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April 2010

Doctors and health professionals are often reluctant to put the ball in the court of the patient because that patients will not be able to cope with the responsibility. Last week a Cochrane review update was published about self-monitoring and self-management of warfarin therapy and challenges this concept. Warfarin is an anticoagulant (“blood-thinner”) and is used in several situations, including atrial fibrillation, pulmonary embolism, deep vein thrombosis and patients who have mechanical heart valves. In the latter case, warfarin therapy is for life. The major risk or side-effect of warfarin is bleeding, which can be life-threatening and so in order to check that the blood is not to thin, the “thickness” of the blood is checked regularly by the INR blood test, and the warfarin dose is adjusted accordingly.

Warfarin is a common drug in both primary care and hospitals and there are huge costs associated with INR testing in healthcare settings. The introduction of portable monitors (point-of-care devices) for the management of patients on warfarin allows self-testing at home. Patients who self-test can either adjust their medication according to a pre-determined dose-INR schedule (self-management) or they can call a clinic to be told the appropriate dose adjustment (self-monitoring).

The systematic review included 18 randomised controlled trials with nearly 5000 patients. The risk of death or a clot-related (thromboembolic) event was reduced by 36% and 50% respectively. Importantly, the benefit of self-management alone persisted, whereas, the benefit of self-monitoring was not statistically significant. In other words, it is not enough to let patients just measure their reading; the benefit comes when they are responsible for a treatment change based on that reading. The same paradigm of “self-management” versus “self-monitoring” needs to be tested in other conditions such as hypertension and diabetes in order to improve outcomes and to empower patients.

Why we need the history of medicine.

Carl Heneghan
Last edited 18th April 2010

‘Wellcome Trust is to close its centre for history of medicine’

Denis Pereira Gray, former president of the RCGP, described the decision as “a real tragedy,”

The issue is in removinh funding form the history of medicine will we able to tell where we are going, if we don’t know where we have come from? If you want convincing then visit the excellent James Lind library

I fear the Wellcome trust may have been hijacked by the heady lights of business and wants to disregard what it might consider as ‘fluff’. Oops, there goes any big grant in the future. The BMJ is right at the heart of the matter this week for highlighting the issue ‘No reason has formally been given for the closure, and a spokesperson for the trust declined to elaborate.’

Here’s a few facts worth digesting upon closure:
• In the past the Centre has been led in the past by Roy Porter, noted for his prolific work on the history of medicine He only wrote or edited over 100 books. That puts most of us to shame. You can get a full list here
• William Bynum, Emeritus Professor who orks on many aspects of the history of medicine is quoted as saying: "The decision has been made by people who are not historians of medicine." It is hard to know who made the decision, was it the current governors? Ultimate responsibility for the activities of the Wellcome trust lies with the Board of Governors. Yet, decision-making authority on research funding is delegated to a number of funding committees and day to day running is managed by the Director of the Wellcome Trust and an Executive Board of senior managers.
• In the last RAE status, the centre was given four stars or "world leading" status for 40% of its work and three stars " internationally recognised" for 25%. On that basis we should be closing down about 90% of UK research that performed worse. Fortunately, in our Dept we performed slightly better so at least I can relax slightly about going out of business on this rating scale.

Created in 1936 under the will of Henry Wellcome along with the Wellcome Collection and its medical history library the constitution states,

The objects of the Trust are:
(point 2) to advance and promote knowledge and education by engaging in, encouraging and supporting:
(a) research into the history of any of the biosciences; and
(b) the study and understanding of any of the biosciences or the history of any of the biosciences.
In 2000 the trust undertook a review of the history of medicine in the UK, exploring its development and current status, and considered its role in this area. Many people with history of medicine interests from both the UK and abroad were consulted.

May I suggest Wellcome, it would be prudent, before closure, to do the same again. Otherwise, I fear this may become a contentious issue on the landscape and damaging to UK historical research into medicine, a valuable subject indeed.

I have always wanted to use Cuba Gooding Junior’s line from “Jerry Maguire” in a piece about evidence-based medicine. Development assistance for health (DAH) has increased to fight major diseases and achieve the Millennium Development Goals. DAH
has risen steadily since 1995 from about US$8 billion to nearly $19 billion in 2006, so you would think that it is imperative to show us where that money is being spent. Think again. Although DAH has grown, most public health spending comes from domestic sources. Good data is lacking on domestic versus external funding, despite efforts by World Health Organisation (WHO) to set up National Health Accounts.

In the Lancet online this week, a systematic analysis of all data available for government expenditures on health in developing countries, including government reports and data from WHO and the International Monetary Fund (IMF).It is an admirable piece of work, finding that DAH has risen by 100% in the last 10 years, mostly due to rising GDP (gross domestic product), slight decreases in share of GDP spent by government, and increases in share of government health spending. At the country level, government expenditures to health decreased in many sub-Saharan African countries. Interestingly, DAH to government had a negative effect on domestic government health spending such that for every US$1 of DAH to government, government health expenditures were reduced by $0•43. On the other hand, DAH to the non-governmental sector had a positive effect on domestic government health spending.

In an accompanying editorial, Devi Sridhar and Ngaire Woods of Oxford University, call for caution in interpretation of these results. Firstly, due to poor quality data, a lot of data in the analysis was missing and had to be imputed. Secondly, NGOs are good at carrying out vertical programmes targeting specific diseases (e.g. HIV/AIDS), but not so good at health system integration. Therefore, the authors’ recommendation of standardised monitoring of government health expenditures and government spending in other health-related sectors is probably the right one.

Can anyone understand Evidence in Health Care Anymore?

Carl Heneghan
Last edited 9th April 2010

Imagine you woke up today, and I told you, over the next week read all the available health information that is published and tell me what we should invest in and equally what we should disinvest in: what choices should you make, on an individual basis and at the public health level to maximise your health and others.

My thoughts are this is now such a complex question it may be impossible to answer. One reason for this is the exponential growth of health care information on the worldwide web. Google search for health currently generates 844,000,000 pages.

In the US, 80% of internet users, 113 million adults, have searched for information on at least one of seventeen health topics. Yet, just 15% of health seekers say they “always” check the source and date of the health information they find online, whilst 3/4 say they check the source and date “only sometimes,” “hardly ever,” or “never,” which translates to about 85 million Americans gathering health advice online without asking whether the information is based on credible sources.

Now, imagine if I made it even more complicated, by telling you over the next year you have to come up with a credible plan for rational disinvestment in health care. Now you’re in trouble, for instance the number of randomized trials has gone from 39 RCTs in 1965 to 26,017 in 2008. At current rates we can expect to see 50,000 RCTs per year published by 2018-9.

Now you’ve managed to wade through all this health information and find the articles you need, you are faced with research which is not always transparent. For instance, the so-called “Sunshine Act”, is currently going through the US legislature, aiming to completely overhaul the interactions between physicians and the pharmaceutical industry. Yet, Fiona Godlee tells us in her editorial today that ‘articles that gave a favourable view on the risks were significantly more likely to have authors with financial ties to the manufacturers’. Even if you can locate the evidence that makes a difference, you are often left wondering can you believe it.

You’ve located the studies you’ve got beyond the vested interests and maybe feeling slightly smug but now you have to intepret the statistics. Do people understand statistics, do they trust statistics?

Most of the concepts are foreign to most individuals, even those with advanced degrees and most of us get through education, including university, without ever taking any kind of class in stats. Many surveys show heaps of people lack basic numerical skills that are essential to maintain health and make informed medical decisions. Yet, low numeracy distorts perceptions of risks and benefits of screening, reduces medication compliance, impedes access to treatments, impairs risk communication, limiting prevention efforts among the most vulnerable.

Based on what I have said do you feel equipped to understand the major evidence in healthcare? Well, I haven’t even mentioned the ten major biases that lead to mis-information and the role the media has in all this in relaying the final message. I’ll leave the last of these to the excellent Bad Science

Let me know, is there anyone out there who can understand Evidence in Health Care Anymore?

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