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Transport to Place of Care
Availability of emergency transport is taken for granted in high-income countries. The debate in such countries relates to such matters as the marginal advantages of helicopters over vehicle ambulances, and what to do when the emergency team arrives at the scene of an accident. But in low- or low-middle-income countries, the situation is very different – in Malawi, for example, there is no pretence that a comprehensive ambulance system exists. The subject of transport does not seem to get attention commensurate with its importance. Researchers love to study the easy stuff – role of particulates in lung disease; prevalence of diabetes in urban vs. rural areas; effectiveness of vaccines. But study selection should not depend solely on tractability – the scientific spotlight should also encompass topics that are more difficult to pin down, but which are critically important. Transport of critically ill patients falls into this category.[1]
Time is of the essence for many conditions. Maternity care is an archetypal example,[2] where delayed treatment in conditions such as placental abruption, eclampsia, ruptured uterus, and obstructed labour can be fatal for mother and child. The same applies to acute infections (most notably meningococcal meningitis) and trauma where time is critical (even if there is no abrupt cut-off following the so called ‘golden hour’).[3] The outcome for many surgical conditions is affected by delay during which, by way of example, an infected viscus may rupture, an incarcerated hernia may become gangrenous, or a patient with a ruptured tubal pregnancy might exsanguinate. However, in many low-income countries less than one patient in fifty has access to an ambulance service.[4] What is to be done?
The subject has been reviewed by Wilson and colleagues in a maternity care context.[5] Their review revealed a number of papers based on qualitative research. They find the theory that one might have anticipated – long delays, lack of infrastructure, and so on. They also make some less intuitive findings. People think that having an emergency vehicle at the ready could bring bad luck, and that it is shameful to expose oneself when experiencing vaginal bleeding.
Quite a lot of work has been done on the use of satellites to develop isochrones based on distances,[6] gradients, and road provision. But working out how long it should take to reach a hospital does not say much about how long it takes in the absence of a service for the transport of acutely sick patients.
We start from the premise that, for the time being at least, a fully-fledged ambulance service is beyond the affordability threshold for many low-income countries. However, we note that many people make it to hospital in an emergency even when no ambulance is available. This finding makes one think of ‘grass-roots’ solutions; finding ways to release the capacity inherent in communities in order to provide more rapid transfers. An interesting finding in Wilson’s paper is that few people, even very poor people, could not find the money for transfer to a place of care in a dire emergency. However, this does not square with work on acutely ill children in Malawi (Nicola Desmond, personal communication), nor work done by CLAHRC WM researchers showing the large effects that user fees have in supressing demand, especially for children, in the Neno province of Malawi.[7] In any event, a grass roots solution should be sought, pending the day when all injured or acutely ill people have access to an ambulance. Possible solutions include community risk-sharing schemes, incentives to promote local enterprises to transport sick people, and automatic credit transfer arrangements to reimburse those who provide emergency transport.
I am leading a work package for the NIHR Global Surgery Unit, based at the University of Birmingham, concerned with access to care. We will describe current practice across purposively sampled countries, work with local people to design a ‘solution’, conduct geographical and cost-benefit analyses, and then work with decision-makers to implement affordable and acceptable improvement programmes. These are likely to involve a system of local risk-sharing (community insurance), IT facilitated transfer of funds, promotion of local transport enterprises, community engagement, and awareness raising. We are very keen to collaborate with others who may be planning work on this important topic.
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The 13 September was World Sepsis Day. Who undertook the study that found that, in resource-limited settings, bolus resuscitation as an intervention in treating children with sepsis was a bad idea?
Email CLAHRC WM your answer.
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Answer to our previous quiz: The second virus to be eradicated through vaccination was Rinderpest, a disease of cattle, which was eradicated in 2011. Congratulations to Sian Scogings who was first to answer correctly.
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Director's Choice - From the Journals
Not Taking a Full Course of Antibiotics
The Academic edition of the BMJ comes out once a month; readers may have noticed that one or more BMJ articles feature in alternate News Blogs. The most recent issue of the BMJ had less papers that caught my eye than most. There was lots of worthy stuff. For example, age-specific dementia incidence is declining slightly,[1] antidepressants may very slightly increase the risk of autism if taken during pregnancy,[2] specialist palliative care has rather small effects on quality of life,[3] exercise and diet reduce the risk of high blood pressure in women who had high blood pressure in pregnancy.[4] There was also an excellent article on the precision of cluster randomised trials by CLAHRC WM collaborator Karla Hemming.[5] But the article that really caught my eye was a commentary on the importance of completing a full course of antibiotics as prescribed.[6]
Of course, we always love articles that confirm our prior beliefs. I have always thought that insisting that people take a ‘full course’ of antibiotics to reduce resistance is illogical. Prolonging exposure of the bacterial population to the antibiotic is likely to increase the chance for selection to take place. And that is exactly what this study confirms. Apparently the idea that it was important to take the full course of treatment was based on Albert Alexander's Staphylococcal sepsis, which re-established itself when Howard Florey’s penicillin ran out.[7] However, the wisdom of continuing antibiotics until the infection is quelled somehow became translated into instructions to finish the course even if infection is no longer a threat. Remember, genetic mutations arise spontaneously and are only selected for when the antibiotic is present in the environment. It follows that the shortest course of antibiotics compatible with effective treatment should be used. And, of course, resistance does not just appear among the organisms causing the infection, but among all the organisms carried in the patient's body, some of which may go on to infect another person. The argument against continuing to take antibiotics once the threat has passed is therefore unequivocal. It may be necessary to continue antibiotic treatment to prevent a relapse, as was the case for the hapless Alexander, and middle ear infections have a tendency to relapse, but we should not insist on taking a full course simply to prevent antibiotic resistance; the opposite is the case.
-- Richard Lilford, CLAHRC WM Director
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References
The Most Dangerous Animal
It is very difficult to know which animal is the most dangerous (human beings aside). The mosquito would be a good answer, while game rangers are fond of surprising tourists by saying that it is the hippopotamus. The latter is almost certainly wrong and you can surprise the game ranger by asking him or her for evidence. There is none. But the snake is undoubtedly a very dangerous creature. Cobras and mambas are lethal, but apparently the greatest number of animal deaths worldwide is from a small, but agile viper, called the saw-scaled viper. This is a viper that likes to bite and it is ubiquitous in areas lacking modern medical facilities.
The problem, recently discovered, is that the anti-venom for this snake tends to be specific to the area in which the viper is found.[1] Small geographical differences in the structure of the protein toxin that causes blood to clot in the vessels accounts for this spatial specificity. This means that anti-venoms must be made locally.
The real problem with snake bite treatment is that anti-venoms are not available when needed or they become damaged during transit and storage. Snakes are very important for local ecologies. A campaign of extermination would probably do humans more harm than good. So the battle between person and snake, which started all those years ago in the Garden of Eden, is set to continue.
-- Richard Lilford, CLAHRC WM Director
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Reference
Association Between Cigarette Price and Infant Mortality
In an effort to reduce smoking rates governments often increase the taxation levied on cigarettes. Previous research has shown that this is an effective strategy, including improvements in child health outcomes. However, tobacco companies often use differential pricing strategies to move the increased taxation on to their premium cigarettes. This lessens the effectiveness of increased taxes as it allows people to switch to the cheaper cigarettes instead. Researchers from Imperial College London set out to assess any associations between price rises, differential pricing (using data on the minimum and median cigarette prices) and infant mortality across 23 European countries.[1] This longitudinal study looked at more than 53.7m live births over a period of ten years. During this time the authors found that a median increase of €1 per pack of cigarettes was associated with 0.23 fewer deaths per 1000 live births in the year of the price hike (95% CI, -0.37 to -0.09), and a decline of 0.16 deaths per 1000 live births in the subsequent year (95% CI, -0.30 to -0.03). Using a counterfactual scenario, the authors estimated that, overall, cigarette price increases were associated with 9,208 fewer infant deaths (i.e. if cigarette prices had remained unchanged then there would have been 9,208 more deaths). Analysis of the price differentials showed that a 10% increase in the differential between the minimum and median priced cigarettes was associated with 0.07 more deaths per 1,000 live births the following year. Further, had there been no cost differential, they estimated that 3,195 infant deaths could have been avoided.
So, while increasing cigarette taxation can have a positive effect, there needs to be more of an effort to try to eliminate budget cigarettes. This is especially true in low-income countries where price differentials tend to be significantly higher than in high-income countries.
-- Peter Chilton, Research Fellow
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Reference
Improving Access to Fresh Food in Low-Income Areas
In a previous News Blog we looked at a paper that found an association between adherence to the Mediterranean diet (i.e. high consumption of fruit, vegetables, and legumes) and reduction in cardiovascular disease risk. [1] So, it can be argued, that for those in low-income areas there is a need to improve their access to fresh fruit and vegetables. But how best to achieve this? Breck and colleagues, on behalf of the CDC, looked at one possibility in a cross-sectional survey analysis. [2]
Previously, the city of New York had attempted to address the issue by granting new licenses for mobile fruit and vegetable carts in those neighbourhoods with poor availability of fresh food. However, only some of the carts (27%) had the capacity to accept the Supplemental Nutrition Assistance Program (SNAP) benefits (a federal aid program to provide food-purchasing assistance) through use of Electronic Benefit Transfer (EBT) machines.
The authors conducted a survey analysis of 779 adults shopping at four carts in the Bronx neighbourhood of New York over several time periods. After controlling for cofounders, they found that those shoppers who were able to pay using their SNAP benefits purchased significantly (p<0.001) more fruit and vegetables (an average of 5.4 more cup equivalents), than those who were only able to pay with cash. While there are promising results from providing consumers with more ways to pay, there are challenges that could prevent widespread roll out of EBT, chiefly the high initial, monthly, and transaction fees that the cart vendors need to pay. Even when provided with financial support, less than one-third of carts were equipped with EBT machines at the time of this study. Although the study has a number of limitations that means causal inferences cannot be drawn, it can be seen as a possible avenue for future research.
-- Peter Chilton, Research Fellow
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References
Another Study on the Hazards of American Football
Head impacts seem to be a common occurrence in American Football, with studies of youth players suggesting they experience around 240-252 impacts per season.[1] [2] In the previous News Blog we looked at research on brain injury in ex-American Football players, which found widespread chronic traumatic encephalopathy.[3] Now a cross-sectional study by Alosco, et al. has looked at the impact playing from an early age has on behaviour, mood and cognition.[4] The authors assessed 214 former amateur and professional football players (who hadn’t played any other contact sport) on a number of psychiatric tests. Multivariate regression analysis showed that those who had begun playing before the age of 12 had at least twice the risk of significant impairments in behavioural regulation, apathy and executive function, and three times the risk for clinically elevated depression, compared with those who were began playing when they were 12 or older. These effects were not linked to age, education or even how long the individual played football for. There were also no differences in the level of play, i.e. those who played professional fared similar to those who only played at high school-level. The authors hypothesise that 12 years old is a critical time for key neurodevelopmental milestones that occur within the hippocampus and amygdala (where clinical functions such as emotion regulation and behaviour are modulated).
Alternative Therapies for Cancer
We often read of cancer patients who forgo or delay traditional conventional options, such as chemotherapy, and instead opt for alternative therapies, such as spiritual healing or herbal remedies given by non-medical personnel. Unfortunately this can have serious survival implications for the patient – in many cases the treatment fails to stop the cancer. However, there is a paucity of actual clinical evidence on the use and effectiveness of alternative therapies. Step in Johnson and colleagues who examined the United States Cancer Database to compare the survival outcomes of patients who underwent alternative therapies with those who received conventional therapies for four cancer types (breast, prostate, lung and colorectal).[1] Although rare, they found 281 patients who had chosen alternative therapies exclusive of any other treatment – these patients were more likely to be younger, female, have a lower comorbidity score, higher income, higher education, and a more advanced cancer stage. When matched with patients who received conventional treatments (on cancer type, age, clinical stage, etc.), they found that alternative therapies were associated with significantly lower five-year survival overall – 78.3% of patients who underwent conventional therapies survived, compared to 54.7% of those who had alternative therapies only (hazard ratio 2.21, 95% CI 1.72-2.83). When looked at by cancer type increased hazard ratios were found for breast (HR 5.68, 95% CI 3.22-10.04), lung (HR 2.17, 95% CI 1.42-3.32) and colorectal cancer (HR 4.57, 1.66-12.61), but there was no significant difference for prostate cancer (HR1.68, 95% CI 0.68-4.17) – the authors suggest this may be because of the long natural history of prostate cancer and the short follow-up of the study.
By itself, undergoing alternative therapies isn’t likely to be harmful, but it should be taken in combination with conventional therapy, and health practitioners need to ensure that patients are fully aware of the impact of their decisions regarding cancer treatment.
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NHS Expo
The NHS Health and Care Innovation Expo was recently held in Manchester, bringing together leaders from health and social care to share ideas, innovations and best practice in support of delivering the Five Year Forward View. Members from key infrastructures, such as the NIHR, have stands to represent their work, which included representations from the national CLAHRC network. Other bodies, such as the Academic Health Science Networks, were also prominent, showcasing projects with industry in collaboration with the local NHS.
With sessions from national leaders from politics, NHS organisations, such as NHS England, the Care Quality Commission, and health professionals it always provides an interesting barometer of strategic priorities across health and social care. For these reasons CLAHRC West Midlands always tries to have representation at both days of the Expo - here is an overview of some issues from the event. For a more general overview you can view their website.
Day One began with “Next steps for Primary Care”, outlining the challenges for GPs implementing the General Practice Forward View, highlighting the variation in practice and service and the scale of the challenges of reducing this variation, along with the opportunities that this brings. Next followed interesting plenaries that very aligned closely to CLAHRC WM’s interests around multi-morbidity and integrated care with sessions on: “The value and contribution of Adult Social Care” and “Crossing the boundaries of integrated care”. The first session counselled against focussing solely or too closely on Delayed Transfers of Care as this is only one facet of a large and complex system, along with a call for nurse and medical training to include more exposure to the social care system, particularly care homes. It also called for a better narrative around a career in social care, with it too often being seen as a minimum wage profession with no opportunity for progression. The second session was introduced through a patient story highlighting the lack of integration between services and the audience voting on key issues during the presentations in order to shape the discussions. One of the key messages to emerge was that the audience and panel both felt the greatest need was to improve the coordination of care, rather than necessarily seeking further innovation in this area.
On Day Two, keynote speaker Simon Stevens (Chief Executive, NHS England) described the innovative work of the NHS and the new surgeries and treatments underway. He emphasised the need to accelerate and expand the changes, working with the pharmaceutical industry and ensuring GPs prescribe low-cost medications. The discussion panel included 87-year old Ethel Armstrong who had worked for 42 years in the NHS, from the day it was first formed: she described her working experience as an NHS cadet, nurse and radiographer through the decades. The session “The 2 Doors of Mental and Physical Health: making it 1 door for both” explored the difficulties faced by people with mental health difficulties in obtaining both appropriate investigations for physical conditions, as well as proper follow-up of the results. A thought-provoking and engaging session “Better Births” included testimonies from patients, midwives, GPs and obstetricians telling their individual stories, interspersed with some live singing! It focused on personalised and joined-up care, expanding choices for women and an emphasis on safety. Keynote speaker Bruce Keogh (NHS Medical Director) stressed the importance of ensuring that systems are set up to make it easy for doctors to implement the care that they know should be given and focused on the achievements of the UK as a positive environment for research and development both now and in the future.
-- Paul Bird & Anne-Marie Brennan
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RCGP Research Paper of the Year Awards
Two papers by CLAHRC WM researchers have won prizes at the recent RCGP Research Paper of the Year Awards.
Congratulations to CLAHRC WM Theme 3 researchers and colleagues who have won the category 2 prize (CVD, Renal, Respiratory, Oral, ENT, and Ophthalmology) for their cluster RCT on targeted case finding for COPD vs. routine practice in primary care. Their study demonstrated conclusively that actively looking for patients with COPD, utilising a screening questionnaire and confirmatory spirometry in primary care, can improve the case detection rate by more than seven times, compared to routine care.
Congratulations also to CLAHRC WM Theme 4 researchers and colleagues who won the category 6 prize (endocrinology (inc Diabetes), Gastroenterology, Musculoskeletal and Trauma, and Dermatology) for their work on characterising those with incident polymyalgia rheumatica in primary care. Their work provided important information on the course of PMR in the community, which will help clinicians manage the condition.
Guides on Clinical Academic Careers Launched
The NIHR have launched two new guides to support healthcare professionals to develop clinical academic careers. They have been developed with Health Education England to provide information on the various awards available, how to apply for awards, and how the awards work in practice should applicants be successful. The two guides are:
For more information, please click here.
The EQUATOR Network
For those not aware, the EQUATOR Network is a centralised location for all things research guidance, described as a 'one-stop-shop' for writing and publishing high-impact health research. It seeks to improve the reliability and value of published health research literature by promoting transparent and accurate reporting, and wider use of robust reporting guidelines. It can be found at: equator-network.org.
The Future of Health
RAND Europe have recently published their findings on the future of health and healthcare in England. The work was commissioned by the NIHR, and aimed to synthesise the views of stakeholders to gain an understanding of the differences and trends affected the future of healthcare, as well as the key drivers of change, in order to inform strategic discussions about the future priorities of the NIHR. To view it online, please click here.
Lancet Commission on Future of Health in Sub-Saharan Africa
The Lancet Commission on the Future of Health in sub-Saharan Africa has recently published a paper detailing the path to longer and healthier lives for all Africans by 2030. There are nine key messages, ranging from the creation of people-centred health systems, to promoting stronger, more effective regional cooperation. Colleagues from the APHRC (African Population and Health Research Center) contributed to this research. To read it online, please click here (subscription required).
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Cross-CLAHRC Care Homes Research
The NIHR are hosting a national cross-CLAHRC event showcasing Care Homes research as an exemplar of CLAHRC's collaborative approach, and how evidence-based change in health and social care has been implemented. The event will be held in London on 23 November 2017, 10:00-16:30. For more information, and to register, please click here. The deadline for registration is 8 November.
RCGP Midland Faculty: Annual Symposium
Keele University are hosting the 2018 Royal College of Practitioners Midland Faculty Annual Education, Research and Innovation Symposium on 17 May 2018. The event aims to inspire, translate and innovate primary care research by showcasing current research and is open to GPs, researchers, GP trainees, Allied Health Professionals, and medical students. The call for abstracts is now open, with delegates invited to present their research either from an individual level, as part of a research group, practice or any other supportive environment. The deadline is 11pm on 25 February 2018. For more information, please click here.
RSM Events
The Royal Society of Medicine are holding are number of upcoming events:
Challenges of Child Refugee Health: Everyone's Responsibility 17 October 2017 - advice from experts on everything from managing infectious diseases to advocacy for migrants.
Clinical Leadership: A Responsibility, Not an Option 20 October 2017 - advice on everything from how to get your voice heard to involving patients in leading change in the NHS.
Social Media: Challenges and Benefits for Mental Health and Wellbeing 14 November 2017 - learn about everything from pro anorexia websites to online radicalisation and how to support patients.
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Rebecca Crosby
Ms Rebecca Crosby is a PhD student based within the Division of Health Sciences at Warwick Medical School. She is funded by CLAHRC West Midlands and works with theme 3, Prevention and Detection of Diseases. Rebecca obtained her BSc in Biomedical Sciences from the University of Warwick in 2014 where her final year project investigated the evidence for the benefit of exercise. Rebecca continued at the University to study for a Masters of Public Health, examining the impact of chronic disease on mental wellbeing.
Rebecca’s current research focusses on cancer screening attendance, specifically the breast screening programme. Her research includes identifying global predictors of attendance at breast screening (mammography) through a systematic review. This work will be followed by a secondary data project analysing if patterns of attendance are changing in South West London. If attendance is changing, the focussed questions will include in whom and how are they changing. Finally, the research will include the development of a questionnaire that will be used in future research to identify the associations between personal characteristics, personal breast cancer risk, and making an informed decision with the uptake of mammography screening.
Rebecca is supervised by Sian Taylor-Phillips, Chris Stinton and Aileen Clarke.
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Re: Class Lectures in Medical School - Nearly Obsolete?
Richard, did you mean to say that it is content, not context heavy lectures are ineffective? … and it also interesting that you consider PBL has already become “traditional”. I would argue that if a lecture changes to the style to be used in Vermont (active learning classrooms with students in small groups) then this approach to teaching cannot really be called a lecture. Flipped classrooms are similar to what one might see in a typical primary school – and we would never “lecture” primary school children. Of course, there is no clear line between classroom-style teaching and a lecture and hybrid styles are also likely to be effective. Students may well learn best in small group sessions facilitated/taught/led by a faculty member but this approach clearly has implications for the cost of delivering education. Do they learn so much better that we could eliminate one year from the programme? Or are the gains in student satisfaction so large that universities reap the benefits from improved NSS score?
-- Celia Taylor, University of Warwick
Author's Reply: Thank you Celia; yes of course content not context. Other interesting points; I like the primary school example. The detail and costs are a topic for enquiry, but Hattie’s review shows that engagement with your audience is among the key determinants of the effectiveness of education and it is possible to achieve it in large classes of many hundreds (ref previous news blog). At a deeper level engaging peoples positive and responding to the audience in how things are explained are key factors.
-- Richard Lilford, CLAHRC WM Director
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Geppert J, Stinton C, Freeman K, Fraser H, Clarke A, Johnson S, Sutcliffe P, Taylor-Phillips S. Evaluation of pre-symptomatic nitisinone treatment on long-term outcomes in Tyrosinemia type 1 patients: A systematic review. Orphanet J Rare Dis. 2017; 12(1):154.
Jeffery J, Hewison A, Goodwin L, Kenyon S. Midwives' experiences of performing maternal observations and escalating concerns: a focus group study. BMC Pregnancy Childbirth. 2017; 17(1): 282.
Kenyon S, Hewison A, Dann SA, Easterbrook J, Hamilton-Giachritsis C, Beckmann A, Johns N. The design and implementation of an obstetric triage system for unscheduled pregnancy related attendances: a mixed methods evaluation. BMC Pregnancy Childbirth. 2017;17(1):309.
Melendez-Torres GJ, Auguste P, Armoiry X, Maheswaran H, Court R, Madan J, Kan A, Lin S, Counsell C, Patterson J, Rodrigues J, Ciccarelli O, Fraser H, Clarke A. Clinical effectiveness and cost-effectiveness of beta-interferon and glatiramer acetate for treating multiple sclerosis: systematic review and economic evaluation. Health Technol Assess. 2017; 21(52):1-352.
Pritchett R, Jolly K, Daley AJ, Turner K, Bradbury-Jones C. Women's experiences of exercise as a treatment for their postnatal depression: A nested qualitative study. J Health Psychol. 2017
Staniszewska S, Brett J, Simera I, Seers K, Mockford C, Goodlad S, Altman DG, Moher D, Barber R, Denegri S, Entwistle A, Littlejohns P, Morris C, Suleman R, Thomas V, Tysall C. GRIPP2 reporting checklists: tools to improve reporting of patient and public involvement in research. BMJ. 2017; 358: j3453.
(also published in Res Involv Engagem. 2047; 3: 13).
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