Stop whinging - it might be your life that's saved

I took my daughter for her first driving lesson this week - one hour down and one hundred and nineteen to go. Lots of learner drivers, and their parents, are having a whinge about the increased number of supervised hours mandated in several states, and for those like my friend with twins, teaching your kids to drive must indeed seem daunting.
Other rules in some states include a total ban on the use of mobile phones for newly licensed drivers, and a limit on the number of passengers aged under 21 late at night.
Yet despite their unpopularity, a quick perusal of the literature appears to generally support the new driving rules.
For a start, according to a paper on the topic from Monash University Accident Research Centre, although novice drivers represent only a minor proportion of the licensed driving population, eg 14% of drivers in Victoria in 2002, they are around four times as likely to be involved in fatal and injury crashes than older, more experienced drivers.
And it’s not only age, but inexperience, that relates to crash risk, the paper says, with “errors in attention, visual search, speed relative to conditions, hazard recognition and emergency manoeuvres” being contributing factors.
On a more positive note, the Monash centre reports Swedish research which found that about 120 hours of supervised driving results in around a 35% lower crash risk than 40 hours. In fact, in 1993 when Sweden made a single change to the licensing system - lowering the age a learner permit could be obtained from 17 years 6 months to 16 years and therefore prolonging the training period – the country experienced a 17% reduction in crashes for all novice drivers.
Other US research, published in JAMA found that in young drivers, fatal injuries increased with the number of passengers in the car at the time.
In any sphere, new rules are almost invariably unpopular.
But as with any public health initiative, the number of beneficiaries can be estimated but not identified by name. Just as we’ll never know who among our hypertensive patients may have had a stroke without our treatment, none of us will ever know who would have lived or who would have died without a change to the rules.
It might be someone we love.

Surrogate sore point

If you had osteoporosis, chances are you’d be happy if offered a drug known to increase bone density. But astute readers would be even happier to take a drug that had been shown not only to make bones denser, but decrease fracture rates.

This distinction between surrogate endpoints such as bone density, and clinically relevant endpoints such as fracture risk, is hardly new, and it was twenty years ago that the FDA shifted the barrier for osteoporosis drugs to reflect the difference.

Right now, diabetes drugs are in the spotlight after reports that while patients on rosiglitazone (Avandia) may have good glycaemic control, it may come with an increased risk of myocardial infarction.

An FDA subcommittee met on 30th July to discuss the cardiac risks associated with rosiglitazone, and voted to recommend that the drug stay on the market but with warning labels and extensive education. In Australia, the Therapeutic Goods Administration has said stronger warnings will be included in the product information for the drug but the exact wording hasn’t yet been determined.
But according to an article by the FDA committee’s chairman in this week’s NEJM, we need a total rethink about the regulation of diabetes drugs.

Endocrinologist Clifford Rosen says it’s not surprising that glycaemic control has been the centerpiece of treatments for type 2 diabetes for many years, with several drugs shown to reduce glycosylated haemoglobin being approved.

“However, change in the glycated hemoglobin level is a relatively poor surrogate for cardiovascular outcomes in type 2 diabetes, accounting for only 5 – 15% of the variation in ischemic risk”, writes Rosen, who urges a “regulatory sea change” on diabetes drugs.

Without one, five years down the track we’ll be in the same position of having a new wonder drug designed to treat a devastating chronic disease but that does more good than harm, he says.

While testing new drugs using real clinical measures such as cardiac events rather than surrogates such as blood tests is costly, in the long run it will save time, money and probably lives.

NEJM 2007 Online 8 August.

Diminishing returns for preventive care

My delightful patient, Mrs M, is now 89. She’s on three antihypertensives and also has high cholesterol – or so we discovered when she had a thrombotic stroke. I felt awful because I hadn’t checked her lipids for ages, and it was several months before she could return to her major past-time of which I’ve been a beneficiary each Christmas – crocheting coathanger covers. (They truly keep your clothes in much better shape.) Maybe if I’d treated her lipids, she wouldn’t have had a stroke.

Anyway, I was reminded of Mrs M on reading an article in this week’s BMJ calling for a rethink on preventative health care in the elderly.

The preventative push doesn’t deal with the problem of how it applies to people who’ve already exceeded an average lifespan, say the GP authors, who claim that fears of ageism have led us to provide treatments which merely change the cause of death rather than prolonging quality life. They use the example of statins to illustrate their case.

Evidence for using statins in the elderly to prevent heart disease is scant, and the largest relevant study is the PROSPER trial, they say. Yet while showing a small positive effect on cardiac mortality and morbidity, the trial also showed a higher rate of death and cancer diagnosis in the treatment group.
Further, the authors question the morality of selecting out and preventing specific causes of death, such as heart disease, leaving older people to die of other conditions that cause more distress. For example, many people regard coronary heart disease as a “good way to go”, they say.

“The best interests of elderly people, who have paid a lifetime of taxes, might lie in investing that money in health care that will genuinely relieve suffering. Cataract operations, joint replacement surgery, and personal care of people with dementia are obvious examples”, the authors say.

It’s an appealing argument, and Mrs M’s had bilateral cataract ops and a knee replacement which have certainly improved the quality of her life. But she’d also like to have avoided a stroke which came close to stealing her independence.
BMJ 2007; 335;285-7.

Super GP clinics not health panacea

It’s like some sort of trump card dragged out by pollies of all persuasions before each election – “GP clinics”. Now Kevin Rudd’s promising us “GP super clinics”; “super-duper GP clinics” will probably be next.
While it’s great that health, especially primary health, is so firmly on the agenda in the upcoming federal election, I can’t be the only one with a sense of déjà vu.
But while overall the clinics have much to recommend them, what really troubles me about the promises, regardless of which side of politics is doing the promising, is the underlying muddy thinking.
To listen to Kevin Rudd you’d think “GP super clinics” are the panacea for all the health system’s ills.
For instance, Mr Rudd says they will reduce the pressure on emergency departments and people will no longer have to go to A and E for every little thing. He’s on thin ice here. For a start, GPs and emergency doctors agree on this one, only a minority of patients attending A and E are in the most serious categories. As well, the clinics are to be set up in the bush and outer suburbs, not necessarily where ED and hospital overcrowding is at its worst.
Nor will new clinics, whether super or not, fix the politicians’ problem of patient demands for medical access 24/7 for non-emergency care.
Furthermore, according to reports most of the funds would go to infrastructure, in other words for the actual buildings by providing grants of between $1 million and $10 million. But lovely as a large purpose-built clinic might be, the lack of them is not our main problem – which is a shortage of GPs willing to work in rural and outer metropolitan areas. The health system won’t be improved significantly by clinics pinching the doctor down the road.
On the other hand, some of the claimed benefits are real. True integrated, multidisciplinary care benefits patients with chronic illnesses, regardless of where they live. And such clinics would be great for training some of the upcoming flood of medical graduates, so long as they’re in the right hands, which brings us to the need for quality assurance. Funding issues are another unacknowledged stumbling block which needs to be overcome.
So bring on “GP super clinics”, but let’s be very careful about expecting them to solve all our problems, and even more careful about how they’re set up and by whom.

Pork-barrelling or meeting community need?

How about this for a great political dodge?
ABC reporter asking the Prime Minister about his dark of night Youtube rescue of a Tasmanian hospital:
“Now Tasmania’s spent years preparing and now implementing a Clinical Services Plan for Tasmania, did you or your office read that before deciding to intervene in Mersey Hospital”.
Like a deft winger sidestepping an unsuspecting defender, Mr Howard’s replied: “Look, we’re aware of what the Tasmanian Government’s plan was, and that was to downgrade the hospital in Devonport”.
As if this was the entire master plan Tasmanian Health has been able to come up with. Sadly, the reporter let him get away with it.
Mr Howard went on to say that communities don’t care which level of government provides health services, and he’s right, but surely some one has to have a big picture view.
In the health-care arena, as in all areas of life, you can’t always get what you want no matter how often Mr Howard may say that “every community in the country should have a ‘legitimate expectation’ of a full range of services”.
But it’s simply not possible to have a fully equipped hospital in every small community given the workforce shortage, finite health dollar, and the need for practitioners to perform a sufficient volume of work to maintain their skills.
Of course, I haven’t fully read the Tasmanian plan either, but it appears to be the efforts of a small state with few doctors trying to best balance the budget and needs of all its constituents, not just those within the boundaries of the marginal electorate of Braddon, currently held by a 1.2% majority by the Libs.
As I understand it, the plan was to downgrade Mersey to a general practitioner care and a day-surgery unit, with patients having to travel 60km for further surgical facilities. The federal government is promising an ED, aged-care facilities obstetrics and surgery, although it’s yet to be seen where the staff will come from.
Whatever your political colours, operation Mersey must be seen as a piecemeal, Bandaid solution for a small community rather than a comprehensive, integrated health plan, which is what we need.
You’d think negotiating a new health care agreement with the states might be a good starting point, but Tony Abbott says there’s no point before the election, which to the government probably is the big picture.