Breathing difficulty in older patients . . . and other storiesBMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4302 (Published 10 August 2016) Cite this as: BMJ 2016;354:i4302
Old and breathless: heart or lungs?
Breathing difficulty is the commonest trigger for acute admission in older patients. Most of it is attributed to heart failure, pneumonia, or chronic obstructive pulmonary disease, but these diagnoses often overlap or change with repeated admissions. A study of over a quarter of a million patients aged 65 and older in 368 US hospitals finds that 32% of patients admitted with pneumonia also receive treatment for other cardiopulmonary conditions, 39% with heart failure receive treatment for pulmonary disease, and 19% with chronic obstructive pulmonary disease receive treatment for heart failure or pneumonia, or both ( J Am Geriatr Soc doi:10.1111/jgs.14303).
Futile CA125 testing continues
In 2009, a well conducted randomised trial showed that women with ovarian cancer who were regularly tested using cancer antigen 125 (CA125) received more chemotherapy than those tested when they had a relapse, which reduced their quality of life without improving survival (Lancet doi:10.1016/S0140-6736(10)61268-8). But practice in the United States has continued unchanged (JAMA Oncol doi:10.1001/jamaoncol.2016.1842). During a 12 month period, a mean of 4.6 CA125 tests and 1.7 computed tomography scans were performed per patient, resulting in a US population surveillance cost estimate of $2m (£1.5m; €1.8m) per year for CA125 tests alone and $16.2m per year with computed tomography scans added. All for no gain and added burden to patients.
Shoe leather doctoring in China
In the middle of the Chinese Cultural Revolution 50 years ago, Mao Zedong gave a speech favouring the training of “barefoot doctors”—mostly farmers in rural China who would receive six months’ training to look after the basic needs of their communities. This may have had lasting effects on the perception of primary care as a career option among Chinese medical students taking five year college courses. In a cross sectional survey (BMC Fam Pract doi:10.1186/s12875-016-0472-5), most of the 2402 respondents indicated some willingness to work in community primary care, but most regarded it as a stepping stone rather than a destination.
Revalidation and resignation
Back home in Britain, primary care doctors are also voting with their feet. One reason that older general practitioners are leaving is the five year cycle of mandatory revalidation. Comments were made by 42 respondents out of 1192 in a national survey, and none were supportive (BMC Fam Pract doi:10.1186/s12875-016-0489-9). Revalidation was depicted as a cumbersome tick-box exercise that had little to do with quality of care or protecting patients.
No substitute for RCTs
Recently, the idea that randomised controlled trials (RCTs) are always better than big observational studies has come under attack. But investigators from Oxford compared the large SEER dataset of breast cancer outcomes with a meta-analysis of RCTs carried out by the Early Breast Cancer Trialists’ Collaborative Group (J Clin Oncol doi:10.1200/JCO.2016.68.8879). In the observational SEER data, radiotherapy was associated with statistically significantly lower rates of mortality from all causes except breast cancer, including from heart disease. In the RCT data, by contrast, radiotherapy was associated with statistically significantly higher rates of mortality from all causes except breast cancer, including from heart disease and from lung cancer.
Surgeon data dangers
A questionnaire sent to all 361 consultant cardiothoracic surgeons in the United Kingdom revealed mixed feelings about the disclosure of individual surgeon outcomes, whereas the majority favoured public disclosure of team outcomes (Circ Outcomes doi:10.1161/CIRCOUTCOMES.116.002749). Many thought that data about individual performance would encourage risk averse behaviour, gaming of data, and misinterpretation of data by the public.
Condom use and attractiveness
Men aged 18-69 were asked to rate the attractiveness of 20 women on the basis of facial photographs and decide whether to indicate their willingness to have sex with or without a condom with each woman (BMJ Open doi:10.1136/bmjopen-2015-010883). If a man judged himself or the woman particularly attractive, he would be less likely to use a condom. Political incorrectness gone mad.