Paper of the Week: 21st January 2020

This week’s blog is brought to you by: Dr Muir Gray

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This is a free pdf with the full articles and accompanying editorials

Authors conclusion

We know that physicians need the best information in order to advise patients and to identify these vaping-related illnesses. In early September, we published a report on pulmonary illness related to e-cigarette use in Illinois and Wisconsin. The 53 cases described in this report had patterns of pneu­monitis that included acute eosinophilic pneumonia, organizing pneumonia and lipoid pneumonia, among others. Products that contained THC were the most commonly reported e-cigarette product exposure. 2019 will be remembered for emergence of vaping-related disease and this article was the first to describe the clinical details.

We have published several other notable articles this year. One, published in April, described heart and lung transplants from HCV infected donors. This study found that treatment with an antiviral regimen for 4 weeks, initiated within a few hours after transplantation, prevented the establishment of HCV infection. Were the results of this trial sufficient to encourage more widespread use of HCV-mismatched transplantation? It is still too early to say, but the results were very encouraging. Another, a trial of ibrutinib and venetoclax for first-line treatment of CLL, showed impressive results: every patient had a response and almost all had a complete response.

These are just a couple of the practice-changing articles published in 2019 that are improving patient care.

3V bottom line

Research can stop as well as accelerate the relentless increase in the volume and intensity of clinical practice.

3VH – Implications for value

This week’s choice is the choice of the new Editor in Chief of the New England Journal of Medicine and the full text of the ten articles plus the related  Editorials is available free.

The ten articles can be classified with respect to value. Two of them are articles on prevention, one on air pollution and the other on vaping and he picked out the vaping article as being particularly worthy of comment.

The other eight articles were on clinical practice and although he highlights two of the articles that have positive implications for improving care, and increasing the intensity of clinical practice, four of the eight articles not on prevention were very clearly articles in which the conclusion was that people should not increase the intensity of what they were doing. They were reports of studies demonstrating that doing more for a particular group of patients was not increasing benefit and, by implication would require resources which would inevitably harm some patients without benefit and therefore would be beyond the point of optimality in the classic language of Avedis Donabedian.

People might expect the New England Journal of Medicine to be promoting high tech healthcare but, as always, the Journal is thoughtful and cautious.

There will inevitably be research findings that increase clinical activity but it is very important to identify which innovations would add value and those which do not. The action for the latter groups is relatively simply stop them being introduced. However even those interventions shown to be effective need to be carefully managed to ensure they are introduced;

  • at or near the quality of service delivered in the research study
  • for patients with the same characteristics as those in the research study and
  • funded as much as possible by stopping some other intervention of less value for the same group of patients

GRIP – Getting Research Into Practice – needs good leadership as the Academic Health Science Networks have found