Richard Lehman’s journal reviews—6 June 2016

richard_lehmanNEJM 2 Jun 2016 Vol 374
Germs, catheters and hospitals
2111 Anyone who has an indwelling urinary catheter will get bacteriuria, sooner or later. I was taught this as a medical student, as a medical HO and urology SHO, and observed it through 35 years as a GP. This article begins by stating that up to 69% of catheter-associated UTIs are considered to be avoidable, provided that recommended infection-prevention practices are implemented. It’s the kind of claim that begs questions: is asymptomatic colonisation the same as “UTI”? Is this a statement about hospitals, or the community, or nursing homes, or all three? Still, it’s hard to argue against taking precautions against introducing organisms into the urinary tract, especially in already sick patients in hospital. And a prevention package may work, according to this carefully reported before-and-after study. Data were obtained from 926 units in 603 American hospitals as they introduced a program designed to reduce catheter infection. Infections went down on the wards but not on intensive care units.

Embedding or embalming practice-based research?
2152 Retirement from clinical practice is a great opportunity for big thinking. Why isn’t every clinical encounter a learning opportunity for the patient, the health professional and the system, we grandly ask. “Because we don’t have the bloody time,” comes the answer from ten thousand people who still do the job. This is a strong theme in a paper about Integrating Randomized Comparative Effectiveness Research with Patient Care. The barriers put in the way of obviously beneficial embedded research in the UK make for squirm-inducing reading: “The overarching [NHS] governance review took 2 years from original application to approval, followed by local approvals (which took a further year in England, but only 2 months in Scotland). Several regions demanded local modifications of the trials, including localised consent forms and, because of prescribing guidelines, mandatory switching from atorvastatin to simvastatin in Retropro 3 months after trial entry. Several [general practitioners] were also warned that Retropro would adversely affect their statin performance targets (most regions restricted atorvastatin prescribing). Review by the ethics committee resulted in a considerable lengthening of the informed consent form.” No wonder that out of 270 practices that expressed an interest in this trial, 17 ended up recruiting patients.

Dissing RCTs is not big or clever
2175 Conducted rigorously in a representative population with the right comparator, a double-blinded randomized controlled trial is the best method yet devised to test a clinical intervention. Here’s an article which traces the history of the RCT and points out all the pitfalls of conducting and interpreting them in real life. If you are familiar with the subject, you won’t learn much that’s new, but you will get the feeling that now and then the authors are hinting that they aren’t really worth the bother, and that lesser standards of evidence will do for most purposes. For a second week in succession I need to mention Vinay Prasad, who has written a fiery critique of this article and this attitude.

That most RCTs are cumbersome, expensive, and deliberately designed to sell products rather than honestly test a hypothesis is no criticism of the RCT as such. But it is a huge criticism of a system which delegates their conduct to people with a financial or career interest in their results, and their publication to journals which can derive a tidy income from selling reprints of them. Somehow I don’t expect this is a criticism which will appear in the NEJM.

Ann Intern Med Jun 2016 Vol 164
You don’t fatten a pig by weighing it
OL It’s hard to argue with the principle that you can’t demonstrate improvement in a system unless you have some way of measuring it. Famously they measured increases in productivity at the Hawthorne Works in 1925 after introducing changes in lighting. It took another 30 years for Landsberger to realize that the improvements in productivity were nothing to do with lighting levels but lots to do with the workers knowing that they were being observed. Now the “Hawthorne Effect” is so embedded in urban myth that many managers assume that if they introduce highly intrusive methods of quality measurement, they are bound to drive up quality. So what happened after Medicare introduced public reporting of hospital death rates for acute myocardial infarction, heart failure, and pneumonia in 2008? Oddly—and perhaps coincidentally—this step (called Hospital Compare) was associated with a slowing in the decline of mortality from these conditions. Let me repeat that in the exact words of the investigators: “Changes in mortality trends suggest that reporting in Hospital Compare was associated with a slowing, rather than an improvement, in the ongoing decline in mortality among Medicare patients.” This is counter-intuitive, but by no means unique. I think there needs to be a term for the obverse of the Hawthorne Effect. I’d suggest we call it the “QOF Effect,” after the UK’s Quality & Outcomes Framework for primary care, where the harrying of professionals to comply with a list of badly judged quality measures resulted in gaming, demoralisation, and a drop in real quality of practice. Having had my rant, however, I would advise against placing too much reliance on this single before-and-after study.

Lancet 4 Jun 2016 Vol 387
WHO on Earth
2276 Some years ago, I took a self-denying ordinance not to mention Richard Horton’s Offline column. But I cannot resist quoting these sentences: “You will never find a World Health Organization official prepared to state on the record that a country is betraying its people by ignoring their wellbeing. The politesse of international health is dishonest, duplicitous, contemptible, venal, and, sometimes, even criminal.” Bravo. In theory, the WHO should be the most valuable institution on the planet. Instead, it is a glaring example of how cynicism, political undermining, and internal sclerosis can destroy a great endeavour. But the only way forward is to rebuild, not to despair.

Scores of belief systems
2302 Medical research is coming to resemble particle physics. The fountains of knowledge are arcane and we have to take a great deal on trust because we cannot possibly replicate or analyse the findings ourselves. This applies across a wide range of areas such as population epidemiology, genomics, observational studies, outcomes research, and scoring systems based on complex data. We rely on experts to tell us what they see. If they tell us that some squiggle on a screen shows the generation of an electron antineutrino via an intermediate heavy W boson, we just have to murmur “amazing” in a knowing way. There’s no means of checking, short of spending a few years learning the subject and using the equipment. In this paper we are told that “The ABC-bleeding score, using age, history of bleeding, and three biomarkers (haemoglobin, cTn-hs, and GDF-15 or cystatin C/CKD-EPI) was internally and externally validated and calibrated in large cohorts of patients with atrial fibrillation receiving anticoagulation therapy. The ABC-bleeding score performed better than HAS-BLED and ORBIT scores and should be useful as decision support on anticoagulation treatment in patients with atrial fibrillation.” OK boss, you know best. But have you actually found out how well this predicts bleeds in little old ladies with AF? Or how much it would cost combined with every prescription for a direct oral anticoagulant?

Predicting tuberculosis
2312 “A third of the population worldwide is infected with Mycobacterium tuberculosis, but less than 10% of these individuals will progress to have active tuberculosis disease during their lifetime; most individuals will remain healthy.” Finding a way of identifying the people at highest risk and treating them prophylactically would be a fantastic step forward for the world. “A 16 gene signature of risk was identified. The signature predicted tuberculosis progression with a sensitivity of 66•1% (95% CI 63•2–68•9) and a specificity of 80•6% (79•2–82•0) in the 12 months preceding tuberculosis diagnosis.” I really hope this is a breakthrough, and that clinical treatment programmes will become possible and affordable. Tuberculosis is a fascinating and tragic enigma throughout human history, wonderfully explored in The White Death by Thomas Dormandy (1998; out of print). Over the last two hundred years, irreplaceable literary genius seems to have been a grave prognostic marker. Imagine if John Keats, Emily Bronte, Anton Chekhov, and George Orwell had not died prematurely. I hate TB.

UK general practice: worked to death
2323 For decades, British GPs have been fed data about their consultation rates, but when Richard Hobbs and his co-authors came to measure changes in GP workload over recent years, he found the data were poor and outdated. Here is an analysis based on very dependable figures from the Clinical Practice Research Datalink (CPRD). In terms of recorded face-to-face consultations, GP workload increased by 16% over the six years ending 2014. I don’t want to labour the point. “These results suggest that English primary care as currently delivered could be reaching saturation point. Notably, our data only explore direct clinical workload and not indirect activities and professional duties, which have probably also increased.” People can work very hard indeed if their efforts are highly valued and there is the promise of amelioration. But the government has gone out of its way to remove any sense of value and hope from general practice. Ironically, this article is open access thanks to funding by Department of Health UK. The money should have come from the Department of Health Australia, the chief beneficiary of despair amongst British GPs.

TheBMJ 4 Jun 2016 Vol 353
In your coding dreams
The first editorial in this week’s print issue of The BMJ has the subtitle “Clinicians need to embrace new coding technology with enthusiasm.” Believe me, there is nothing less likely in the entire universe.

A senior moment
These weekend rantings of mine are now given the status of “Research Update” by the print issue of The BMJ, and because of a Monday holiday, last week’s were rushed into print without checking. Finding two articles on renal replacement therapy for ICU patients from different European countries, I struggled to compose a sentence in schoolboy German rather than to read the actual trial from Germany. Alas, my mistake is now embedded in print for all to see throughout eternity. The German trial contradicted rather than confirmed the French one, as many a baffled nephrologist tweeted to inform me. I shall abjure nephrology henceforth forever, and perhaps even check on what I write in the future.

When a Roman emperor celebrated his triumph at Rome after a great victory, he would be accompanied by a slave who whispered from time to time “Remember that you are but a mortal, great Caesar.” Legend does not recount what happened to these slaves afterwards. Here is a trial in which telephone callers reminded people with raised cardiovascular risk that they were mortal and should do something about it. The fate of these callers is similarly unknown. We do not know if they were thrown into vats of boiling oil. And like Roman emperors, the recipients of this advice did not display much measurable benefit. Or, to give this trial its due, “This evidence based telehealth approach [sic] was associated with small clinical benefits for a minority of people with high cardiovascular risk, and there was no overall improvement in average risk.” But, “only 16% of those sent information about the trial expressed interest in participating, and only a third of intervention participants received the full course of intended telephone encounters.” Beware: I have a special vat of boiling oil ready for anyone who mentions the word “telehealth.”

Is migraine a CV risk factor?
Migraine in women has been studied more closely than migraine in men, according to a wonderfully sensible commentary accompanying an analysis of migraine and cardiovascular risk from the Nurses’ Health Study. Like several previous observational studies, this shows a small increase in absolute risk of CV events in women who reported migraine. This is not confined to stroke. So what’s to be done? The editorial concludes that “At present, migraine is probably best thought of as a situation in which the medical urge to ‘do something’ (beyond currently recommended assessments for cardiac risk and advocating a healthy lifestyle) should be resisted, especially when migraine is a patient’s sole risk factor. As Will Durant has observed, ‘One of the lessons of history is that nothing is often a good thing to do.’”

Plant of the Week: Rosa “Lady Hillingdon, Climbing”

I know nothing of the original Lady Hillingdon, or if she was a climber in real life. The enchanting rose that bears her name flowers a deep yellow-orange and has handsome purpled leaves. If I were Lord Hillingdon and she entered my drawing room, I would propose marriage immediately, be she the poorest blacksmith’s daughter.

This really is a most beautiful plant at a time when there is no shortage of beauty. Beguilingly fragrant too, at a time when there is no shortage of fragrance. And reasonably easy to please too, though we planted our previous one in dry shade and she sulked and died. Perhaps she needs a rich sunny home with attentive servants.