Cardiac rehabilitation-the poor relation of treatment and prevention
Coronary heart disease (CHD), which usually presents as a heart attack (or myocardial infarction, MI) is the most common cause of death and disability both in the UK and globally. The way in which CHD is treated and prevented therefore has huge implications for patients, health professionals and policymakers. Once a person has a heart attack, prevention of further heart attacks, stroke or death, or secondary prevention, is crucial. There is strong evidence for benefit of several drugs and treatments after heart attacks to this end, including aspirin, statins, ACE inhibitors and beta-blockers. Such treatments have undoubtedly saved lives, but studies in the US and the UK, have shown that between 30-60% of MI patients receive appropriate treatment. There are strong arguments for giving more people the right drugs with benefits in terms of mortality and cost-effectiveness. Current NICE guidelines therefore recommend these treatments for all patients following a heart attack.
This week, the British Heart Foundation reported that only 38% of such patients were receiving adequate rehabilitation care. “Cardiac rehab includes advice from dieticians, physiotherapists and psychologists about how to live with the consequences and improve the survival chances following heart attacks, coronary artery bypass operations and angioplasties.” The components of cardiac rehab have benefits individually and together. For example, a review of 46 trials including 9000 patients showed that exercise-based rehabilitation reduces all deaths by 20%, and cardiac deaths by 26%. Some patients are too ill to benefit from cardiac rehabilitation, and others choose not to partake or continue with the rehabilitation programme.
Provision of drug treatment and primary angioplasty programmes has improved more than cardiac rehabilitation, which has remained the poor relation. This is partly because we tend to favour treatment rather than prevention, and pills rather than behaviour changes. To a greater extent than other treatments, cardiac rehabilitation needs the commitment of the patient. However, this does not mean that we cannot be innovative in designing ways of increasing access to this vital aspect of care for patients after MI.
Carl Heneghan and Matthew Thompson on Tamiflu in children: what’s all the fuss?
Carl Heneghan:The last few days has been hectic since the publication of our systematic review in the BMJ on the use of antivirals in children. By now, you are probably aware of the findings given the media interest. Basically, our study raised questions about the usefulness of antiviral flu drugs in preventing and treating flu in children, indicating the harmful effects may not be justified by the limited benefits provided. This puts us in direct conflict with the DOH policy of antivirals for all. I think what is important in the present pandemic is to remember how we spent a number of years preventing a similar strategy with the use of antibiotics in sore throat; especially when the published research showed limited benefits in mild disease and the emergence of resistance became a real issue. We have been slightly overwhelmed by all the media but are trying to keep a cool head. Having just come out of an interview on the Becky Anderson Show on CNN live at 9 o’clock on Wednesday there are a couple of things I have learnt over the last few days that have been helpful. One is to keep up-to date with the news on a daily basis. Why? Well when you are live on TV and the interviewer asks you in a forceful way: “WHO continues to recommend use of antivirals as treatment for people who are severely ill or are at risk of other health complications,” “isn’t your advice in direct conflict with the WHO?“ Difficult question to answer when you are on live TV and you are about to directly question whether the WHO advice is correct. However, as I said keeping up to date is the trick, because if you read the rest of the guidance it goes on to say: “However, it also stressed that the antiviral, made by Swiss pharmaceutical giant Roche, should not be taken by those showing just mild flu-like symptoms.” Having knowledge of and being able to reverberate the above statement made the whole interview go much smoother. Over the last few days Matthew and I have also been canvassing a number of GP colleagues to see where they stand on this and reassuringly they are in accordance with the advice in mild disease. On a lighter note, what is the best way to keep up to date? I find google news and reader effective. You can easily set yourself up email feeds for key words and guidance and alerts on google reader. Also, believe it or not, I find twitter very useful: I follow about 50 people or organizations – such as the BMJ who give great information and updates on news stories as they emerge: but, because they only have 140 characters you never feel overwhelmed by the amount of information provided. Finally doing the press briefings with two of you makes it a lot easier; you can bounce ideas off each other, check where you are up to and distribute some of the workload around so you can meet all of the commitments. Carl Heneghan is Clinical Lecturer and Deputy Director of the Centre for Evidence-Based Medicine in the Department of Primary Health Care at the University of Oxford. He is also a General Practitioner.
Matthew Thompson:The last few days have been a bit of a whirlwind, with normal work and meetings put on hold for now. Fortunately, I have a quiet day in surgery this week, so managed to gather thoughts and do some real work and see some real patients. This is certainly the biggest press event I have been involved in, and suspect the same is true for our Department. Left me thinking how often the BMJ gets such international attention. Overall, it was great to have a paper fast tracked in the BMJ - the usual weeks or months of waiting to hear about reviews etc was compounded into a couple of weeks, and at times days. What this meant was rapid fire back and forth responding to the journal, editor and proof reader comments – helpfully all fielded by Carl while I managed to drag myself away from my holiday in France to check manuscript versions etc at a cyber cafe. I thought the paper would generate some press interest, but was honestly surprised that it has been such a big story. I suppose the combination of swine flu, children, government policies, big pharma etc. was too much to ignore, especially on a relatively quiet week in the press. The question now in my mind, is what to make of the media onslaught that followed? First of all I was amazed by the skills of many of the reporters - they seemed to be able to turn new information (after all we have been working on this paper for a couple of months, they had a few minutes) into coherent questions and statements for live TV. They did this incredibly rapidly. For instance it took the BBC four minutes to post the story online after the embargo time. Carl and I both did a bunch of live interviews on TV and radio. Years ago, I used to be terrified to put my hand up in the class at school (you know the shaky voice, trembling chest type anxieties); but overtime the nerves for these big occasions have lessened. I think the major issue is being confident in knowing what you are talking about form a knowledge and a methodological aspect In terms of live TV interviews what I found tricky was looking directly into the camera (which you cannot really see as it is disguised in some black hole), while being blinded by studio lights, while the producer is giving you a countdown in one ear, and all the time trying NOT to look at the screen, with the live pictures on it, which were always curiously situated off to one side. If you do look at the screen to the side then you have the appearance of looking really shifty! Was the reporting fair? Well mostly it was. Clearly no-one is going to report the umpteen thousand words of carefully crafted systematic review, so very brief take home points were inevitable. A few of the headlines were ever so slightly over the top, i.e. the “pig flu drug bad for children”, and you could clearly see how both the print and TV would try to grab attention with a catchy headline followed by more balanced report. As the media interest died down (as it inevitably does), I wondered if it had been too over the top. A day in surgery was a good way to reflect on it all, none of my patients mentioned that they had seen me on the news, which I was kind of glad about. It was nice “just” being a GP for a day again and focussing on day to day clinical problems (interesting no-one with suspected swine flu that day though…). Should we have done a press release at all, or just let it sneak out there via the on line BMJ and eventually trickle into the news? Well, we believed the research and our conclusions were valid, and that we were addressing a really important clinical problem …..so why not? Should we have told the UK Department of Health first, or asked for comments from the WHO, or the pharmaceutical manufacturers of the antivirals….. where would you stop? What if they didn’t really like our conclusions, would we have changed anything? Not really. So, if the point of research is to actually inform clinicians, patients, policy makers etc, I think we were right to get this particular research study out there into the world. Matthew Thompson is a GP in Oxford, and a clinical scientist at the Department of Primary Health Care at the University of Oxford. He trained originally in Glasgow, but has since worked in South Africa and the USA as a GP. He combines GP work, with research mostly into children’s health issues in primary care, as well as teaching evidence based medicine and supervising academic GP fellows.
US Healthcare debate 2009. Should passion and anecdote ever outweigh evidence?
Gobsmacked, bamboozled, annoyed: my emotions on following news stories about the ongoing US healthcare reform debate this week. Then came the onslaught on the UK’s National Health Service by various Americans and Tory MEP, Daniel Hannan. Hannan described the NHS as “a 60 year mistake" and that he "wouldn't wish it on anyone". The Republican former vice-presidential candidate Sarah Palin has called health rationing by NICE "downright evil" , referring to it as a “death panel”. Stephen Hawking has come to the defence of the NHS and even the PM has been Twittering his support.
Everybody is entitled to an opinion. Hannan’s last blog entry on 14th August had drawn over 450 comments from both supporters and fervent opposers of his standpoint. When a person in authority gives an opinion, it is naturally given more coverage than if a member of the public made a statement. Therefore, politicians have a responsibility to check their facts before opening their mouths and we, the public, whether in the UK or the US, have a responsibility to check the facts. In his blog, “The NHS row: my final word”, Hannan argues the sales pitch for his book, “The Plan: Twelve Months to Renew Britain”, which has “a lengthy chapter on healthcare which sets out how Britain compares with other countries in terms of survival rates, waiting times and so on”. Since when did whether or not a book is a bestseller equate to factual scientific evidence? And would you take financial advice from a doctor? Would you take plumbing advice from a banker? Then why are we listening to a politician/bookseller to tell us what is best for the US or the UK’s health?
As somebody who trained and works in the NHS, I know that it has many flaws and many changes are necessary. However, we have to get our facts right when comparing with other systems. I have previously blogged about how charges and private user fees make health systems less fair and less efficient. I am not going to repeat the evidence that is freely available in the public domain. In a nutshell, the UK spends half of the US on healthcare as a percentage of GDP and per capita, has lower infant mortality and higher survival rates as a population. Most importantly, the US comes bottom out of industrialised nations in terms of health equity and 15% of its population do not have health insurance, whereas every UK citizen, regardless of who they are, what colour they are, where they are, is entitled to NHS care.
Atul Gawande, a surgeon and public health advocate in Boston, wrote a great piece in the New Yorker in June about the financial incentives which have led to a country with spiralling health costs and inadequate health services for its population, and makes a strong case for universal health insurance in the US. This week’s NEJM includes a review of recent US nationwide opinion polls, showing that “most of the public wants a major change in the health care system. But majority support for a specific legislative proposal will depend on Americans’ believing that they and the country will be better off if such a change is enacted”. Obama has higher approval ratings than Bill Clinton, the last man to attempt US health reform on this scale and he likes evidence-based medicine, which shows that the US is failing its citizens at the moment. If he can’t make America focus on the health of its population, nobody can.
Steroids good in sore throat, Tamiflu not that good in swine flu
It has been difficult to resist blogging about swine flu as the furore surrounding the pandemic has grown over the last four months, but I am finally giving in to temptation. Recently, the estimated new cases of swine flu per week fell from 110,000 to 30,000 in England. The government has stuck by its policy of offering antivirals to anyone infected and has stockpiled Tamiflu, but it now appears that this strategy may be unhelpful in children. The UK Department of Health has moved from the “containment” phase to the “treatment phase”, recommending antiviral treatment in “at-risk groups, “…defined as those who are at higher risk of serious illness or death should they develop influenza,” including children under the age of 5.
A meta-analysis by members of Oxford’s Centre for Evidence-Based Medicine studied the seven randomised trials of Tamiflu (oseltamivir) and Relenza (Zanamivir) in seasonal flu in children, and has shown that Tamiflu probably has no role in children. Although none of the trials looked specifically at swine flu, the authors concluded that the H1N1 virus was unlikely to be that different. Importantly, there was no added benefit of use in Tamiflu in children with asthma, a population defined as high-risk by the Department of Health. Conversely, Tamiflu increased the risk of vomiting in already sick children. Their bottom line for treatment was that Tamiflu reduced the course of flu by 1 day (on average) in an illness that usually last 7-10 days. Their bottom line for prevention was that a 10-day course of Tamiflu propylaxis reduced the risk of flu by 8%, meaning that 13 children need to be treated to prevent 1 case of flu. “In the current pandemic, there is a pressing need to understand the benefits and potential adverse effects of these drugs as the current evidence base supporting this age boundary is limited.” That’s an understatement if ever I heard one.
The CEBM boys and girls have also been busy doing another meta-analysis in this week’s BMJ, but this time looking at the role of steroids in sore throat in adults and children. An evaluation of 8 trials including 750 patients showed that steroids increased the chance of complete resolution of pain at 24 hours by three-fold, particularly in severe throat infections. It seems we sometimes can’t see the wood for the trees when it comes to drugs. We are much more likely to trial complex, expensive therapies than simple, older, and often more effective treatments, which might actually save the National Health Service some money.
Will a 48-hour working week for doctors affect patient safety?
Ara Darzi’s departure as health minister last month was steeped in speculation and controversy for many reasons including how long one has to serve as a government minister to earn a place in the House of Lords, and whether clinicians can be effective in political roles and vice versa. Like many others, I think he has left his legacy by emphasis on at least three crucial aspects of the NHS: high-quality care for all; “clinicians as practitioners, partners and leaders” and innovation.
This week’s New England Journal included Darzi’s recommendations for US health reforms, which are being debated and observed all over the world. One of his prescriptions is “placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies”. One facet of this responsibility is ensuring safe working conditions for health professionals. In the NHS Next Stage Review, published in July, he talks of the significant changes in work culture in the last decade: “Pay and conditions have been made fairer. This was an almost silent revolution in making sure that the NHS recognises and rewards the talents of all its staff. Significant workforce contracts were changed, in partnership with the professions. There was an unprecedented investment in education and training that saw the largest expansion in the numbers of doctors, nurses, and other clinicians for a generation.”
One of the major changes of the last 10 years has been in doctors’ working hours. This happened largely due to the large body of evidence from all over the world, but particularly from the US, that showed negative outcomes for patients when doctors (usually early in their training) worked 100-hour weeks. In critical care, medicine and surgery, the mistakes made when doctors were tired were probably of most concern. Studies have shown that less mistakes happen when doctors were not sleep-deprived. Comparisons were made between working conditions in other professions with a similar responsibility for the lives of others. Doctors’ hours were found to be far longer. The long hours also had negative impact on doctor and patient satisfaction and medical training. This week, under European law, it became illegal for doctors to work more than 48 hours per week in the UK.
It is very unlikely that all doctors in all hospitals will immediately meet these time limits largely due to work culture and constraints on time and resources within the NHS. There are also legitimate concerns about the adequate training of future generations of doctors. Data suggest that it is not just doctors’ hours that are the problem and focusing on this aspect alone will not bring a comprehensive solution in the UK or in other countries. However, as long as future changes are made in consultation with doctors and with the welfare of patients in mind, as Darzi recommends, we are surely moving in the right direction.