diagnosed in the developing world; men, too, are at increased risk, accounting for almost two-thirds of sufferers. In Iran, there are 17.6 cases per 100,000 of the male population; in China, the rate is 24; and in England, it is 14.

The remainder of the article can be read here. Please post comments below.

Or perhaps not so much a makeover, but a radical shift in how drug research is decided upon, performed and reported. The suggestions come from Sir Iain Chalmers, who is editor of the James Lind Library in Oxford, and Silvio Garattini, director of the Mario Negri Institute for Pharmacological Research in Milan. Writing in the British Medical Journal, they say that their proposals would not only benefit patients but also industry, which is not winning any prizes for popularity at present.

They are:

1) Patients to be involved in shaping the research agenda – in other words, making sure research questions have resonance in real life and real-world situations

2) Legal requirements for research to be published, including trial protocols, by all (mandatory publication of trial data has had legal backing in the US since late 2007; no such protection for patients currently exists in the UK)

3) Independent evaluation of drugs. As the paper says: “The monopoly that the drugs industry has in evaluating its own products, and the secrecy surrounding this process, leads to biased evidence that is currently only rarely questioned by independent studies.”

4) A requirement to demonstrate “added value” for all new drugs – is this drug better than the current best drug treatment, or does it benefit in addition to it, and is it better than non-drug treatments? Too often, trials are done comparing a new treatment to placebo where there is a known intervention which is better than placebo. This means that uncertainty about how to use it best persists.

The authors say that these would help improve public confidence in pharma, would improve returns from investment in R&D, but could also improve efficiency in other ways. For example: “Tim Mant, a director of a major contract research organisation, has acknowledged how frustrating it is to be commissioned to organise a clinical trial that he knows is going up a scientific blind ally because he has been there previously with another company but cannot divulge information that is commercially confidential.”

I hope that people in the pharmaceutical industry take notice: I would genuinely love to write about the improvements that are being made.

The weight-loss industry never seems to slim down. Now it is no longer just liposuction that surgery offers. Bariatic surgery, which deals with the treatment of obesity, is another option, but isn’t a quick fix. Like any operation, it has its risks – and people carrying extra weight often face problems with anaesthesia.

The National Institute for Health and Clinical Excellence (Nice) recommends weight-loss surgery, but only in specific circumstances: it is considered suitable for adults with a body mass index of greater than 40kg/m2, or for those with a BMI above 35kg/m2 who have another condition such as high blood pressure or type 2 diabetes and who have been unable to lose weight through diet, exercise or medication. The patient must receive intensive care via a specialist obesity service, and is encouraged to submit to long-term follow-up. Nice also recommends that surgery is used in the first line where the BMI is above 50kg/m2.

This kind of surgery usually consists of reducing the size of the stomach or bypassing it. It is often successful: one study found that there was a mean reduction in body weight of 23.4 per cent after surgery. However, this study didn’t compare surgery with medication used for weight loss – and indeed a lack of comparative evidence is one criticism levelled at the surgery.

The remainder of the article can be read here. Please post comments below.

I was talking to a composer a few weeks ago. “This stuff doesn’t really exist except when it’s played,” he said, pointing to his score with heavy despair. “Whereas you’ve got a job where you can actually see that you are doing something good.” He couldn’t understand that my protests to the contrary were genuine: doctors cannot always be sure that they are making a positive difference.

Medical history is stuffed with examples of bad practice – lobotomy for just about anyone with a mental health problem, tonsillectomy for most people with a sore throat, bed rest for everyone with low back pain. I may exaggerate, but only a little. Even now, we don’t seem to appreciate the value of analysing what we are doing.

The US Senate has just passed a bill putting $1.1bn into research aimed at identifying which medical treatments work and which don’t. This sounds like a good idea, but of course not all research is created equal. Regular readers will be aware, for example, of the conflicts surrounding the Department of Health recommendation that all over-65s receive a flu vaccination. Some evidence supports vaccination, some indicates that it does not improve mortality rates. What to believe?

The remainder of the article can be read here. Please post comments below.

The BMJ have got a good personal view written by Emeritus Professor Michael Oliver. It’s entitled “Let’s not turn elderly people into patients” and is based on the Prof’s own experience of healthcare.

I suspect there are a fair amount of doctors both in hospitals and general practice who sometimes talk, over coffee, about whether or not their medication does any good at all and in fact just does harm – or maybe I just associate with medics who are as cynical as I am. The trouble is that this attitude may be cynical, but is often correct. All medicines have side effects. Medication used for preventing cardiovascular disease is increasingly commonly used in more people – especially, as the Prof says, in older people, 75+ - yet the margin of possible benefit may be small. Sure, if people want to take medicines and have been properly and fairly advised about them, fine. But all too often, standardised protocols are applied with such rigour that the person’s opinions about their options aren’t highly prioritised.

I doubt that there has ever been a golden age in medicine, but the current obsession with clinical guidelines, and the GP contract and hospital targets which prioritise political targets over clinical ones are dreadful. What is worse is that the medical “profession” seems to have given up objecting and has more or less accepted them.

Duchy Originals was established by the Prince of Wales in 1990 to raise the profile of organic food and farming. Lines from the company, which gives its profits to the Prince’s own charities, include Rose and Mandarin Shampoo, oaten biscuits, sherbet lemons and handmade Sandringham Strawberry Preserve.

With regal glee, the Duchy website recently announced a new product range. “Suffering from the sniffles? Try a Duchy Herbal Remedy!” Andrew Baker, Duchy’s chief executive officer, said: “Our decision to launch these products reflects The Prince of Wales’s passion for integrated healthcare.” Well, my own pleb’s passion is for evidence-based healthcare that doesn’t cost more than it needs to. So, let’s look at the evidence.

First, the “Detox Artichoke and Dandelion Tincture”. It allegedly can “help support the body’s natural elimination and detoxification processes”. There is no scientific evidence to support the need for “detox”. Detox is a concept which is designed to make us feel that there is a quick fix to long-term excess. There isn’t. The product costs £10. I think this represents particularly bad value.

The remainder of the article can be read here. Please post comments below.

The number of computer programs that promise to sharpen, train and preserve brain function seem to be proliferating. There has been a lot of press coverage about a paper in the journal Alzheimer’s and Dementia . The authors reviewed all the evidence available on interventions aimed at preserving cognitive function in healthy elderly people. Just as I say in point number five of the 10 steps to health in ’09, the authors point out that there is no decent evidence that these kinds of programs work. Furthermore, they may even come with potential harms.

As Professor Peter Snyder, one of the co-authors, wrote in an e-mail to me yesterday: ”There are several lifestyle-related things that older persons can do that have much better clinical data supporting their effectiveness, for possibly delaying onset of dementia.  First, there is truly excellent physiological, neurological and clinical outcomes data supporting the role of regular exercise – even three times per week for 20 minutes per session of exercise (e.g., fast walking).  Second, we know that obesity, diabetes and heart-disease are all risk factors for Alzheimer’s disease.  Finally, I suspect that remaining cognitively active does indeed offer some protective benefit… the point of my paper is that there are no credible data to support the increased benefit of these marketed products and brief interventions, over maintaining a socially active lifestyle, remaining engaged and active with family and friends, learning new hobbies, music or a foreign language, playing Suduku or crossword puzzles, cooking, and reading good books on a regular basis.”

Personally, I find this advice very life-affirming.

The snow falls, public transport grinds to a halt, schools are closed, and the Met Office issues “severe weather” warnings.

And death rates go up: as the temperatures drop, so-called “excess winter mortality” kicks in. This phenomenon has been noted in many other countries, too, but why does it happen? A reasonable suggestion is that fuel poverty and cold living conditions cause people to become unwell and a proportion to die. A large study published in the BMJ a few years ago, found that for people aged over 75, being female or having respiratory illness were risk factors for increased mortality. But there was no relationship found between increased mortality and either having trouble heating the house or suffering financial difficulties. In other words, providing winter fuel allowances – which the UK does - was not, according to this study, going to be enough to protect people from excess winter mortality. Interestingly, a study trying to find risk factors for excess winter mortality in New Zealand concluded that there was a ‘surprising’ lack of relationship to commonly supposed risk factors – making it difficult, of course, to know what to do to protect people from it.

In Siberia, there is only excess winter mortality when the temperature dips below 0 degrees C, unlike in Europe where the excess mortality starts above this. So what do they do differently in Siberia? In an interview study of 1,000 Russians, published in the BMJ in 1998, the researchers noted their ability to keep their homes cosy even when outside temperatures dipped below -25 degrees C,  and the admirable amount of clothing they wore. The average number of items of clothing was 16, with the average layers of clothing worn being 3.7. This reflects another study published by the Lancet in 1997 which concluded that fewer clothes, less activity and colder homes across Europe were all related to higher mortality.

It is therefore quite nice to not only feel justified in my rather large collection of assorted hats, gloves, scarves, coats, boots and various other apparel which I  can now not only consider essential, but can also heartily recommend to others.

Margaret McCartney’s Blog

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A forum on healthcare policy and professional issues, by Glasgow-based GP and FT Weekend columnist Margaret McCartney.

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