Monday, 22 October 2018

Non-pharmacological prescription, the first choice treatment

Cristina Roure




Regular physical activity, directed exercise, social prescription or cognitive therapies don’t perform miracles, but neither do the medications that are prescribed daily in consultations and instead we accept them as a necessary evil, allocating 1 in 5 euros that is spent on health to pay for medicines that are not always taken, that don’t always produce the expected benefits when they don’t cause more harm than good.

Surprisingly the medical community find it hard to accept the role that non-pharmacological interventions and particularly physical activity should have not only in the prevention and treatment of chronic diseases, but also to combat frailty in an aging population like ours which moreover, lives submerged in a lifestyle that, after the incessant search for comfort, avoids any effort.

Perhaps this resistance is not so surprising if we think that the paradigm of medical research which influences clinical behaviour is centred on pharmacological clinical trials, which is where sponsorship is concentrated. Yussein Naci and John PA Ioannidis, whom you probably remember from their work "Why Most Published Research Findings Are False"(1), compared the evidence of the benefits of physical exercise and those of pharmacological treatments on mortality (2). The authors conclude that if studied, interventions based on physical exercise have an effect on mortality equivalent to drugs. The problem is that there is a great asymmetry and a clear bias in the prioritization of research that favours pharmacological interventions over the rest. In other words, the current medical research model makes it difficult to establish that which is the best treatment for a disease, if it transpires that such treatment is not pharmacological.

Mike Evans, in his viral video "23 and a half hours", talks about physical activity as the investment that brings the greatest return in health for anyone. If it were a drug, it would undoubtedly be the blockbuster of the century (3).
  • It has more indications than any drug we can imagine. In fact, it’s difficult to find diseases in which physical exercise doesn’t provide any benefit. If not, consult the Handbook for Health Professionals of the Swedish Public Health Institute, which summarizes the updated scientific knowledge on how to prevent and treat up to 33 diseases through physical activity (the 2017 edition is not yet translated, but the 2010 edition is excellent (4).
  • The necessary dose is modest, just 30 minutes a day 5 days a week.
  • Its efficacy is similar or superior to that of drugs (reductions of 30-50% of the risk) (2). Adherence is complicated, it’s true, but it’s also true in the case of medications that don’t exceed 50% in chronic treatments.
  • In general, it’s safer and cheaper than pharmacological alternatives.




Despite this, 80% of medical records don’t collect data on physical activity. In contrast, the number of prescriptions per user is already 27, and continues to grow, and almost half of people taking multiple drugs receive non-recommended drugs or with no or questionable clinical efficacy.

The formal and individualized medical prescription of physical exercise (type of exercise, dose, frequency and duration suitable for each patient), as an essential part of the treatment plan equivalent to pharmacological prescription, is not widespread in our environment. It’s not just about advising physical activity. It’s necessary to know the benefits and risks of each type of exercise in each patient and assess their level of physical activity, their abilities, find a shared objective and, of course, there will be effort to support adherence and follow-up if we want it to be effective.

But this treatment is available free at the corner pharmacy and therefore, the patient should be guided to the most appropriate community resource and refer him when necessary to specialized resources. Moving part of the pharmacological prescription in consultations for another type of prescription such as physical exercise or social prescription will also require transforming the current consultation model based on quick visits and the prescription of a medication for each problem. It’s not easy but there are successful experiences in the US (5), the Nordic countries and New Zealand. Intermountain Healthcare offers several ways to deal with the change of habits with patients in an environment of high care pressure, such as a medical consultation, depending on the time available (1 minute, 5 minutes or more).

There is no doubt that pharmacological interventions have their place and show their maximum benefit in some acute and serious diseases, but in primary, secondary prevention and especially in the transformation of the years of life gained from years of healthy life we will have to use more than medicines. There is nothing miraculous about non-pharmacological interventions but what is extraordinary is that, despite being so simple and providing so many benefits, it’s still so difficult to introduce.


Bibliography

  1. Ioannidis JPA. "Why Most Published Research Findings Are False". PLoS Medicine. 2005;2(8):e124. doi:10.1371/journal.pmed.0020124.
  2. Naci H, Ioannidis JPA. "Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study". The BMJ. 2013;347:f5577. doi:10.1136/bmj.f5577.
  3. Academy of medical Royal Colleges. "Exercise: The miracle cure and the role of the doctor in promoting it. 2015".
  4. Professional associations for physical activity, Sweden (yrkesföreningar för fysisk aktivitet, yfa). Physical Activity in the Prevention and Treatment of Disease. Swedish national institute of public health 2010. isbn: 978-91-7257-715-2.
  5. Sallis R., Franklin B., Joy L., Ross R., Sabgir D., Stone J. "Strategies in promoting Physical Activity in Clinical Practice." Progress in Cardiovascular Diseases, 2015; 57: 375-86.

Monday, 15 October 2018

Break the "ill-fated trio": falls-immobility-delirium, an outstanding issue in the quality of hospitals

Marco Inzitari




The pressure on the safety of patients and medical errors to which we are all subject, together with the fear of professionals for possible complaints resulting from adverse events within the hospital (Hospital Acquired Conditions - HAC, for Americans), are changing the hospital culture, prioritizing the prevention of falls, in many cases, on top of mobility, functionality and, finally, the well-being of patients.

This is what happened in the US from 2007-2008, when the Centre for Medicaid and Medicare Services decided to penalize the billing of episodes of patients affected by different HAC, including falls with injury, to the Affordable Care Act (Obamacare), which penalizes hospitals with worse results in this sense. In our context, in recent years some care areas have also been rewarded or penalized, at the contract level, according to an indicator of intra-hospital falls.

Monday, 8 October 2018

The laws of medicine








Siddhartha Mukherjee, oncologist, researcher and professor at the University of Columbia, is the author of a small essay, The Laws of Medicine: field notes from an uncertain science (2015), which I found interesting enough to recommend to clinicians who desire to think a little more about what they do. "In the medical school," says the author, "they taught me a lot of facts, but they did not prepare me to navigate the immense spaces between these facts. Right now I could write a thesis on the physiology of sight, but I feel lost when I try to understand the conniving network that makes a man, who was prescribed home oxygen, give a false address to the service providers, embarrassed (I later learned), because he lived on the street."

Wednesday, 3 October 2018

Social addiction to biometrics

Salvador Casado



Mirrors are polished surfaces that reflect the image projected on them.  It is a technology that the ancient Egyptians and Greeks already knew and that has evolved over time. Today the majority of the population carries a pocket mirror that also allows immortalizing the images that come to it in the form of an auto-photo. In addition, modern mirrors reflect multiple variables and information of their owner. They measure his steps and the distance he travels, his activity pattern, his movements, his level of communication. They can measure the sleep/wakefulness rhythm and give a report on the quality of sleep and if we connect some specific gadget they can measure blood pressure, blood sugar and even do an electrocardiogram.

Monday, 1 October 2018

Treatments, tested








The other day, Xavier Bonfill and Iain Chalmers presented the Catalan edition of the book Testing Treatments. Better Research for Better Healthcare. This caught my attention and after 12 years of delay, I was motivated to read the work. It’s necessary to clarify that in 2006, the year of its first edition; I was a hospital CEO and had neither the head nor the time for this. Maybe one day we will have to talk about what the executives read. Be that as it may, this text is considered one of those that have laid the foundations of modern clinical management, which concentrates its focus on effectiveness, a goal as coveted as it is difficult (1).

Journalist Nick Ross, in the presentation of the first edition of the book, wrote: "This book is good for health; it shines light on the mysteries of how decisions about life and death are made. It goes to show how these criteria are generally lacking and it challenges doctors from around the world to change their ways.” On the other hand, Ben Goldacre, in the prologue of the second edition (2011), provides a really interesting quote: "The true purpose of the scientific method is to make sure that nature doesn’t mislead us into thinking that we know something that we don’t really know".