A controversial study of the effects on patient mortality of sleep deprivation among resident physicians that came under fire last year has been criticized again, this time for its publication by the New England Journal of Medicine.
The researchers examined deaths among people cared for by resident doctors who could work duty periods of 28 hours or more (flexible group) and among those cared for by residents who worked 16 to 28 hours in one shift (standard group). All other working conditions were the same in the two groups, including a cap on working more than 80 hours per week, averaged over four weeks.
The non-inferiority, national, cluster randomized study of doctors at 117 general surgery residency programs across the United States found no difference between the two groups in the proportion of postoperative deaths and serious complications at 30 days among patients (9.1% in the flexible group and 9.0% in the standard group (P=0.92); unadjusted odds ratio for the flexible policy group 0.96 (92% confidence interval 0.87 to 1.06), P=0.44; non-inferiority criteria satisfied).
The FIRST (flexibility in duty hour requirements for surgical trainees) trial came under fire in November 2015, when the Health Research Group of the watchdog body Public Citizens and the American Medical Students Association charged that the study was unethical, in part because patients were not told that they were in a study.
This briefing from the Kings Fund considers some of the key publications and policy announcements that have come out in the wake of the 2015 Spending Review and offers a commentary on what they might mean for the future landscape of the NHS.
Related: Spending Review 2015: a view from The Kings Fund
Inefficient use of staff, expensive supplies, patients staying in hospital too long and reliance on agency workers costs health service billions
The final report from Lord Carter’s review of efficiency in hospitals has been published.
Unwarranted variation: a review of operational productivity and performance in English NHS acute hospitals sets out how non-specialist acute trusts can reduce unwarranted variation in productivity and efficiency across every area in the hospital to save the NHS £5 billion. Of these savings up to £2bn comes from the workforce budget, through: better use of clinical staff; reducing agency spend and absenteeism; and adopting good people management practices. The report acknowledges that although there is exceptional practice already happening in the NHS, the overall average is not sufficient and more needs to be done to bring poor performance up to meet the best.
1. Goodwin, G. The Mental Elf Blog. Published online: 5 February 2016
Generic problems provide a counterpoint to the ‘positive regard’ (Nutt and Sharpe, 2008), which may characterise NICE’s approach to psychosocial interventions. Jauhar and colleagues have done some hard yards to identify bias in the NICE methodology. What they conclude is damning. But, make up your own minds whether NICE was biased or not. It matters.
2. Laws, K. The Guardian. Published online: 5 February 2016
NICE claim that they provide ‘evidence based’ healthcare guidance, but Keith Laws believes this isn’t the case when it comes to psychological therapies like CBT.
We routinely hear about bias and questionable research practices in the world of ‘Big Pharma’, while psychological therapies are often portrayed as pursuing a ‘purer’ path. Is it possible, however, that an organisation as renowned as the National Institute for Health and Clinical Excellence (NICE), whose recommendations apply to health practices in England and Wales but exert influence internationally, might be biased in favour of psychotherapy?
In our paper published in Lancet Psychiatry, we re-assess the evidence used by NICE to recommend psychological therapies as an intervention for bipolar disorder. The diagnosis of bipolar disorder typically describes a cycling between periods of depression and mania (where the latter may involve grandiose ideas, increased drive and decreased sleep, which can all culminate in psychosis and exhaustion if untreated).
Maloney, S. BMJ Clinical Evidence Blog | 4 Feb, 16
From our research we learned that 96% (n=810) of our health professional study participants felt that there was a role for social media in communicating research evidence, and that 80% of participants already used social media for professional purposes. With these overwhelming numbers we felt that there was no more point in looking at the acceptability of social media by health professionals – instead, it was time to focus on investigating how social media can impact on the translation of evidence to practice and on behaviour change.
At the time, we could not locate any published studies that reported an empirical evaluation of the impact and role of social media on translation of health research into practice. This was the catalyst for our investigation to explore the efficacy of social media as an educational medium to effectively translate emerging research evidence into clinical practice.
Outcomes of our trial included a significant shift in clinician attitudes toward social media, increase in knowledge exam results, and the majority of participants reporting a change in their clinical practices. Approximately 70% of the participants reported that receiving the social media posts increased their use of research evidence within their clinical practice.
The use of social media for improving the translation of evidence to practice is certainly not without its problems – however, our traditional methods are problematic also, such as the lag time for the publication process.
Given the expanding costs of medical education and professional development, both to the individual and to employers, I believe there are a number of focus areas for further research in this field. These include investigating the cost-effectiveness and cost-benefit of education practices, along with head to head comparisons of varying approaches available to social media for the translation of clinical evidence to practice.
The NICE forward planner has been updated with improvements to take account of financial reporting periods, more detailed profiling of costs and savings, a tool to calculate local resource impact and case studies.
This tool helps you plan and implement NICE guidance. Use it to:
view upcoming NICE guidance
get indicative costs or savings for upcoming guidance
understand the resource implications of published guidance.
Recent improvements to the planner:
financial planning time frames consistent with health and social care organisations
new worksheets showing previous, current and future financial years
resource impact profiles showing costs and savings over 5 years where possible
colour coded categories showing cost saving, cost neutral, low cost, medium cost, and high cost guidance
Objectives: To assess the effects of a home-based telehealth intervention on the use of secondary healthcare and mortality.
Design: Observational study of a mainstream telehealth service, using person-level administrative data. Time to event analysis (Cox regression) was performed comparing telehealth patients with controls who were matched using a machine-learning algorithm.
Setting: A predominantly rural region of England (North Yorkshire).
Participants: 716 telehealth patients were recruited from community, general practice and specialist acute care, between June 2010 and March 2013. Patients had chronic obstructive pulmonary disease, congestive heart failure or diabetes, and a history of associated inpatient admission. Patients were matched 1:1 to control patients, also selected from North Yorkshire, with respect to demographics, diagnoses of health conditions, previous hospital use and predictive risk score.
Interventions: Telehealth involved the remote exchange of medical data between patients and healthcare professionals as part of the ongoing management of the patient’s health condition. Monitoring centre staff alerted healthcare professionals if the telemonitored data exceeded preset thresholds. Control patients received usual care, without telehealth.
Primary and secondary outcome measures: Time to the first emergency (unplanned) hospital admission or death. Secondary metrics included time to death and time to first admission, outpatient attendance and emergency department visit.
Results: Matched controls and telehealth patients were similar at baseline. Following enrolment, telehealth patients were more likely than matched controls to experience emergency admission or death (adjusted HR 1.34, 95% CI 1.16 to 1.56, p<0.001). They were also more likely to have outpatient attendances (adjusted HR=1.25, 1.11 to 1.40, p<0.001), but mortality rates were similar between groups. Sensitivity analyses showed that we were unlikely to have missed reductions in the likelihood of an emergency admission or death because of unobserved baseline differences between patient groups.
Conclusions: Telehealth was not associated with a reduction in secondary care utilisation.