Archive | June, 2014

Ancient Egypt and the ‘hierarchy of evidence’

30 Jun

by Jonathan Stokes, PhD student in Multimorbidity theme


One of the first things you learn when training in any sort of biomedical research is the ‘hierarchy of evidence’ (picture above), what counts as the ‘best’ type of evidence in our field. As you can see from this pyramid, randomised controlled trials (RCTs) – where a population is randomly split into two or more groups, an intervention is carried out on one, and the other acts as a ‘control’; results look at the difference between the two groups after a period of time – are at the very top (not counting ‘Systematic reviews’ which are simply compilations of many studies from the lower points of the pyramid). RCTs work so well, and are rated so highly in the hierarchy, because by definition and set-up they control for as much variation as possible. They control for variation both between the two groups involved, as well as between the settings they are subjected to. This is great from a statistical point of view, but stripping context and the variation naturally found in any population between individuals gives us extremely unnatural results i.e. the interventions assessed in this way don’t work in the same way when these are used in the much more complex, real world. And this is especially true when we look at more and more complex interventions e.g. integrated care, for more and more complex patients with multimorbidity – you can find more details on this specific issue in my personal blog page here. Not only do RCTs apply only incompletely to the actual context they’ll be used in, but they also cost an absolute fortune, and take years to do properly. Not always the most practical solution perhaps, particularly in assessing an intervention which has particularly low risk of harms for instance. This lack of real-world applicability can be a real problem, especially when working in a ‘translational’ research centre, where we try to focus on crossing the ‘translational gaps’ between evidence and actual practice. Surely, we want to create evidence here which applies and can be used in the ‘real world’. For this reason, I’d argue that the age old ‘hierarchy’ of evidence in biomedical research is as outdated as its architectural equivalent of the ancient Egyptians. By no means am I arguing not to use RCTs under any circumstances by saying this! RCTs are a great source of evidence in the appropriate circumstances, and for example, I wouldn’t want to be taking any medicine that hadn’t been thoroughly tested with one. But, we need to move away from the simplistic attitude that our evidence can sit neatly in a hierarchy. For starters, look how low down experiential, person-centred, qualitative evidence sits. This is an important area of understanding for the type of care we want to provide to patients! We have a new ‘multimorbidity’ disease paradigm. Our health system needs to adapt to this, and so does our research. Particularly in a time where budgets are being squeezed, if we can save money on a completely inappropriate RCT here and there, for instance, and can instead put some of the abundant routine data we have lying around to good use, we shouldn’t be afraid to do so because of some ancient paradigm.

Asthma still kills: how might this be prevented?

20 Jun

by Christian Thomas, PhD student in Medication Safety theme Image Last month the National Review of Asthma Deaths (NRAD) released figures regarding 195 people who died as a result of asthma in the UK. The report, which reviewed asthma deaths from February 2012 – January 2013 found that death could have been avoided in nearly half of patients. The importance of people with asthma being informed about their illness in order to avoid preventable death was emphasized. Significant improvements to the way asthma is treated have been made over the last 50 years. On the one hand, it is important that health professionals are up to date with evidence based medicine. Equally important, is that patients and parents or carers of those who suffer with asthma, do everything possible to avoid preventable deaths such as making sure medicines are taken correctly and being prepared for factors in the environment which may affect asthma symptoms. As part of the NRAD, asthma patients were urged to be aware of their triggers e.g. such as hay fever; non-steroidal anti-inflammatory drugs e.g. ibuprofen; smoking; minimising time spent around other people smoking; attend or book an asthma review with GP/nurse at least once a year and to make sure to have been given a personal asthma action plan as these have been shown to improve asthma care. Crucially, people with asthma must ensure preventative inhaled corticosteroids are taken as directed by their prescriber. Parents and/or carers of children with asthma are encouraged to explain ‘how’, ‘why’ and ‘when’ the child should be using their inhalers as well as how to spot when their asthma is not controlled. Children must be aware of not only when to call for emergency services but how to do so. Asthma hospitalizes 65,316 people a year in the UK and is known to affect people of any age. Although commonly associated with children or with those in old age, the NRAD reported the median age at the time of initial diagnosis of asthma was 37 years old in those who died. 69 percent of patients in the review were diagnosed after the age of 15 years. Asthma should not be dismissed as a cause of respiratory symptoms. If you or someone you know is suffering from wheeziness, breathlessness, chest tightness or a cough (especially during the night) ensure to visit the GP or nurse. Once diagnosed, a pharmacist can also assist with ensuring an inhaler is taken correctly. A recent review of 906 people with asthma who received advice regarding their inhaler technique from their pharmacist in Greater Manchester, found over half of survey respondents felt that their quality of life had improved for using the service. References GRAY, N., LONG, N. C., MENSAH, N. 2014. Report of the Evaluation of the Greater Manchester Community Pharmacy Inhaler Technique Service. LEVY et al., 2014. Why asthma still kills – The National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: Healthcare Quality Improvement Partnership.

Medication Safety: Are you sitting comfortably?

3 Jun

by Denham Phipps, Research Fellow in Medication Safety theme of the Greater Manchester PSTRC

Denham Phipps blog 3 June 14

While we university researchers are mainly intrepid and fearless, one thing that causes us trepidation is the prospect of being asked what we do for a living. “Research, you say? And what do you do research on?” The answer to that question could either start a conversation, or end it.

To those for whom the answer is “medication safety”, though, either outcome could speak volumes. Sometimes, this topic of conversation has come up with people who have actually experienced a medication error –an incorrect prescription from a doctor, maybe, or the wrong item from a pharmacy. (Of the 900 million or so prescriptions that we in England receive from GPs each year, some five percent are estimated to contain an error of some kind.[1] So, while errors are relatively infrequent, there are enough of them for us to be interested in reducing their occurrence). The people who have spoken to me about their experiences have expressed various feelings: relief that the error was spotted before any serious harm resulted (which it often is:; amazement that an error should happen in the first place; concern that it could happen again, either to themselves or to somebody else.

I once got talking to a former RAF nurse who now works in a civilian hospital. She recalled how medicines were managed in her service days: no matter where in the world RAF medical staff were stationed, they could expect the system for storing, issuing and documenting medication to be the same. This was in contrast to her experience in civilian healthcare, where different organisations had their own systems, much to everyone’s confusion. She also talked about the problems that she encountered when, having spotted medication errors, getting the staff involved to recognise and take responsibility for them.

Our research topic, though, is sometimes a conversation killer. What does this tell us? We have already seen that the majority of prescriptions are turned around without any apparent problems, so for the many people who use GPs and community pharmacies it is just not something that they have had cause to think about. Medication safety matters to these people too, we suspect – but there may be other, more obvious concerns such as accessibility, availability and value for money.

What do you think? We on the Medication Safety theme are holding discussion groups with the general public. We want to find out your views and experiences about medication safety: what it means to you; what can go wrong; how healthcare professionals and service users stop things from going wrong; what you think should be done to improve medication safety. If you don’t get to join one of our discussion groups but have something you’d like to share, then feel free to drop me or Sally Giles a line.

[1] Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe study.