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How do we prioritise the priorities?

Ami Banerjee
Last edited 15th August 2011

Evidence-based medicine aims to put best evidence into practice. Another less-publicised application EBM and epidemiology is the shedding light on the best use of resources or the “biggest” health and public health issues. The National Institute for Health and Clinical Excellence (NICE) aims to judge which treatments and technologies are most “cost-effective” in order to advise policymakers of the treatments which give most “bang-for-buck”.

We are bombarded with priorities, goals and commitments. The United Nations’ Millennium Development Goals are an example of how different stakeholders can be galvanised towards a common set of targets, which may be as important as achieving the goals. Research priorities have begun to be set in the same way. The Grand Challenges in Global Health have highlighted the areas of greatest need in global health research. These are high profile initiatives with scientific financial backing from key players including the Gates Foundation and the Wellcome Trust. Both journals and funders have continual “calls for proposals”, whether it is the Lancet’s latest call for health research in China, or the strategic goals of the Wellcome Trust.

How good are these goals at picking the right priorities? At first glance, they may be wide open to multiple biases and conflicts of interest depending on the interests, both financial and scientific, of stakeholders and the goal-setters. The Delphi method tries to avoid this problem by using the “collective intelligence” of many experts in several questionnaire-led rounds. For example, this method has been used to set the Grand Challenges in Mental Health.

At the World Congress of Epidemiology last week, during a keynote speech by Ivor Rudan, I learned about the Child Health and Nutrition Research Initiative, or CHNRI method, designed to suggest the “best bets” for health research priorities on the basis of evidence and several stages of scoring of different options.

There will inevitably be some wastage in research funding but it is surely a good sign that institutions, whether local or global, want to channel resources towards areas of greatest need and potentially greatest benefit, and that we are developing better tools to set these priorities.

Diet-the Cinderella risk factor

Ami Banerjee
Last edited 1st August 2011

Working in cardiology, it is sometimes hard to keep up with the stream of high-tech gadgets, new drugs and treatment technologies which are constantly changing diagnosis and treatment of cardiovascular disease (CVD). For example, cardiovascular drugs (such as those against cholesterol and lipid disorders, and antithrombotic agents) account for the majority of blockbuster pharmaceuticals.

There is no question that CVD is common, causing more than 150 000 deaths annually in the UK alone, with annual costs in excess of £30 billion. That is why there have been massive, coordinated efforts to focus on every aspect of heart disease treatment and prevention.

However, we tend to focus on the expensive, labour-intensive, training-intensive strategies. For example, primary angioplasty is an invasive procedure to open up blockages in the blood supply to the heart immediately after a heart attack. It requires training of all staff, 24/7 cover and the necessary equipment and post-procedural care. A conservative analysis estimated the cost of a primary angioplasty in usual working hours to be £5176 with an extra £245 if undertaken out of hours. The authors of this study estimated that angioplasty added £4520 for each quality-adjusted life year (QALY) gained. Expensive stuff when you are providing this service to the whole population.

Are there cheaper, lower-hanging fruit? Of course there are, but no drug companies or vested interests are pushing them. Of the neglected risk factors with most public health impact, diet is the Cinderella at the Cardiovascular Ball. In this week’s BMJ, an economic model of CVD in the UK shows yet more evidence for Geoffrey Rose’s population strategy to disease. The authors give us three poignant take-home messages from the study. First, a 5% reduction in mean cholesterol or blood pressure in the population would save the UK at least £80-100 million. Second, legislation to reduce salt intake by 3 g/day (and we are currently having 8.5g/day on average) would prevent 30 000 cardiovascular events and save £40m a year. Third and perhaps most interestingly, legislation to reduce intake of industrial trans fatty acid by approximately 0.5% of total energy content may add 570 000 life years, saving £230million a year. NICE has been pushing for a dietary ban of trans-fats for some time.

Nobody is saying we don’t need the latest and best evidence-based tools and therapies for CVD prevention, but these numbers are hard to argue with. As I finish a night shift, I am going to forego my greasy fry-up for a bowl of muesli after reading this.

It is impossible to avoid the outrage and scandal of the News of the World if you were in the UK this week. One media organisation went too far in its pursuit of sensitive data by tapping phones, and there have been hourly revelations since then, revealing a much greater system problem. Has the media lost its way? Yes it has. The “big scoop” has become more important than respect for individuals and their lives, and the right to know has trumped the right to privacy.

As the scandal crosses the Atlantic and more people lose their jobs, the last few days made me reflect about analogies between the media and medical research, and possible lessons for EBM. Like the news headline writers, data is the major part of what medical research is about as well. It is sensitive data because the content is health information of patients. Thankfully, medical research has to go through multiple levels of ethical review before it is carried out and perhaps the rather lame Press Complaints Commission needs to be replaced with a proper code of ethics for journalism and a body that can enforce it.

The history of medical research has had plenty of ethical issues and scandals which have largely led to improvements in guidelines and the way in which research is conducted. Perhaps most importantly, the involvement of Nazi doctors in unethical research during the Holocaust led to the establishment of the Nuremberg code: ten principles of ethical conduct in medical research in 1949. The World Medical Association developed the Declaration of Helsinki to guide the medical research community regarding human experimentation. But scandals still continue to happen. The impact of Andrew Wakefield’s bogus Lancet paper about MMR has led to huge consequences for childhood immunisation across several countries. Conflicts of interest in research and clinical practice have led to inappropriate regulation of medical devices.

Medical researchers have the privilege of working in fields where their findings can genuinely impact human lives, and ethical research can be done in every area of medicine to make treatment and the patient experience better, even in end-of-life decisions in the intensive care unit.

As a researcher with an interest in epidemiology, a lot of my work involves using patient databases to formulate and test hypotheses. The aim is not “to publish or perish” and get as many papers from the data as possible, and nor is it financial reward. We as researchers should always remember why we are doing what we do: to discover more about health and disease in order to improve outcomes for patients.

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