Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trialBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4220 (Published 29 October 2009) Cite this as: BMJ 2009;339:b4220
All rapid responses
Perhaps this study should be re-titled "Effect of Academia taking an
interest in General Practice, with regular pep-talks", and subtitled
"Subliminal messaging re: managing Hospital Admission Rates" ?
It is interesting that this effect did not depend on the putative
interventions; there was no measurable difference in effect on
cholesterol or BP process measures, yet hospital admissions declined.
That's benefit enough, you might think.. until you ask " What happened to
patient well-being, morbidity and mortality ? "
Perhaps people who needed hospital admission didn't get it ??
One could focus further study on CHD morbidity. Such advice and keen
interest as was shown in this study , also pertains under the QOF
incentive scheme. Yet Des Spence is unimpressed with any outcomes
change.. Perhaps this is a new "Toyota Way" ? Give me academic
"personalised interest" anytime ( and some away-days !), instead of
blanket overburden with muda, mura, and muri ?
Grimshaw et al. "Effect of clinical guidelines on medical practice: a
systematic review of rigorous evaluations."
The Lancet, Volume 342, Issue 8883, Pages 1317-1322
Parsons HM: What caused the Hawthorne effect? A scientific detective
Adm Soc 1978, 10:259-283. Publisher Full Text
Des Spence: Dr Doom
BMJ 2009;339:b4663, doi: 10.1136/bmj.b4663 (Published 12 November 2009)
Jeffrey Liker (2003), The Toyota Way: 14 Management Principles from
the World's Greatest Manufacturer, First edition, McGraw-Hill, ISBN 0-07-
Competing interests: No competing interests
The sheer size of the published literature dealing with coronary
heart disease (CHD) makes it unlikely that any investigator is familiar
with all that information. A PubMed search listed 209695 titles. Hidden
within that mass is 604 titles dealing with CHD and blood viscosity and
565 titles dealing with CHD and blood rheology. The lack of any mention
by Murphy et al of either of the last 2 topics, makes it likely that they
are unaware that there is a role for impaired blood flow in the
pathogenesis of CHD.
Although the paper concerned patient care and secondary prevention of
CHD, the paper provided no insights into the group's concept of the
pathophysiology of the disorder they were investigating.
Cholesterol levels were assessed, but elevated cholesterol as a cause
of increased blood viscosity and of reduced red cell deformability was not
recognised. Nor was there any recognition of the published reports which
show blood viscosity as a causal factor in hypertension. At least since
the 1980s it has been shown that smoking increases blood viscosity, but it
was unclear just what was meant by the statement, "For all measurements of
blood pressure we also considered smoking status."
As early as 1964, Mayer had reported the results of a study of blood
viscosity in healthy subjects and in those,
"...with unequivocable evidence of coronary heart disease."
He concluded, "It is suggested that the higher viscosity of whole blood
and plasma is a contributory factor in the development of the clinical
symptoms of coronary heart disease and possibly of atherosclerosis
itself." Many other investigators have reached similar conclusions.
There was early interest in the fact that natives with a diet rich in
fish had a low incidence of heart disease. In 1985 Kromhout et al
reported that a daily intake of 35 grams of oily fish reduced the
incidence of coronary heart disease by 50% in a 20 year long follow up
study. Simons et al (1988) reported that 16 grams daily of fish oil as
MaxEPA, reduced triglycerides by 58% and plasma cholesterol by 34%.
Others have reported similar findings.
Therefore, is it reasonable to make recommendations about patient
care when a major factor is not recognised or considered ? As the first
objective should be to lower blood viscosity, patients should be advised
to stop smoking; to reduce their dietary intake of saturated fats; to
increase their dietary intake of oily fish and to include a session of low
intensity activity during each day. All four recommendations will lower
Competing interests: No competing interests