The Quantified Self: A Clinician's Perspective

Digital health was a hot topic at Social Media Week London (#SMWLDN) this week and I was lucky to be involved with a session called The Next Stage of Digital Engagement: The Quantified Self (hosted by CIPR). The session was voted runner-up by MarketMeSuite in (take a breath) The Most Slightly Terrifying and Yet Apprehensively Exciting Talk Award category.

Our chairman was Drew Benvie, founder/MD of Battenhall and author of Body Data: Applied Thinking in Quantified Self and Wearable Technology . My co-panellists were David Clare, Digital Consultant at Hotwire and author of OneMoreLifeHack, and Steve Davies, Director of Ruder Finn UK and author of Bionic.ly.

We all gave our very own and different perspectives on The Quantified Self (QS). This is the concept of self tracking body data and sharing this via social media. It also concerns the application of the web, apps and wearable tech to personal health and productivity.

Steve spoke about how he and others in the QS community are monitoring their bodily functions, blood biochemistry and genetic makeup to learn about their health. By 2023, the computing power of an iPhone will fit into a red blood cell raising all sorts of exciting possibilities for invasive body monitoring.

David spoke of how the rise of the QS movement is being driven by an explosion in DIY digital health technologies, how businesses (including the pharma industry) might tap into this body data to tailor products more appropriately, and how the QS community is growing from a small hacker community to a mainstream phenomenon.

I spoke about how patient body data is monitored and transmitted between ambulances and hospitals during the treatment of heart attacks, how cardiologists are using implantable devices in patients which can be monitored remotely, and how the QS movement may provide us with healthy body data that allows us to predict and therefore prevent illness.

During the interactive session, we touched on the concerns regarding data privacy, the dangers of over-testing and medicalization of healthy people, and much more.

The session was streamed live and is available to watch here (there are some issues with sound overlay at the start, so you may want to fast forward to the start of Steve's talk at 04:00. My talk starts at 14:00) :

http://new.livestream.com/smwlondon/events/2394741/videos/30811376

Photo of panel courtesy of @ManeeshJuneja

  

London's First Health Tech Forum Meet

The London chapter of the Health Technology Forum (HTF) met for the first time earlier this month and I was fortunate to speak at the event. The HTF is the brainchild of Silicon Valley health tech enthusiast and deal maker, Pronoy Saha, who has created an international network of HTF chapters based in the US, Singapore, India and now the UK. Pronoy hopes that this network of HTF chapters will answer the following question: How can technology be used to narrow the healthcare gap between rich and poor?

 

He believes that by bringing entrepreneurs, technologists, futurists, and clinicians together, answers to this and similar questions will be found in the health tech space. A feature of these meetings is the involvement of clinicians who play a vital role in the adoption of healthcare technologies.

My impressive co-speakers were Battenhall founder Drew Benvie, MedCrunch's Ben Heubl, and telehealth expert Charles Lowe. For me the talk of the evening was Drew Benvie's vision of the Quantified Self and how this will apply to digital health in the future. Continuous harvesting of personal data for maintaining personal fitness, disease prediction/avoidance and management of chronic illness is an exciting prospect. Applying these technologies to healthcare will no doubt lead to more personalised treatments during illness.

 

I spoke about how several technologies are being applied to the emergency treatment of heart attacks. These include technologies used during treatment (drug coated coronary stents, a variety of other invasive technologies, genetically engineered monoclonal antibody based drugs and so on) as well as for communication between ambulances (or helicopters) and coronary care units. A recent radio interview where I describe such a case can be heard here. Implantable devices which can be monitored remotely are routinely used in cardiology departments.

 

I also emphasised the role of the UK's National Health Service (NHS) in future digital health. The NHS is uniquely placed to apply new technologies to cost effective, patient centred healthcare. A nationwide healthcare system with comprehensive data capture has the ability to apply new treatments effectively, safely and rapidly to a huge number of patients, as it has done in the treatment of heart attacks.

 

Details regarding the London chapter of HTF are available here. Another review of this meet is available here.

The Stenting of George W Bush: Why the Controversy?

 

A coronary artery stenting procedure performed last week on former US President George W Bush has generated controversy. After an abnormal treadmill test (done as part of a routine screening programme), he had a CT coronary angiogram which demonstrated a coronary artery stenosis. He was then transferred to an interventional cardiology centre where a stent was inserted into the coronary artery via the femoral artery. Two physicians (neither a cardiologist) claimed that the stent was unnecessary in the Washington Post. Larry Husten writing in Forbes asked a similar question. Burt Cohen writing for Angioplasty.Org gives a more balanced view. Meanwhile, on Fox News, Professor Marc Siegel struggled to get a stent out of its packaging with his teeth on live TV ('Pull the flap at the back,' I could hear many of us screaming). If nothing else, watch the video for a really good laugh.

 

 

The simple truth is that it is not possible to make any comment about this case without knowing all the details. And those details are private between the patient and his cardiologist. 
 

The debate about routine screening tests is not the focus of this post. Briefly, routine screening treadmill tests in the ABSENCE of symptoms are not recommended in the UK, but they do happen (for example, in athletes). I learnt last week that in France all men aged 65 years are offered an appointment with their cardiologist (which I suspect might lead to a treadmill test; can anyone confirm?). It is entirely possible that Bush said something to trigger concern, despite his excellent level of fitness.

In symptomatic patients, treadmill tests are not a 'rule out' test. In other words, a normal result does NOT rule out coronary artery disease. But treadmill tests are cheap, often immediate, and an abnormal result can guide further investigation. In some patients who have no obvious symptoms, a treadmill test can be used to unmask these. The value of treadmill testing (compared to more expensive tests for which patients may wait several weeks) is still being debated.

 

Once the treadmill has been performed, changes on the ECG (or EKG) can indicate ischaemia, in other words reduced blood flow to the heart muscle. Minor ECG changes may have quite reasonably led to a CT angiogram ('I think that this is normal but I want to be sure'). Major ECG changes would have led directly to an invasive angiogram.

 

An anatomically severe narrowing of the coronary artery is likely to have been stented. While 'ad hoc' stenting is frowned upon by some in the elective/stable setting, the interventional cardiologist may already have had evidence of ischaemia. The treadmill test was abnormal. Alternatively the interventional cardiologist may have performed a pressure wire study, measuring what is known as an FFR (fractional flow reserve) across the stenosis. This would have indicated whether the narrowing was functionally important.

Much attention is being paid to the COURAGE trial in this debate. This study (published in 2007) recruited 2300 patients between 1999 and 2004. Patients who had a 70% coronary stenosis AND objective ischaemia (<10% in most patients) or angina were randomised to PCI (Percutaneous Coronary Intervention; stenting) or optimal medical therapy (For more on randomised trials, click here). PCI did not provide a mortality benefit over 4.6 years.

In this study, less than one third of the patients had significant (>10%) ischaemia and so to me it is not surprising that the study did not demonstrate a benefit. It is probably reasonable to ask why patients with no angina and no significant (>10%) ischaemia were having angiograms in the first place. 38% of patients had had a previous heart attack and 85% of the PCI procedures were elective (planned). This does not reflect current clinical practice in the UK where only 30% of PCI procedures are elective (the remainder are emergency or urgent) and all patients with heart attacks are treated urgently.

We know that FFR guided PCI improves clinical outcomes in patients (11% were asymptomatic) from the FAME II trial. We now await the results of the ISCHEMIA trial where patients are being randomised BEFORE angiography. The results of this trial are therefore more likely to reflect current clinical practice.

In conclusion, I think that it is impossible (and perhaps even rash) to say that Bush's stenting procedure was unnecessary. Perhaps a more pertinent question should be this. Why was the PCI performed via the femoral artery? In the UK, 60% of PCI is performed via the radial artery.


Vinod Achan is an interventional cardiologist and clinical lead for primary angioplasty at the Surrey Heart Attack Centre. Listen to his recent interview on BBC radio regarding the treatment of heart attacks and cardiac arrests.

 

 

 

Is Relentless Media Attack on NHS Justified?

The UK's National Health Service has been under a blistering media attack. First, Charles Moore in the Telegraph describes the NHS as the “worst in the Western world” (1). According to him, “the NHS cannot look at the whole patient and meet his/her medical needs”. On Twitter, his editor Tony Gallagher describes the article as “really good”, and he is praised by Douglas Carswell MP. Next, in The Independent on Sunday, Ian Birrill describes the NHS as “a toxic institution”, one where “myopic worship has fostered a culture of complacency that kills patients” (2). Again he has been praised on Twitter by Jane Merrick (political editor of the IoS), Charlotte Leslie MP (MP for BristolNW) and Lord Ashcroft.

What is going on? It would appear that at least two of the above have had bad personal experiences of the NHS with care of relatives or themselves. Could that justify such vitriol in the national press?

Now might be a good time to clear up a few things. Firstly, the NHS is not the CQC (Care Quality Commission). We need a powerful regulator of hospitals in both public and private sectors, and the CQC has failed us in that. But do not tar the NHS with the same brush. Secondly, there are pockets of excellence within the NHS just as there are pockets of abject failure. To use examples of failure as a rod with which to strike all NHS staff demoralises them and fails to recognise their vital role in society.

The NHS is the backbone of healthcare in the UK. It is who we turn to when we are really sick. It doesn’t matter how sick you are, the NHS takes you in and does its best to fix you.  It also trains all our doctors and nurses. Yes, even those who now work in the private sector. Of course, the NHS is not perfect. But it does its utmost to deliver healthcare as a basic human right. It certainly is not complacent.

Funding cuts, staff shortages and increasing patient expectations are putting a strain on the NHS. See how our funding compares to other systems:

 

 

Is it the worst healthcare system in the world as Charles Moore and Ian Birrill would have us believe? Three years ago patient satisfaction with the NHS was the highest it had ever been. Research clearly demonstrates that the NHS provides the most cost efficient, high quality healthcare when compared to all other healthcare systems in the developed world (3). A report by The Commonwealth Fund (4) puts the UK in the top two for safe care, effective care, efficiency and equity (see chart).

 

 

 

We scored poorly on patient centred care (communication, continuity, feedback and patient preferences), and that may have been the price we paid for delivering the most cost-effective universal healthcare system in the world. For most of us in the NHS, this shines a light on where we must focus our efforts next. No complacency there.

How do we persuade the media to stop this unjustified attack on the NHS as a whole? What are their motives?

Please participate in the Twitter debate using #stopNHSattack.

References:

3. Comparing the USA, UK and 17 Western countries’ efficiency and effectiveness in reducing mortality (C Pritchard, M Wallace), J R Soc Med Sh Rep 2011

4. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally (K Davis, C Schoen, K Stremikis), 2010 Update

 

Effective Data Transparency: Cloudier Than You Might Think

 

 

Data transparency, the development of a safe and open culture of data sharing between clinicians and patients, is a noble aspiration. I have no doubt that it will improve the quality of data collection and lead to improvements in clinical care. Tim Kelsey, NHS National Director for Patients and Information, says that data transparency is the future of the people's NHS (1). It is one of the core strategic principles of NHS England. As part of this drive to improve data transparency, outcome data for nine surgical specialities AND interventional cardiology are being published this summer. An important issue that has not been discussed is how this data will be presented and interpreted by the public.

Jeremy Hunt says that patients will see which surgeons apparently have the best outcomes (2). Patients will be able to choose the best surgeons. Really? Cardiac surgery is cited as an example of how this model can drive improvement. Cardiac surgeons have published their outcome data since 2004 and mortality rates have apparently dropped to half those in Germany and a fifth of those in Portugal. What is often not discussed is how this may have led to risk avoidance amongst some surgeons.

MACCE (major adverse cardiovascular and cerebrovascular events) data for all interventional cardiologists in England will be published shortly. This is not a bad thing. However, we should exercise caution when looking at the data and bear in mind the effect this may have on many cardiologists. BCIS (British Cardiovascular Interventional Society) explicity states that you CANNOT compare the performance of cardiologists on the basis of the data. This is unlikely to be the view of government and the public.

For one thing, the data does not discriminate between cardiologists working in high volume heart attack centres and those only doing planned (elective) cases. Cardiologist A in a high volume heart attack centre will have a high volume of complex emergency work (usually 1/3rd of his/her cases) of which a proportion will be of extremely high risk. Patients following cardiac arrest who have been intubated and ventilated (and possibly on a Lucas chest compression device) have a high risk of death even if their angioplasty is successful, but are not considered separately in the data. Cardiologist B may only perform low risk elective cases or avoid taking high risk patients to the operating theatre (known as a catheterisation laboratory or 'cath lab'). While Cardiologist A has an elective mortality of 0%, his/her overall mortality may be 5%. Cardiologist B may have an elective mortality of 1%, and yet appear better overall.

Imagine the following clinical scenario (imagined but based on cases we frequently treat). A 50 year old man has a cardiac arrest at home and receives CPR from his wife. An ambulance crew arrives within 5 minutes and shocks him out of ventricular fibrillation. He is intubated on the scene, airlifted to a Heart Attack Centre by an air ambulance where a specialist interventional cardiology team reopens his blocked coronary artery within 15 minutes of him landing on top of the hospital.

The interventional cardiologist who takes full responsibility for treating this man considers many factors. One, that he may already be brain dead and that saving his heart may not save his life. Two, although the situation appears futile, there is a real chance that this man’s life may be saved. To adopt a non-interventional treatment strategy is to guarantee death (3). Three, the best chance of saving this man’s life depends on an immediate angioplasty and cooling. This is evidence based. Four, the man’s wife, an ambulance crew and an air ambulance crew have fought hard to this point to save his life. Is it fair that the cardiologist may deny potentially life-saving interventional treatment when the patient arrives at the door of his/her 'cath lab'?

Now there is a further consideration, namely the effect that taking on this extremely high risk case may have on the cardiologist's published outcome data. Many of us will swiftly put this consideration to one side and get on with the urgent job in hand.

Data transparency and publication of outcomes are here to stay in a patient centred NHS. But as patients use complex data to make comparisons between cardiologists, will some cardiologists begin to avoid high risk emergency work? How do we help patients to navigate the jungle of data they will be faced with?

Vinod Achan is a Consultant Cardiologist and Lead Consultant for Primary Angioplasty at the Surrey Heart Attack Centre, Frimley Park Hospital

 

 

 

 

From Skullduggery to Scurvy: Patient Centred Evidence Based Medicine

James Lind (1716-1794)

Good clinical practice depends on the following: the individual expertise of the clinician, an understanding of the best available external evidence and informed patient choice. Education of patients is increasingly important so that they can make informed choices about their own treatments. The importance of clinical evidence must be emphasised to patients as well as all clinical staff.

 

Clinical evidence typically comes from clinical trials. A comparison of a new treatment with a control, ie. an existing treatment or placebo (a fake treatment with no plausible biological effect), is known as a controlled trial. The first documented clinical trial was performed by James Lind (pictured above), a naval surgeon who proved in 1747 that citrus fruits (now known to contain vitamin C) cured scurvy (which at the time killed a huge proportion of sailors). He took 12 sailors with scurvy and divided them into six pairs. Each pair was given a different diet which varied from seawater, a mixture of garlic, mustard and horseradish, and citrus fruits. The sailors given citrus fruits made a striking recovery.

 

Until this point, treatments were largely unproven and often quackery (skullduggery even). An example of this was the popular practise of blood-letting which most famously killed the first US president, George Washington in 1799. Over 5 litres of blood were drained over a day to treat his throat infection, resulting in his death.

 

Now clinical trials often involve hundreds if not thousands of patients. These patients must be randomised, in other words selection of patients for both (or more) treatment arms of the trial must be completely random. This ensures that there is no difference between the treatment group and the control group at the beginning of the trial. For example, randomisation ensures that healthier patients are not selected by chance to receive the new treatment. After receiving informed consent, patients must not know whether they have received the new or control treatment (single blinded trial). Where possible, physicians must also not know which treatment they have given (double blinded trial). The best possible trial therefore is a randomised, controlled, double blinded trial.

 

The best available evidence for a treatment does not end there. One positive trial should stimulate other trials to confirm the evidence. A single positive result can be the result of sheer luck (despite statistical significance). It is important that ALL available evidence is considered by the treating clinician. These are best obtained from rigorous systematic reviews of treatments, such as those provided by the international non-profit Cochrane Collaboration.

 

Negative results MUST also be included in any analysis of the best available evidence. Evidence that a treatment does not work is just as important as evidence that it might. However, it has been estimated that only half of all registered and completed clinical trials are published. Positive trials are twice as likely to be published than negative ones. The reasons for these are complex and being addressed by the AllTrials campaign. One example of this is the failure of the pharmaceutical company Roche to disclose all trial data concerning Tamiflu to the Cochrane Collaboration. The UK government has spent £500 million stockpiling Tamiflu on the basis of data that is not complete.

All clinical staff should be trained in interpreting clinical trial data and placing this in the context of best available clinical evidence. As patients play a more central role in their treatment, we should also make a bigger effort to educate them on how to interpret the evidence about their own treatment.

 

May 20th marked International Clinical Trials Day, commemorating the anniversary of the very first clinical trial by James Lind

 

An Elevator Pitch (or Lift Pitch) on NHS Reforms

 

 

 

The Health and Social Care (HSC) Act was passed in March 2012 and came into effect on April 1^st 2013. GP led CCGs (Clinical Commissioning Groups) became responsible for the NHS budget and are now compelled to use competition as a means of improving NHS services. To most of us this seems like a good thing at first glance. Many of us are unaware of what this really means. To help public awareness, here is my ‘Elevator Pitch’ on NHS reforms. An Elevator Pitch is a summary of a concept or argument, short enough to be delivered between floors in an elevator. In the UK, we might call this a Lift Pitch.

The NHS is one of the most efficient healthcare systems in the world. It provides universal, comprehensive healthcare to EVERYONE. Healthcare is free at the point of delivery. We do not run the risk of personal bankruptcy when we fall ill. NHS hospitals are run on a non-profit basis where savings are reinvested in healthcare. Clinical outcomes are excellent. The US spends 2.4 times more on health per person than the UK, yet Britons live longer than Americans. Despite these achievements, the NHS has come under significant attack in the media. Budget cuts at a time when the NHS is at its most efficient have led to staffing shortages and ultimately problems outlined in the Francis Report.

The HSC Act 2012 removes the Secretary of State’s legal obligation to provide or secure healthcare for everyone. The NHS is also now subject to EU Competition law. Section 75 (being debated in the House of Lords today) compels CCGs to invite bids for all health services from ALL willing providers. This leads to a free market based system where expensive tendering processes will consume much of the CCG budgets and time. In the US, administration costs account for 20% of healthcare expenses, three times higher than in the UK.

Healthcare providers will compete against each other for the contracts. This may improve some services. However, barriers between primary care and hospitals will move us away from integration and data sharing. There is a risk that profit making organisations will cherry pick lucrative contracts, leaving difficult and expensive services to non-profit organisations. The irony is that a last minute amendment to the HSC Act makes this even more likely. The amendment declares that the only services NOT subject to competition law are those which can ONLY be provided by a current provider (most likely to be complex, expensive services).

As NHS budgets become tighter and healthcare becomes more expensive (largely as a result of spiraling administrative costs), the NHS is likely to change from a mostly single payer (government funded) system to a US style multiple payer healthcare system, what Don Berwick refers to as a ‘zoo of payment streams’. We only have to look to the US to see how our healthcare system might look in a few years.

Vinod Achan

For my blog on Don Berwick, see here.