The inadequate evidence base for monitoring in chronic diseases
We often undertake projects with folk who visit the department, and for this systematic review, Ivan Moschetti visiting from Italy and Daniel Brandt from Canada did a great job, undertaking the majority of the spade-work.
Our conclusion is pretty straightforward: ‘Many guidelines for cardiovascular disease do not report clearly what to monitor and what to do if a change is detected. If no evidence is available to support a specific monitoring schedule, this should be explicit in the guideline, with a description of the new research that would fill the gap’.
A lot of money is spent on monitoring in chronic diseases, and based on what we found a considerable amount of it is wasted. Read more
Mobile phones and healthcare improvement
I remember as a medical student how averse to mobile phones the hospital environment was, particularly around patients on cardiac monitors, and even in hospital corridors. Thankfully, most hospitals are more sensible in their approach these days; allowing relatives and patients to use their phones in most hospital areas at a time when communication is very important to them.
Most of the fear around health risks posed by mobile phones has focussed on cancer. A major review of existing studies showed that mobile phone use led to “no increased risk within approximately 10 years of use for any tumor of the brain or any other head tumor”. This data is particularly strong for fast-growing tumors (e.g. malignant glioma). On the other hand, for slow-growing tumors (e.g. meningioma and acoustic neuroma), the observation periods of mobile phone use within studies have been too short. Similarly, a case-control study published this year in the BMJ showed no association between risk of early childhood cancers and maternal exposure to mobile phone base stations during pregnancy.
It turns out that mobile phones are of great interest to medical researchers: 2602 hits in Pubmed to-date with 160 review articles. For over 10 years, the potential of telemedicine and mobile phones as a force for good in healthcare has been explored. The benefits of mobile phone usage in disease management programmes have been found across many diseases, from reducing frequency and duration of heart failure hospitalisations and self-monitoring of glucose in diabetes to obesity and hypertension.
A systematic review titled, “Healthcare via cell phones identified 25 studies that evaluated cell phone voice and text messaging interventions, with 20 randomized controlled trials and 5 controlled studies. “Frequency of message delivery ranged from 5 times per day for diabetes and smoking cessation support to once a week for advice on how to overcome barriers and maintain regular physical activity. Significant improvements were noted in compliance with medicine taking, asthma symptoms, HbA1C, stress levels, smoking quit rates, and self-efficacy, …….with implications for both patients and providers.”
As bluetooth technology improves to allow remote assessment of patients, particularly in blood pressure monitoring, it seems that mobile phones may represent one of those rare technological advances that can also be useful in low resource settings. The Lancet Online published the results of a randomised controlled trial from Kenya today showing that mobile phone communication between health-care workers and patients starting antiretroviral therapy improves adherence to therapy. 538 clinic patients starting antiretrovirals were randomised to either receive weekly SMS messages from a clinic nurse or to standard care with impressive NNTs. To achieve greater than 95% adherence, only 9 patients needed to receive SMS messages, and to achieve suppression of the viral load of HIV only 11 patients needed to get SMS reminders. The (SMS) message is very clear. Health professionals have to stay afloat of technology and use all available tools to improve healthcare outcomes, maybe even more so in resource-poor settings.