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Placenta praevia – more than just a “case”

2 Feb, 17 | by BMJ Clinical Evidence

Like many things in Obstetrics, placenta praevia is unpredictable. In the past women who bled were often admitted from 34 weeks but now the care is often more individualised with more women staying at home. Women are told to have safety precautions in place, and that they must be able to attend hospital quickly in the event of a bleed. However, there are those who have recurrent bleeds and, ultimately, are advised to stay in hospital until delivery.

We don’t often appreciate the emotional toll on women who have the constant anxiety of a potential bleed hovering over them. This unpredictable threat can be a great source of stress due to a very real risk of obstetric haemorrhage and preterm birth. more…

A call for action: improving decision-making in the commissioning of health services

27 Oct, 16 | by BMJ Clinical Evidence

sian-jonesalison-turnerBy Siân Jones and Alison Turner

While evidence based medicine (EBM) has been promoted for over 20 years and has influenced other disciplines like nursing, little attention has been paid to decision-making in NHS clinical commissioning: the planning and purchasing of services to meet the healthcare needs of the local population. Where EBM supports clinical decisions on an individual patient basis, there is no equivalent philosophy for commissioning, where decisions are made that can affect hundreds of thousands of people. more…

Beyond the App – a novel take on personalizing digital health can increase its effectiveness

7 Oct, 16 | by BMJ Clinical Evidence

talya-miron-shatz_croppedBy Talya Miron-Shatz

As a health professional, you know that digital health tools, such as wearables and apps, abound. You hope these help patients adhere to medication, monitor their blood pressure, manage their diet and other treatment, maintenance and prevention tasks which take place outside of the clinical encounter, and have an effect on health outcomes. You also know that these tools are not always effective. In fact, a systematic review found that only 39% of randomized control trials using mobile health to promote adherence to medication reported significant improvements between groups. more…

Digital health interventions: Hype or hope?

30 Sep, 16 | by BMJ Clinical Evidence

emBy Elizabeth Murray

Digitising the NHS is back in the news with the publication of the Wachter report on using IT in the NHS to achieve healthcare’s triple aim of better health, better healthcare and lower cost. As Wachter says, not “giving highest priority to digitisation would be a costly and painful mistake”.[1] 

Although the report focuses on digitising secondary care, many of the recommendations are equally applicable to digital health interventions (DHI). DHI are interventions delivered on a digital platform, such as the web or mobile phones, which aim to deliver health care or health promotion, including behaviour change,[2][3]  self-management support,[4] or treatments such as Internet Cognitive Behavioural Therapy (ICBT). Because of their potential to combine personalisation with scalability, they hold out real hope for delivering better health, better healthcare and lower costs, but the potential has yet to be realised, despite the millions of commercial “health apps” available. more…

Clinical search, big data and the hunt for meaning

22 Sep, 16 | by BMJ Clinical Evidence

JRB profile picture v2By Jon Brassey

I’ve been running the clinical search engine the Trip Database for nearly twenty years and as it has evolved, opportunities have arisen for working with other sectors or individuals with different perspectives. Recently this has involved the academic info retrieval world: a chance conversation with academics at the University of Glasgow, changed the way I looked at search. One really important notion I learnt about was clickstream data – the data websites collect of the user’s interaction with the site. In the case of Trip this data would equate to the search terms used and the articles users click on.

One thing’s for sure, Trip has lots of it. With a million searches per month (the vast majority being health professionals) we’ve amassed hundreds of millions of data points in the years since we started collecting it. This qualifies as big data. As with all big data projects the trick appears to be making sense of it all and that is a journey I feel we’ve only just started. more…

The importance of getting evidence into health service decision making, even where there is uncertainty

22 Jun, 16 | by BMJ Clinical Evidence

DT

By David Tovey

Earlier this week I attended the launch of a Kings Fund paper in the rarefied setting of Portcullis House, an annex of the Palace of Westminster. The subject was “Bringing together physical and mental health: A new frontier for integrated care”. A panel that included Presidents of the Royal Colleges of Physicians and Psychiatrists, was chaired by a member of the House of Lords. The diagnosis was an important and topical one: care for people with long term physical conditions is insufficiently holistic and frequently omits psychological effects.  The mirror image is also true, perhaps with even more serious consequences: people with long term mental illness suffer and die as a consequence of inadequate physical care. So, unmet need in both scenarios and a stimulating basis on which to construct my Evidence Live 2016 presentation on the subject of “Translating Evidence into Better Quality Health Services”.

What is the appropriate response? In passing, I can’t help but notice that until very recently, it would have been inconceivable that such a meeting would not include at its centre, the crucial role of general practice or primary care. Yet, on this occasion, neither rated more than a passing reference, and the Royal College of General Practitioners was conspicuously absent. That seemed a problem – both for the NHS and for primary care itself. What about evidence? It would not be true to say that evidence was completely absent, but it was not central to the discussion that followed the presentations, and it ranked a long way behind “an increase in resourcing” in terms of its visibility as a potential solution. more…

Beware evidence “spin”: an important source of bias in the reporting of clinical research

21 Jun, 16 | by BMJ Clinical Evidence

Kamal R Mahtani

 

By Kamal R Mahtani

Spin [WITH OBJECT] Draw out and twist (the fibres of wool, cotton, or other material) to convert them into yarn, either by hand or with machinery: “they spin wool into the yarn for weaving”

 

Does the name Malcolm Tucker ring a bell? The Malcolm Tucker I am referring to is the fictional character from the BBC political satire The Thick of it. Tucker (played by Peter Capaldi) was a government director of communications, skilled in propaganda, more specifically in the art of “spinning” unfavorable information into a more complimentary, approving (and sometimes even glowing) public facing message. Whether the show accurately reflects real life governmental politics, or whether real life politicians ‘copy’ the show, remains a topic of discussion. Either way, “spin” in the political arena feels like something we are increasingly getting used to, almost expect.

 

“Spin” in reports of clinical research

For many researchers, the number of publications, and the impact of those publications, is the usual currency for measuring professional worth. Furthermore, we are increasingly seeing researchers discuss their work in public through mainstream and social media, as more of these opportunities arise. With this in mind it probably won’t come as such a shock to imagine that researchers might be tempted to report their results in a more favorable (again, even glowing) way than they deserve i.e. to add some “spin. more…

Too many drugs, too few medicines! The translational failure of animal research

20 Jun, 16 | by BMJ Clinical Evidence

Emily SenaBy Emily Sena

374 interventions have been reported to be effective in experimental stroke; 97 were tested in clinical trials but only one of these was shown to be effective. The principle of drug development goes that if a therapy improves outcome in animals the next step is to test it in humans in a clinical trial, with the hope that important improvements in outcome will be seen. The reality is that there are huge amounts of animal data (too many drugs), from experiments that are not designed with sufficient rigour or adequately reported, and important improvements in outcomes are usually not seen in clinical trials (too few medicines).  Many animal experiments are failing in their objective effectively to inform human health.

And there are a lot of drugs around – in 2013, 350 publications describing animal experiments were published every day! I understand that the average life scientist has neither the desire nor the need to consume this amount of information, but even within a limited research domain relevant data accumulate rapidly. In an endeavour where future ideas, decisions and directions are based on our existing knowledge it is important that we are able to identify, critique and synthesise data in an unbiased, timely and useful manner. more…

Too much medicine – Prescription drugs are the third leading cause of death

16 Jun, 16 | by BMJ Clinical Evidence

Peter GotzscheBy Peter C Gøtzsche

Our prescription drugs are the third leading cause of death after heart disease and cancer.[1] Based on the best research I could find, I have estimated that psychiatric drugs alone are also the third major killer,[2] mainly because antidepressants kill many elderly people through falls.[3] This tells us that the system we have for researching, approving, marketing and using drugs is totally broken. [1][2]

What makes this tragedy particularly absurd is that the vast majority of the deaths can easily be prevented. Non-steroidal, anti-inflammatory drugs (NSAIDs) carry a huge death toll, primarily by causing bleeding stomach ulcers and myocardial infarction, and most of those who die could have done well without drugs or by taking paracetamol. The idea that NSAIDs have an anti-inflammatory effect has been disproven by placebo controlled studies.[4][5] more…

Threats to traditional systematic reviews

15 Jun, 16 | by BMJ Clinical Evidence

JRB profile picture v2By Jon Brassey

For many years systematic reviews have been placed on a pedestal, relatively free from critical scrutiny. Frequently seen as being at the top of the ‘evidence pyramid’ they have been adopted as the main way of assessing the worth of an individual intervention.

More recently threats to the pre-eminence of systematic reviews have come from multiple areas. Some authors, including myself, have been critical of groups such as Cochrane for creating methods that are so costly in terms of finance and time that too few are done and the majority are not being kept up to date. more…

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