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Director's Choice - From the Journals
The Messy End of Science
Sometimes science gives us nice clear-cut answers. Director’s choice normally focusses on such studies. Today I focus on the opposite – the messy end of science, where standard statistical methods are too clunky to give a clear answer. Last weekend’s BMJ (12 April 2014) was stacked full of articles on anti-flu drugs [1-11] based on the meta-analysis that Tom Jefferson and colleagues carried out [3] when the full data-set was finally wrenched from the hands of the drug company. Tom's meta-analysis was excellent, but I am less enamoured of the rather self-righteous tone of the extensive commentaries. There is an undisputed moral component to what went on (companies should not be allowed to sequester data obtained from patients), but that is where turpitude ends. Decision makers across the world are taken to task for spending £12 billion on Tamiflu® [1] when evidence on effectiveness could not be regarded as definitive. But since when do policy makers need definitive evidence in order to act? Chief Medical Officers simply have to make a best judgement on the evidence available at the time. Yes, in retrospect, enough money was wasted to procure four aircraft carriers.[12] But the Chief Medical Officers across the globe are paid to make an informed guess based on the information available in real time. The most important message is simple – companies should no longer be allowed to sequester data in their vaults – full transparency is essential.
But then what? Will clarity prevail? I am afraid not. The reason is that science is increasingly giving us messy answers – short-term outcomes when we really need longer term outcomes; a mixture of statistically positive and null results; treatments that are effective against placebo, but have not yet gone head-to-head; and so on. Take clot-busting medicine for stroke of over 3 hours duration – the pivotal clinical trial was done in academia, not a drug company. The primary outcome yields a null result, deaths were increased in the short-term, but a secondary outcome, based on questionnaire, showed improvement.[13] This led to a positive recommendation for treatment followed by criticism that guideline writers were tainted by their industry associations.[14] Again these problems would not have arisen if science had given a more clear-cut result. Similarly, the situation with Tamiflu® remains murky. It does block the receptor used by the virus to gain access to human cells, it shortens the duration of illness, and when used prophylactically it reduces symptomatic cases by over a half. However, it causes side-effects, and there was no measurable effect on admission rates (95% CI 0.57–1.50) or deaths, although this might have been because any improvements were too small to detect. The real problem is that frequentist statistics are just not up to the job in these ambiguous cases where there are multiple competing objectives and high risks of false null results, especially for the most important outcomes. We will never get out of the mud until we use a statistical method that surfaces the subjective element and that can interface axiomatically with a grounded Decision Analytic framework, whereby probabilities, values and money can be reconciled. Above all, the notion that statistics can obviate the need for judgement is an eidolon that must be scotched along with the idea that drug companies can withhold patient data.
-- Richard Lilford, Director CLAHRC WM
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References
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Low-Income Country Research or International Research
In a recent post, the CLAHRC WM Director described the similarity between service problems faced in Africa and those in the West Midlands. There are a number of arguments for conducting research with an international perspective rather than with a high- vs. low-income perspective. For a start, the diseases we face are becoming more similar with the rapid rise of non-communicable diseases in low-income countries. Secondly, the social issues are becoming more similar as middle classes emerge rapidly in the South, while a deprived class is differentiating itself in richer countries, even in previously egalitarian societies such as the Nordic zone. Lastly, the educational ‘distance’ between the researchers themselves is reducing apace. For example, while Africa may still have quite high illiteracy rates, literacy is very high among young adults, except in post-conflict situations.[1] Likewise enrolment in African Universities have more than doubled in the last two decades, even if teacher/ student ratios have deteriorated.[2] There is a high rate of North-South interchange of researchers. In short, we are approaching a situation of equality in research capacity. Of course the differences between countries have not all been ironed out, but the differences between researchers and the topics they research are getting narrower.
The CLAHRC WM will increasingly take an International perspective, comparing and contrasting problems and their solutions across the world. In order to do this we will foster egalitarian networks of researchers, managers and patient and career representatives across the world.
-- Richard Lilford, Director CLAHRC WM
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References
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In January, NICE released their new guidance to promote and support individual approaches to the design and implementation of behavioural interventions. It is especially relevant for interventions aimed at improving health behaviours, such as smoking cessation, reducing alcohol consumption, encouraging safe sex, and improving diet and physical activity levels. It recommends that services and interventions include proven behaviour change techniques, tailored to individual needs, such as setting goals and planning, feedback and monitoring, and social support.
If you are interested in learning more, then please consider attending the upcoming inaugural CLAHRC WM Knowledge Exchange Forum (details here).
Top 5 tips
- Plan behaviour change interventions to meet the needs of local communities.
- Tailor interventions to meet individual needs.
- Recognise there are times when people may be more open to change, e.g. at a life-changing moment, such as becoming a parent, or when hearing a medical diagnosis, such as heart disease or diabetes.
- Use proven behaviour change techniques when designing interventions.
- Plan for monitoring and evaluation before the intervention takes place.
-- Laura Elwell, Birmingham Children's Hospital
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The next round for the Health Foundation's Improvement Science Fellowship programme is now open, closing 12:00pm 1st July 2014.
The programme offers support for up to five fellows to develop their potential to become leaders in the field of improvement science, building practical knowledge about what works to improve healthcare. It offers funding for 3 years to lead original, applied research dedicated to improving healthcare in the UK, and a tailored leadership development programme.
Find out more about how to apply.
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Congratulations to Tom Marshall, CLAHRC WM Co-Director, on completing the 2014 London Marathon in a time of 3 hours, 12 minutes.
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07 May 2014
Inaugural CLAHRC WM Knowledge Exchange Forum (KEF), exploring the public health role of hospitals.
Hospitals have an important role in health promotion and encouraging behavioural change in patients and their families. This KEF will provide an opportunity to examine:
- how West Midland hospitals might best work with their partners to, for example, reduce second hand smoke exposure by children or levels of obesity;
- the evidence on behavioural change interventions with patients and their families;
- the applicability of ‘asset based approaches’ that draw on wider resources in the community.
We are not covering hospitals’ responsibilities for staff wellbeing in this KEF.
The format will be short presentations, each followed by a Q&A session for clarification, before a wider action-orientated discussion among attendees. The outcome will be a CLAHRC WM action plan.
If you would like to attend, then please email j.m.sartori@bham.ac.uk
19-20 Jun 2014
Health Services Research Network Symposium 2014.
Nottingham Conference Centre.
Details
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CLAHRC Personality of the Issue
Nathalie Maillard
Nathalie Maillard is Head of Programme Delivery for CLAHRC WM. Nathalie is an experienced operations and research manager with skills in project and programme management, health services research management and stakeholder engagement. She graduated from University of Birmingham in 2002, with a BMedSc degree, specialising in neuroscience. In 2008 she completed an MSc in Health Care Management & Policy at the same University, specialising in Health Economics (for which she won a prize for her dissertation that explored methods for priority-setting in healthcare).
Nathalie has worked for the University of Birmingham since 2004. Her previous roles include Programme Manager of CLAHRC for Birmingham and Black Country; Deputy Programme Manager for Department of Health research commissioning programmes; and Research Associate. She took a short-break in her career to take maternity leave (Aug-12 to Jun-13) and is now the mother to fraternal twin girls, Amelie and Sasha.
If you have any CLAHRC WM outputs, be sure to contact Nathalie and let her know and please remove the ‘file to junk’ function from her email address…
Click here for more information and contact details.
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Discussing Sexual Wellbeing in Stroke Patients:
Healthcare Professional's Views.
Using in-depth interviews, our researchers found that sexual wellbeing of patients and their partners was infrequently raised, but simple changes can be made to help 'normalise' discussion of sensitive topics.
CLAHRC BITEs (Brokering Innovation Through Evidence) - accessible bite-sized pieces of research that aim to summarise findings from our published work and make recommendations for practice for health and social staff locally and beyond. Previously published BITEs can be found here.
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