The gaps between evidence, quality and policy
Microcredit is an idea that has won the brains behind it, Professor Muhammad Yunus, a Nobel Peace Prize, and has received billions of dollars in terms of global funding. The idea was simple: very small loans could make a disproportionate difference to a poor person, and so the Grameen Bank and many similar institutions like it have opened around the world. However, only one randomised control trial has ever been done for this intervention in Hyderabad and actually showed no benefit. So what we are saying is that billions of dollars have been spent with potentially no effect. Shouldn’t this study have been done earlier?
It got me thinking that regardless of the arena, whether policy, clinical practice, healthcare or economic, lack of the right kind of evidence can lead to the wrong intervention. As large-scale NHS reforms are upon us, this is particularly important.
Quality improvement is something which all adaptive organisations should be doing as part of their daily work, but it turns out that this fairly new discipline is gaining huge popularity because this vital component of clinical practice has been neglected.
In JAMA this week, the results of an RCT of a multi-centre, multi-component intervention to improve quality of intensive care were published. Like Atul Gawande’s surgical checklist, the authors took 6 quality measures that have been proven to improve patient outcomes(prevention of ventilator-associated pneumonia (VAP), prophylaxis for deep venous thrombosis (DVT), daily spontaneous breathing trials, prevention of catheter-related bloodstream infections, early enteral feeding, and prevention of decubitus ulcers) and looked at over 9000 ITU (intensive therapy unit) admissions across 15 Canadian hospitals.
ITUs were randomised to receive an intensive programme (including audit, video-conferencing and expert-led education) to increase adherence to these 6 measures or to continue normal practice. The authors found that the adoption of the 6 target measures was twice as likely in the intervention group, compared with the control group.
In an accompanying editorial, the urgent need for high quality science such as this complex trial, in quality improvement is highlighted. If it can be done in critical care medicine, then it can be done in any area of healthcare or policy. The fact that it was funded by a healthcare organisation as opposed to a central funding agency is also seen as a positive aspect, since all stakeholders have a part to play in improving quality and reducing costs. Those parties that argue that evidence is too difficult or takes too long might end up making costly mistakes.
Slow and steady wins the race when it comes to heart failure
Heart failure is a major cause of death all over the world, but also causes a lot of disability as a chronic condition, especially with ageing populations. 2-3% of the population suffer with heart failure. Heart failure patients are often prescribed a whole range of medicines to treat their blood pressure, kidney disease and many other conditions. One more tablet called IVABRADINE (or Procoralan) looks set to join the list. I just saw the results of the SHIFT trial presented at the European Congress of Cardiology in Stockholm today and they were simultaneously published in the Lancet online.
50% of heart failure patients have a high heart rate (defined as greater than 70 beats per minute). Beta-blockers reduce the heart rate and have been shown to reduce mortality in heart failure. However, they are not always tolerated well, partly because they also cause a drop in blood pressure. Ivabradine is a new drug which reduced heart rate without much effect on blood pressure, and so may be a new option to treat heart failure.
The SHIFT trial was a double-blinded, placebo-controlled, randomised controlled trial of ivabradine in 6500 patients with moderate to severe heart failure and a regular heart rhythm. This trial specifically looked at the heart rate of patients at the start of the trial (“baseline”) and throughout the trial. The main or primary outcome of the trial was death or hospitalisation due to heart failure. Double blinding means that neither the patients nor the researchers knew which treatment the patients received. Controlling with a placebo allows the researchers to estimate the effect of the drug beyond no treatment. Randomisation means that patients randomly received placebo or the drug (in this case, ivabradine), and removed bias in the selection of patients. The trial lasted for just under 2 years.
Basically, ivabradine reduced death and hospitalisations by 18%, and the drug was very well tolerated, with few side effects of unduly low heart rate (bradycardia) or low blood pressure. The authors concluded that for every 1 beat per minute increase in heart rate, there was a 3% increase in mortality in a continuous relationship. They also found that baseline heart rate predicted the degree of risk of death, and interestingly, patients with the highest heart rate at baseline had the greatest reduction in heart rate with the drug, ivabradine. High heart rate has been shown to be a “risk marker” for outcome of patients with heart failure. This trial seems to suggest that a high heart rate may also be a “risk factor” for heart failure, i.e. it may have a role in causing the disease. Either way, “the slower, the better” seems to be the motto for the heart when it is failing.