Informed Decision Making for patients and doctors to produce ...

Informed Decision Making for patients and doctors to produce ...

Dr Aseem Malhotra, Honorary Consultant Cardiologist, Lister Hospital Stevenage Academy of Medical Royal Colleges Choosing Wisely Steering Group Kings Fund Member of Board of Trustees Special thanks to Professor Sir Muir Gray,Professor Robert Lustig, Professor Simon Capewell, Professor Terence Stephenson, Professor Dame Sue Bailey, Dr Fiona Godlee and Professor Rita Redberg YOU CANNOT DRUG PEOPLE INTO BEING HEALTHIER

Half of what you learn in medical school will be shown to be either dead wrong or out of date within 5 years of your graduation; the trouble is nobody can tell you which half. The most important thing to learn is how to learn on your own David Sackett Efficient Health Care Requires Informed Doctors and Patients Seven Sins that contribute to Lack of knowledge

Biased funding of research (research funded because it is likely to be profitable, not because it is likely to be beneficial for patients) Biased reporting in medical journals Biased patient pamphlets

Biased reporting in the media Commercial Conflicts of interest Defensive medicine Medical curricula that fail to teach doctors how to comprehend and communicate health statistics. Ref: G. Gigerenzer, J.A Muir Gray. Better Doctors, Better Patients, Better Decisions, Envisioning Healthcare 2020, Misleading health statistics

There are many ways of presenting a benefit. RRR, ARR or NNT Communicating relative risks as opposed to absolute risk or NNT ( numbers needed to treat) can lead laypeople and doctors to overestimate the benefit of medical interventions. For example in high risk type 2 diabetics primary prevention with Atorvastatin 10mg, RRR 48% in stroke over 4 years. Reduces risk of suffering a stroke from 28 in 1000 to 15 in 1000 i.e 13 in 1000 or ARR od 1.3% NNT need to treat 77 to prevent 1 stroke. Mismatched framing in medical journals compounds the issue. If treatment A reduces the risk of developing disease from 10 to 7 in 1000 but

increases the risk of disease B from 7 to 10 in 1000 the journal article reports the benefit as a 30% risk reduction but the harm as an increase of 3 in 1000 or 0.3%! One third of articles in the Lancet, BMJ and JAMA between 2004 and 2006 used mismatched framing Such asymmetric presentation of data for benefits and harms is likely to bias toward showing greater benefits and diminishing the importance of the harms WHO Bulletin 2009 It is an ethical imperative that every doctor and patient understand the difference between absolute and relative risks to protect patients against unnecessary anxiety and

manipulation Gerd Gigerenzer, Director of Harding center for risk literacy, Berlin. Case Study

49 year old type 2 diabetic and overweight man is reviewed in OPD 9 months following emergency coronary stenting Reports disabling and persistent chest pain in recent weeks which is atypical in nature for having a cardiac origin After checking there is no acute problem, no new ECG changes, blood tests normal, Cardiologist organises urgent repeat angiogram Coronary angiogram reveals the stent is patent, no flow limiting coronary stenosis

as cause of pain. Patient reassured commenced on proton pump inhibitor ( could this be acid reflux?) and discharged back to GP with routine out patient review planned in six weeks Patient is seen in Cardiology out patients six weeks later still complaining of disabling chest pain and also now mentions accompanying muscle aches. Wife is concerned its making him depressed. GP has referred him to a gastroenterologist. Patient advised to stop statin medication for 2 weeks on trial basis Returns to clinic 1 week later elated. Thank you doctor-. After months of misery my pain has disappeared but now I am worried. My GP said you must never stop your statin or you could die!

Abramson J, Rosenberg H, Jewell N, Wright JM, BMJ 2013;347:f6123 doi: 10.1136/bmj.f6123 (Published 22 October 2013) Call for retraction there are only one or two well- documented (problematic) side effects Myopathy and muscle weakness occurred in one in

10,000 people he said and there was a small increase in diabetes - Professor Rory Collins Guardian, March 2014 Statin controversy Statins letter to Health Secretary signed by leading doctors including the President of the RCP,

Sir Richard Thompson, past chair of the RCGP, Clare Gerada, Chair of National Obesity Forum David Haslam, Prof Simon Capewell rejecting NICE move to lower threshold to offer treatment. (2014) Guidance based upon industry sponsored data and several members of the GDG had financial ties to Pharma companies sponsoring statins. Side effects not taken into account including type 2 diabetes.

Increased GP appointments No mortality benefit in the group. No access to raw data Loss of professional confidence GPC In light of the Cochrane review of the effectiveness of antiviral influenza treatments, the GPC will request that NICE refrain from recommending a reduction to the current treatment threshold for primary prevention of cardiovascular disease with statin therapy unless this is supported by evidence derived from complete public

disclosure of all clinical trials' data Sunday Times Investigation, 18th September 2016

Sir Rory Collins, a professor of medicine and epidemiology at Oxford University, led a review into statins, published in The Lancet earlier this month, which found that not more than one in 50 people will suffer side effects. Collins, who believes millions more Britons could benefit by taking statins, is also co-inventor of a test that indicates susceptibility to muscle pain from them. The test, branded as StatinSmart, is sold online for $99 (76) on a website that claims 29% of statin users will suffer muscle pain, weakness or cramps. The marketing material also claims that 58% of patients on statins stop taking them within a year, mostly because of muscle pain Royalties from the licensing of the patent can be used to fund university research, but Collins and his co-inventors have waived personal fees.

Boston Heart Diagnostics said it stood by its claims about statin side effects and that they were based on published research. It also cited a US taskforce on statin safety that said randomised controlled trials such as those used in the Lancet study led by Collins had major limitations because patients with statins intolerance were often excluded. Peter Wilmshurst Centre of Evidence Based Medicine, Oxford 2014 Pharmaceutical companies and medical device companies have a fiduciary obligation as businesses to make a profit

and declare a shareholder dividend by selling their product. They are not required to sell consumers ( patients and doctors) the best treatment, though many of us would like that to be the case. REAL SCANDALS: 1. Regulators fail to prevent misconduct

by industry and 2.Doctors, institutions and journals that have responsibilities to patients and scientific integrity collude with industry for financial gain The IIlusion of innovation Of 667 new drugs approved by the FDA between 2000 and 2008 only 11% truly innovative. 75% essentially copies of old ones. Drug companies spend twice as much on marketing than they do on research and development

It is no longer possible to trust much of the clinical research that is published or to rely on the judgement of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine Dr Marcia Angell possibly half of the published literature may simply be untrue Richard

Horton, editor of the Lancet - 2015 Several recent scandals including universities covering up research misconduct Something is rotten in the state of British Medicine and has been for a long time Richard Smith (2016) UK: The fat man of Europe? 2/3 adults obese or overweight obesity will double by 2050

1/3 children obese or overweight Obesity costs NHS 5billion+ 10 billion by 2050 Snack Foods Are Everywhere

Car washes Book stores Hardware stores Gas stations Office buildings (vending machines) Health clubs/gyms

Video stores Car repair shops Brownell & Warner Milbank Quarterly, 2009 Burden of disease attributable to 20 leading risk factors in 2010 expressed as a percentage of global disability-adjusted life-years Global Burden of Disease Group. 2012 380 2245 Pioppi; the home of the Mediterranean Diet

A book that marries the secrets of Pioppi with the latest cutting edge medical, nutrition and exercise science to bust the myths prevalent in todays weight loss, and health industries

The Mediterranean Diet has been wrongly interpreted for decades Eating fat does not make you fat and saturated fat does not clog the arteries Cholesterol can be good for you! ( and if youre over 60 bad cholesterol protects you from an early death) Physical activity and obesity is a myth ( you cant outrun a bad diet) Dietary changes is more powerful than any

drug for preventing and treating heart disease and type 2 diabetes (which is reversible) and effects/benefits are immediate Myth busting The preservation of the means of knowledge among the lowest ranks is of more importance to the public

than all the property of all the rich men in the country John Adams, 2nd US President, 1775.

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