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Richard Smith: Using data to improve care and reduce waste in health systems

30 Sep, 14 | by BMJ

richard_smith_2014Annual expenditure on healthcare in the United States is currently $2.8 trillion, and about a third of it is wasted, says the Institute of Medicine. The sum wasted is about five times the GDP of Bangladesh, a country of 160 million people. This is waste on a spectacular scale, and reducing it while improving the quality of care is the main aim of the information technology developed by Optum, the services part of the UnitedHealth Group, said Richard Migliori, a former transplant surgeon and chief medical officer of the UnitedHealth Group. I don’t come to tell you what to do, said Migliori speaking last week to the Cambridge Health Network, but I hope to at least elicit your sympathy. more…

The BMJ Today: Thinking diagonally

30 Sep, 14 | by BMJ

will_Stahl-TimminsNational commitments to reducing global CO2 emissions are in the spotlight again after the recent United Nations talks.

Earlier this year, the Intergovernmental Panel on Climate Change published their strongest statements yet about the possible health impacts of global warming. These impacts include increased vulnerability to disease and injury through a variety of mechanisms, including: climate and weather variability; changing patterns of vector borne diseases; and changes to air quality. more…

Richard Lehman’s journal review—29 September 2014

29 Sep, 14 | by BMJ

richard_lehmanNEJM 25 September 2014 Vol 371
1189  This week we start with mepolizumab. Before we know it, we encounter losmapimod. Enough is enough. I think the World Health Organization should convene an extraordinary meeting of the International Nonproprietary Names Committee with the sole purpose of Stopping Silly Names. Medical practitioners are serious people and they should not be expected to trade in nonsense words. When humanized monoclonal antibodies were new and few, it might have made sense to end all their names in zumab, but now there are so many nobody can remember which is which. Mepolizumab is targeted against interleukin 5. The first of two trials in severe asthma with sputum eosinophilia shows that it allows a useful number of people to avoid the regular use of oral corticosteroids or to reduce their dose. In the 24 weeks of the trial, the rate of adverse effects was the same as placebo. more…

The BMJ Today: Death talk in India

29 Sep, 14 | by BMJ Group

deputy chair of MJA on stage (1)How viable is a system of “verbal autopsy” to determine future health policy in a country where most deaths occur outside hospitals, are not attended by doctors, and are not medically certified? Meera Kay finds out more about India’s recently completed Million Deaths Study and the training of non-medical field workers to record written narratives, from families or other reliable informants in the local language, which describe the events that preceded the death.

In a country which has around 110 million smokers, some of these deaths will be smoking related. Last month an expert panel recommended a nationwide ban on e-cigarettes, arguing that their safety has not yet been established. In the meantime, tobacco companies see a market in e-cigarettes to grow and earn huge profits in. more…

Neal Maskrey: When paradigms shift

26 Sep, 14 | by BMJ


When paradigms shift it’s always disconcerting. Thomas Samuel Kuhn published The Structure of Scientific Revolutions in 1962 and it’s become a decisive text on the nature of science. He used the term “paradigm” to describe the belief system that underpins puzzle solving in science. Far from discovering any absolute “truth,” normal science progresses routinely within the boundaries of the belief system as theories are refined, puzzling data are mostly explained, and measurements become increasingly precise. Aristotle’s Physics, Newton’s Principia, and Darwin’s Origin of Species are examples of works that defined paradigms of particular branches of science at certain times. more…

The BMJ Today: Beyond doing no harm, helping can get tough

26 Sep, 14 | by BMJ

kristina_fisterMedicine can do great things, but at today’s things look rather bleak. Nine out of 10 people who are transferred to hospital with cardiac arrest don’t survive to discharge. Some argue that most of these ambulance transfers should not happen at all; others disagree. It’s not about the cost, as Americans have calculated the savings would be less than 0.1% of what the health system loses owing to fraud. But transfer might harm. Do join the discussion, as did Robert H Trenkamp, who tells us better hospital care is possible for these patients and that not so many need to die.

Harm can also come from not including patients in medical decision making. When asked to single out one thing that has made the most difference in her field in her lifetime, Angela Coulter opts for the development of evidence based, patient decision aids. more…

David Lock: Avastin and Lucentis—It’s time for NHS commissioners to act rationally by limiting the choices for wet AMD patients

26 Sep, 14 | by BMJ

The news that a Cochrane Review has concluded that Avastin (bevacizumab) is as safe as Lucentis (ranibizumab) to treat patients with wet age related macular degeneration (“wet AMD”), along with other studies that have shown the two drugs have broadly the same level of clinical effectiveness, comes as no surprise to those of us who have been involved in this debate for a number of years.

Lucentis is a “licensed” drug for wet AMD, whereas Avastin is not licensed for this condition. But Avastin is not an unlicensed drug per se; it is just licensed for a different condition, namely treating patients with certain cancers. The beneficial use of the drug for wet AMD patients seems an unintended and highly cost effective benefit. There is nothing unlawful in clinicians using an unlicensed drug to treat NHS patients, as paediatricians know because they use unlicensed drugs all the time. So why should the NHS keep paying out for a drug that is 10 times more expensive than an equally safe and clinically effective alternative? more…

David Pencheon: Public health’s essential role in sustaining the NHS

25 Sep, 14 | by BMJ

david_pencheon_3Simon Stevens, chief executive of NHS England, illustrated the state of public health at last week’s Public Health England conference by showing the audience his assistant’s lunch deal bought on the way to Warwick. A cheese and pickle sandwich is not bad, but why include the sugary drink and packet of crisps? He then pulled out the “Juicy Bits” that were included in the deal. He had high hopes that they were pieces of fruit, but no, they were sugary sweets. Disgusted, he gave the lunch back to his assistant sat in the front row.

Public health, Stevens said, has a vital role in sustaining not only the health of the public but also the health of the NHS. Spending more on bariatric surgery than on preventing type 2 diabetes, as England apparently does at the moment, is not sustainable. more…

Richard Smith: Patients harmed by misdiagnosed preferences

25 Sep, 14 | by BMJ

richard_smith_2014Linda is 58 and has been diagnosed with breast cancer. She would have preferred not to have surgery but was convinced by her surgeon that it would be the best option. After her operation, the hospital contacted her to apologise as she had not had breast cancer. She’d been misdiagnosed. An inquiry, legal action, and compensation followed.

Susan is 78 and has also had breast cancer. She too did not want surgery but was told that it was the best treatment. Six weeks after her operation, she met a friend of the same age who had also had breast cancer. She had been treated with hormone therapy, having been told that she would probably die of something else before her breast cancer. Susan felt profound regret, but no action followed.

These two women have both been damaged by the health system, said Al Mulley, director of the Dartmouth Centre for Health Care Delivery Science, at a meeting at the Health Foundation last week. And, he said, misdiagnosis of preferences is everywhere. For example, three quarters of surgeons think that losing a breast is the main anxiety of women with breast cancer, but only 7% of women rank that as their main anxiety. more…

The BMJ Today: Time to engage with politics and policy

25 Sep, 14 | by BMJ

Emma-ParishNo sooner had I finished reading my colleague’s blog about taking a global view of health, than I found myself reading Jocalyn Clark’s analysis, which questions where the efforts for solutions to global health issues should be focussed. She states her case clearly: good health is interlinked with the economy and the “medicalisation of global health problems reinforces short term thinking.” She worries that the solutions to three global health concerns—mental health, non-communicable disease, and universal health coverage—are “tilted in favour of biomedical and technical definitions” to the detriment of social and political considerations. more…

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