Beruflich Dokumente
Kultur Dokumente
%
Baseline risk
so patients
are likely to want more of it. Some patient
groups, notably in the UK the Richmond Group
of C harities, are organising patients to demand
more self m anagement.
Businesses
Companies that insure their workforce against
ill health and promote healthy behaviour benet
the company as well as individual workers. The
same is true for health insurers. The South Afri-
can insurance company Discovery is seeking to
improve the health of its customers by providing
them with incentives to do so. When incentives
work, the insurer is encouraged to extend the
programme to a larger section of the population.
Competition between health insurance compa-
nies may promote the spread of incentives for
behavioural change.
Conclusion
The NCD pandemic threatens the sustainability
of health systems. They must identify and imple-
ment new evidence based policies to survive. But
to have a major impact innovations must spread.
Professionals, markets, consumers, governments,
international organisations, and businesses can
encourage the spread of innovationbut can also
block spread. We need perhaps to spend less time
studying innovations and more time studying
and when appropriate promotingtheir spread.
Paul Corrigan adjunct professor
Christopher Exeter senior fellow
Richard Smith adjunct professor, Imperial College
Institute of Global Health Innovation, London, UK
Correspondence to: R Smith richardswsmith@yahoo.co.uk
Contributors and sources: The authors wrote the hrst drah of
dilerent sections of the report from which this paper is derived.
Many written and verbal comments were received from the
working group (listed in acknowledgments), and the report then
revised. RS shortened and edited the report to the present paper,
and all three authors approved the hnal version.
Competing interests: All authors have completed the unihed
competing interest form at www.icmje.org/coi_disclosure.pdf
(available on request from the corresponding author) and declare:
CE is an employee of Imperial College Institute for Global Health
Innovation. PC and RS are unpaid adjunct professors. RS works for
the UnitedHealth Group, which helped sponsor the Global Health
Policy Summit where the report from which this article is derived
was presented. The UnitedHealth Group together with the National
Heart, Lung, and Blood Institute funds the China Rural Health
Initiative and Primary Care 1u1. RS is an enthusiast for the polypill,
takes the pill, and participated in a recently reported trial. PC was
health adviser to Tony Blair when he was prime minister of the UK.
Members of the NCD working group: Paul Corrigan (cochair),
Imperial College London; Richard Smith (cochair), UnitedHealth
Chronic Disease Initiative; Stephen Bloom, Imperial College
London; Richard Bohmer, Harvard Business School; Kacey
Bonner, British Consulate-General, Los Angeles; Andres Cabrera,
University of Granada; Catalina Denman Champion, El Colegio de
Sonora, Mexico; Prabhakaran Dorairaj, Centre for Chronic Disease
Control, India: Christopher Exeter, Imperial College London;
Catherine Gordon, US Centers for Disease Control and Prevention;
Sian Grilths, Jockey Club School of Public Health and Primary
Care, Chinese University of Hong Kong; John Grumitt, Diabetes
UK and International Diabetes Federation; Christine Hancock,
C! Collaborating for Health; Oliver Harrison, Abu Dhabi Health
Authority; Mike Hobday, Macmillan Cancer Support; Alex Jadad,
Centre for Global E-Health Innovation, University of Toronto;
Desmond Johnson, Imperial College London; Sneh Khemka, BUPA;
Dinky Levitt, University of Cape Town; Lijing Yan, George Institute
for Global Health, China; Michael Macdonnell, Global Health Policy
Forum; Stephen MacMahon, George Institute for Global Health,
Australia; Victor Matsudo, Physical Fitness Research Laboratory of
Sao Caetano do Sul, Brazil; Sarah Morgan, KPMG; Andy Murdock,
Lloydspharmacy; Venkat Narayan, Rollins School of Public Health;
Robyn Norton, George Institute for Global Health, Australia; Anand
Parekh, US Department of Health and Human Services; Parashar
Patel, Boston Scientihc Corporation; Neil Pearce, London School of
Hygiene and Tropical Medicine; Rodamni Peppa, Boston Scientihc
Corporation; Cristina Rabadan-Diehl, Olce of Global Health,
National Heart, Lung and Blood Institute, US National Institutes
of Health; Hilary Thomas, KPMG; Denis Xavier, St.Johns National
Academy of Health Sciences, India.
Provenance and peer review: Not commissioned; externally
peer reviewed.
1 UN. Political declaration of the high-level meeting of the general
assembly on the prevention and control of non-communicable
diseases. lu11. www.un.org/ga/search/view_doc.
asp?symbol=A/66/L.1
l WHO. Global status report on non communicable disease lu1u.
lu11. www.who.int/nmh/publications/ncd_reportlu1u/en.
! Center for Medicare and Medicaid Services. Chronic conditions
among Medicare beneficiaries, chart book. CMS, lu11.
/ Barnett K, Mercer SW, Norbury M, Watt GCM, Wyke S, Guthrie B.
Epidemiology of multimorbidity and implications for health care,
research, and medical education: a cross-sectional study. Lancet
lu1l;!Su:!7-/!.
' Smith R, Corrigan P, Exeter C. Countering non communicable
disease through innovation. lu1l. www.georgecentre.ox.ac.
uk/news/GHPSlu1lNCDREPORT.pdf.
6 Weqaya. www.weqaya.ae/en/index.php.
7 Hajat C, Harrison O, Shather Z. A profile and approach to chronic
disease in Abu Dhabi. Global Health lu1l;S:1S.
S George Institute. The China rural health initiative. www.
georgeinstitute.org/global-health/improving-healthcare-poor-
rural-communities-china.
9 Gibson PG, Powell H, Wilson A, Abramson MJ, Haywood P,
Bauman A, et al. Self-management education and regular
practitioner review for adults with asthma. Cochrane Database
Syst Rev 1996;l:CDuu1117.
1u Foliaki S, Fakakovokaetau T, DSouza W, Latu S, Tutine V, Cheng
S, et al. Reduction in asthma morbidity following a community-
based asthma self-management programme in Tonga. Int J
Tuberc Lung Dis luu9;1!:1/l-7.
11 Lonn E, Bosch J, Teo KK, Pais P, Xavier D, Yusuf S. The polypill
in the prevention of cardiovascular diseases. Circulation
lu1u;1ll:lu7SSS.
1l Wald NJ, Law MR. A strategy to reduce cardiovascular disease by
more than Su%. BMJ luu!;!l6:1/19.
1! Health and wellness innovation lu1!. CollaboRhthym. http://
newmed.media.mit.edu/collaborhythm.
1/ Fairall L, Bachmann MO, Lombard C, Timmerman V, Uebel K,
Zwarenstein M, et al. Task shifting of antiretroviral treatment
from doctors to primary care nurses in South Africa (STRETCH): a
pragmatic cluster randomised trial. Lancet lu1l;!Su:SSu-9S.
1' Fairall LR, Zwarenstein M, Bateman ED, Bachmann M, Lombard
C, Majara BP, et al. Effect of educational outreach to nurses on
tuberculosis case detection and primary care of respiratory
illness: pragmatic cluster randomised controlled trial. BMJ
luu';!!1:7'u-/.
16 Lambert EV, da Silva R, Fatti L, Patel D, Kolbe-Alexander T,
Derman W, et al. Fitness-related activities and medical claims
related to hospital admissions, South Africa, luu6. Prev Chronic
Dis luu9;6:A1lu.
17 Patel DN, Lambert EV, da Silva R, Greyling M, Nossel C, Noach A,
et al. The association between medical costs and participation
in the vitality health promotion program among 9/S,97/
members of a South African health insurance company. Am J
Health Promot lu1u;l/:199-lu/.
1S Patel D, Lambert EV, da Silva R, Greyling M, Kolbe-Alexander
T, Noach A, et al. Participation in fitness-related activities of
an incentive-based health promotion program and hospital
costs: a retrospective longitudinal study. Am J Health Promot
lu11;l':!/1-S.
19 Lorig KR, Holman H. Self-management education: history,
definition, outcomes, and mechanisms. Ann Behav Med
luu!;l6:1-7.
lu Richmond Group of Charities. www.richmondgroupofcharities.
org.uk/.
l1 Syed S, Dadwal V, Rutter P, Storr J, Hightower J, Gooden R, et
al. Developed-developing country partnerships: benefits to
developed countries? Global Health lu1l;S:17.
Cite this as: BMJ ;:f
BMJ | 4 MAY 2013 | VOLUME 346 21
LETTERS
Letters are selected from rapid responses posted on bmj.com. Aher editing, all letters are
published online (www.bmj.com/archive/sevendays) and about half are published in print
O To submit a rapid response go to any article on bmj.com and click respond to this article
Competing interests: None declared.
1 World Bank. The growing danger of non-communicable
diseases. Acting now to reverse change. lu11.
Cite this as: BMJ 2013;346:f2652
What partnership working
means to the alcohol industry
It is an oversimplification to say that the
ideological schism that divides the public health
community is between those who are prepared
to work alongside the industry and those who
are not.
References to the WHO Global Strategy to Reduce
the Harmful Use of Alcohol require clarification,
particularly claims that industry is simply doing
what WHO asked for in the strategy. Not so.
The strategy, which was unanimously
endorsed by WHO member states in ,
restricts the actions of economic operators
in alcohol production and trade to their core
roles as developers, producers, distributors,
marketers, and sellers of alcohol. It stipulates
that member states have a primary responsibility
for formulating, implementing, monitoring, and
evaluating public policies to reduce harmful use
of alcohol. The development of alcohol policies
is the sole prerogative of national authorities. In
WHOs view, the alcohol industry has no role in
formulating policies, which must be protected
from distortion by commercial or vested interests.
WHO is grateful to the many researchers and
civil society organisations that carefully watch
over the behaviour of the alcohol industry. This
behaviour includes direct industry drafting of
national alcohol policies, or drafting through the
International Center for Alcohol Policies, other
entities, or public health consultants, which
it funds. As recent reports document, some of
the most effective policy options to reduce the
harmful use of alcohol, as defined by WHO, are
absent in these policies.
Although the
length of treatment correlated with the increase
in risk, the dose of clarithromycin was not
mentioned, only the duration of treatment.
Chronic rhinosinusitis is one of the most
prevalent otolaryngological conditions in the UK,
affecting an estimated .% of the population.
European guidelines on the management of
chronic rhinosinusitis without nasal polyps
recommend, among other drugs, low dose
macrolides for weeks.
However, a
more recent trial using azithromycin in a similar
number of patients recalcitrant to standard
treatment found no evidence of benefit.
this needs careful support and training, and
recognition that we are in the early stage of our
knowledge about appropriate clinical use.
The situation is not helped by trusts imposing
measures without adequate input from clinicians
and patients on the usefulness of these
measures, the lack of appropriate information
technology infrastructure, or the inappropriate
use of PROMs data as stand alone measures of
performance.
Unless we develop the evidence base on how
to use PROMs in direct clinical work they may
continue to be just one more bureaucratic burden
and may end up doing more harm than good.
Miranda Wolpert Director, CAMHS Evidence Based
Practice Unit (EBPU), Anna Freud Centre and
University College London, London NW! 'SD, UK
miranda.wolpert@annafreud.org
Competing interests: MW is a founding member and paid
director (one day a week) of the CAMHS Outcomes Research
Consortium (CORC), a not-for-proht learning collaboration
committed to using PROMs to inform service development.
She has developed with colleagues a training package in
the clinical use of PROMsUsing Patient Reported Outcome
Measures to Improve Service Electiveness (UPROMISE).
1 Black N. Patient reported outcome measures could help
transform healthcare. BMJ lu1!;!/6:f167. (lS January.)
l Glasziou P, Irwig L, Aronson JK. Evidence-based medical
monitoring: from principles to practice. Blackwell, luuS.
! Wolpert M, Fugard AJB, Deighton J, Grzig A. Routine
outcomes monitoring as part of children and young peoples
improving access to psychological therapies (CYP IAPT)
improving care or unhelpful burden? Child Adolesc Ment
Health lu1l;17:1l9-!u.
/ Freely available training materials and emergent thinking
on use of outcome measures and data in context of child
and adolescent mental health provided by EBPU. UCL.
www.ucl.ac.uk/clinical-psychology/EBPU/presentations/
presentations.php.
Cite this as: BMJ 2013;346:f2669
HEALTH AND SOCIAL CARE ACT
Training in the brave new NHS
Having recently been on a course entitled How
does the NHS work . . . quick before it changes
again (yes, really), I am worried about the impact
of the latest changes on doctors training and
doctors and medical students ignorance of how
the NHS works.
Northumberland, UK
)
P
A
S
P
(
m
m
H
g
)
PASP=.RVESA + .
r=., P<.
Scatter plot of pulmonary artery systolic pressure (PASP) against
right ventricular end systolic area (RVESA).
Fig 1 Fig 2
BMJ | 4 MAY 2013 | VOLUME 346 39
LAST WORDS
Billions of pounds
are being spent
chasing a ghostly
surrogate endpoint:
low blood sugar
been withdrawn; pioglitazone has been
linked to bladder cancer; and exenatide
and sitagliptin double the risk of acute
pancreatitis.
13
14
All this is an exam-
ple of the scientihc illusion that is so
called evidence based medicine, where
research is just mechanically reclaimed
statistics pulped into junk educational
nuggetsmere marketing by another
name.
There remains another fundamen-
tal question. Can diabetes be reversed
or cured by weight loss? A small, well
designed study of 11 patients irrefu-
tably showed that it can.
15
And clini-
cal eect is more important than any
statistically significant yet clinically
undetectable eect that a huge study
funded by the drug industry might hnd.
The therapeutic approach in diabetes
is upside down. The complicity of doc-
tors and lack of dissent against the drug
model of diabetes care is bad medicine.
Des Spence is a general practitioner, Glasgow
destwo@yahoo.co.uk
References are in the version on bmj.com.
Cite this as: BMJ 2013;346:f2695
Type 2 diabetes is a modern plague
largely brought on by lifestyle and is
considered a progressive, non-revers-
ible condition. The polypharmacy
of chronic disease is the drug indus-
trys lottery win, and no more so than
in diabetes, with new drugs and the
increasing use of analogue insulin in
type 2 diabetes worth tens of billions of
pounds worldwide.
1
The drug industrys business plan for
diabetes follows a familiar pattern:
1) Conduct questionable research
and control the original data.
2) Schmooze the politicians, health
regulators, and patient groups to
suggest undertreatment and need for
urgent action.
3) Recruit tame diabetologists, mas-
sage them with cash, and get them to
present at marketing events that mas-
querade as postgraduate education.
4) Pay doctors to switch to newer
drugs in dubious international post-
marketing trials.
2
5) Seek endorsement from the
National Institute for Health and Care
Excellence to bully doctors to treat
diabetes aggressively with drugs.
3
And so the complexities of diabetes
are reduced to simply lowering blood
sugar.
What is the annual cost of this
approach? In the past decade, spending
on insulin in the UK has risen 300%,
to E311m,
4
and on oral anti-diabetes
drugs 400%, to E277m. And have you
ever wondered why companies gener-
ously give away glucose meters? Test
strips are a E166m market, the value
of which has risen 300% in 15 years.
4
But do analogue insulins, new drugs,
and self monitoring of blood glucose
improve outcomes? Does even tight
glycaemic control make a dierence? No
data on mortality or morbidity exist for
the new therapeutics.
5-11
Likewise inten-
sive glycaemic control is not superior
with respect to mortality and cardiovas-
cular disease.
12
So billions of pounds
are being spent chasing a ghostly surro-
gate endpoint: low blood sugar. Worse,
there is evidence that these new drugs
cause harm. Rosiglitazone has already
We lived for three months in a rolled
up newspaper in a septic tank. We used
to have to get up every morning at six
oclock and clean the newspaper, go to
work down the mill, fourteen hours a day,
week-in week-out, for sixpence a week,
and when we got home our Dad would
thrash us to sleep with his belt.
1
Every time doctors tell me about their
working hours before the European
working time directive came into force
I think of the At Last The 1948 Show
sketch.
A bit of exaggerating aside, working
100 hour shihs sounds like a pretty
horrible existence. Good riddance to it.
But at least you got high quality, on the
job training, and you got paid for it.
Unfortunately, its been partially
replaced with silly online quizzes and
fatuous portfolios that need to be done
in your own time. Here is an actual quote
from the e-LfH (e-Learning for Healthcare)
too enraged to properly take it in. You
could strip out most of the material and
lose nothing of value.
Junior doctors want a decent
education. We dont want our time
wasted with box ticking work. It feels as
though whoever is in control of junior
doctors training has too little regard for
our time and is all too willing to throw
another acronymed assessment onto
the pile.
We must demand a more active role
in designing our curriculum. We need
to scrap the quantity and focus on the
quality. Those who set the standards
must be made to justify every minute
of training they ask of us. Box ticking
doesnt help anyone.
Oliver Ellis is a foundation year doctor,
Mersey Deanery
oli.ellis@googlemail.com
Competing interests: None declared.
References are in the version on bmj.com.
Cite this as: BMJ 2013;346:f2708
online training course, as endorsed
by the UK Foundation Programme:
Click on the Poetry Archive website
and choose a poem from the sections
on Death and Grief. Listen to it and then
consider these questions: How did it
make you feel? . . . These mild feelings
may help you to understand how
complex overwhelming untreated grief
can bring about quite profound physical
changes and have an impact on health
over months or years.
2
How did it make me feel? Mostly
patronised. A little outraged. The aim
was to simulate feeling sad, so you can
empathise with bereaved patients and
relatives. Anyone who needs sadness
explained to them wont be hxed by an
online course.
There are some useful bits in that
module, and scattered throughout the
e-LfH site, but its so padded out with
this sort of pap that my brain becomes
FROM THE FRONTLINE Des Spence
Bad medicine: the way we manage diabetes
LAYING FOUNDATIONS Oliver Ellis
Portfolio of pap
Twitter
Follow Des Spence on
Twitter @des_spence
Anyone who needs
sadness explained
to them wont be
fixed by an online
course
40 BMJ | 4 MAY 2013 | VOLUME 346
MINERVA
Send comments or suggest ideas to Minerva: minerva@bmj.com
A pain in the neck
type of headache
Try the picture quiz in
ENDGAMES, p
Weve damp coming down our walls, doctor, and
my chests never been so bad. Can you do us a note
for housing? Doctors responding to such requests
can now cite a good longitudinal study to back
them up: the European Community Respiratory
Health Survey (Occupational and Environmental
Medicine 2u13;7u:325-31, doi:1u.1136/oemed-
2u12-1uu963). In the study, 71u/ young adults
from 13 countries who did not report respiratory
symptoms or asthma at baseline were followed
prospectively for nine years. There was an excess
of new asthma in participants in homes with
reports of water damage (relative risk 1./6, 95%
confidence interval 1.u9 to 1.9/) and indoor
moulds (1.3u, 1.uu to 1.68) at baseline, and a
dose-response effect was observed. Dickensian
landlords take note.
For decades, the tablets that doctors have given
people with osteoarthritis have damaged their
upper gastrointestinal tracts, predisposed them
to have heart attacks, and made little difference
to their pain. What if there was a substance
that actually reversed the disease process and
promoted the repair of articular cartilage? A study
from Japan reports on a novel disease modifying
drug that seems to repair cartilage when injected
into joints (Annals of the Rheumatic Diseases
2u13;72:7/8-53, doi:1u.1136/annrheumdis-
2u12-2u17/5). It works by upregulating the
expression of Runx1. For those of you who think
this probably refers to the mating call of the
Vietnamese pot bellied pig, I should explain that
Runx1 and other runt related transcription factors
are vital for collagen differentiation. And for people
with arthritis waiting for a quick fix, I might opine
that another 1u years will be needed to test the long
term efficacy and safety of these compounds.
Many medical terms date from the time when
textbooks were written in Latin; many more
from the time when most doctors learnt Latin
and Greek at school; still others have been
invented in our own time, simply to baffle us.
An article in the Journal of Allergy and Clinical
Immunology (2u13;131:1u/1-7.e3, doi:1u.1u16/j.
jaci.2u12.u9.u28) seeks to determine whether
the clearance of apoptotic inflammatory cells
(efferocytosis) by airway macrophages was
associated with altered inflammation and reduced
glucocorticoid sensitivity in obese asthmatic
patients. Macrophage is a reasonable 19th
century word from the Greek meaning big eater.
Apoptotic is a late 2uth century coinage, also
based on Greek and meaning liable to give up and
die. And now for efferocytosis. Think Latin for bear
(fero) and away (e). Bearing away cells. Minerva
has never heard of this word before, but evidently
efferocytosis happens less often in the airways
of obese people with asthma, than in non-obese
people with asthma. Their air passages get clogged
up with dead gunk, if youll pardon my Greek.
Perfection is not attainable by mortals, and even
Minerva herself sometimes has trouble reaching
it. But in Italian, perfezionamento can mean
improvement rather than perfection. The Parkinson
Institute of the Istituti Clinici di Perfezionamento in
Milan looks at ways of improving the lot of patients
with Parkinsons disease who have developed
dopamine dysregulation syndrome (Journal of
Neurology, Neurosurgery and Psychiatry with
Practical Neurology 2u13, doi:1u.1136/jnnp-
2u12-3u3988). The institute found that better
outcomes were strongly related to good caregiving.
The technical fixes were tricky: duodenal levodopa
infusion can be used, or deep brain stimulation of
the subthalamic nucleus.
If you strain any chamber of the heart, the
myocytes will produce a surge of short lived
peptide hormone: atrial natriuretic peptide if its
a strained atrium, or B type natriuretic peptide
(BNP) if its a ventricle. And with heart failure
being the largest cause of hospital admission and
readmission throughout the developed world,
its tempting to think that daily measurement
of BNP in high risk patients at home might be a
good way of anticipating (and hence preventing)
cardiac decompensation. In the HABIT trial
reported in the Journal of the American College of
Cardiology (2u13;61:1726-35, doi:1u.1u16/j.
jacc.2u13.u1.u52), patients were given a finger
stick test to measure their BNP every day. But in
people with heart failure, natriuretic peptide levels
go up and down from hour to hour: so although this
study found that daily BNP certainly gives a signal,
it is difficult to separate from noise.
The shrinkage of modern standing armies means
that army musicians, when not playing dirges for
dead prime ministers, are increasingly deployed in
combat roles. The occupational health department
of the United Kingdoms Ministry of Defence
thought that it was important to determine whether
its musicians were experiencing hearing loss as
a result of their day job (Occupational Medicine
2u13, doi:1u.1u93/occmed/kqtu26). Sampling
of 8/ military musicians suggested that they
were at no greater risk of hearing loss than their
administrative counterparts after 8-12 years in
service, and that there was no difference between
the various instruments played. It seems to
Minerva, however, that it is essential to be deaf
before taking up the bagpipes.
Cite this as: BMJ 2013;346:f2705
A young woman presented with painful vesicular
and ulcerative lesions on her oral mucosa, tongue,
and lips with associated crusting. She also had
low grade pyrexia and vesicular lesions on her
fingertips with an erythematous base, which had
appeared a few days after the oral lesions. Swabs
from both sites were positive for herpes simplex
virus type 1 (HSV1) using polymerase chain
reaction. She was managed symptomatically.
The course of primary HSV1 infection is usually
uncomplicated in an immunocompetent host, and
the lesions last 1u-1/ days. Lesions are usually
at one anatomical site, although autoinoculation
can cause lesions at different sites.
Suneeta Teckchandani (suneetatec@doctors.org.uk),
consultant physician, C Papafio, consultant
dermatologist, Medical Assessment Unit, Calderdale
and Huddersfield NHS Foundation Trust, Huddersfield
Royal Infirmary, Lindley HD EA, UK
Patient consent obtained.
Cite this as: BMJ 2013;346:f2683