(2) DOES PSYCHOLOGICAL TREATMENT FOR ADULT SEX OFFENDERS WORK?

(3) SHOULD PATIENTS HAVE TO OPT OUT OF ELECTRONIC RECORDS?

(4) PARENTS ADVISED TO USE MINIMUM DOSE TO TREAT CHILDHOOD FEVER

(1) TAKING MEDICINE REGULARLY (EVEN PLACEBO) IS GOOD FOR YOU

(A meta-analysis of the association between adherence to drug therapy and mortality)
http://bmj.com/cgi/content/full/333/7557/15

(Commentary: The healthy adherer and the placebo effect)
http://bmj.com/cgi/content/full/333/7557/18

People who take their medicine regularly, even dummy (placebo) medicine, have a lower risk of death than those with poor adherence, finds a study in this week’s BMJ.

This intriguing finding supports the concept of the “healthy adherer” effect, whereby adherence to drug treatment may be a marker for overall healthy behaviour, say the authors.

They analysed 21 studies involving over 46,000 participants. For those with good adherence to drug therapy or placebo, the risk of mortality was about half that of participants with poor adherence.

Possible reasons for this effect are that participants with good adherence to study drugs (even placebo) may also have good adherence to other healthy behaviours, which could independently affect the risk of mortality, explain the authors. Conversely, participants with poor adherence may have consciously chosen to use a lower dosage or have other conditions, such as depression, that affect adherence.

“Our findings support the tenet that good adherence to drug therapy is associated with positive health outcomes,” they write.

“Moreover, the observed association between good adherence to placebo and lower mortality also supports the existence of the healthy adherer effect, whereby adherence to drug therapy may be a surrogate marker for overall healthy behaviour.”

In an accompanying commentary, US researcher Betty Chewning suggests that it is quite possible that people who adhere to healthy lifestyles also tend to take care of themselves by greater adherence to prescribed treatments.

She points to research showing that healing may lie not in the treatment but rather in patients’ emotional and cognitive processes of “feeling cared for” and “caring for oneself.” And she suggests that practice based on these hypotheses “could yield extra value in treatment regimens that patients agree to, believe in, and will sustain over time.”

Contacts:

Paper: Scot Simpson, Assistant Professor, Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
Email: ssimpson{at}pharmacy.ualberta.ca

Commentary: Betty Chewning, Director, Sonderegger Research Institute, School of Pharmacy, University of Wisconsin, USA
Email: bachewning{at}pharmacy.wisc.edu

(2) DOES PSYCHOLOGICAL TREATMENT FOR ADULT SEX OFFENDERS WORK?

(Editorial: Psychological interventions for treatment of adult sexual offenders)
http://bmj.com/cgi/content/full/333/7557/5

Psychological treatment for adult sex offenders can reduce reoffending rates but does not provide a cure, say experts in an editorial in this week’s BMJ.

Sexual offending is a public health issue and a social problem. Psychological treatment is widely used and is often mandated in the sentencing decision for sexual offenders. But just how effective are psychological treatment programmes? Are they too readily accepted uncritically?

Specialists in psychology and criminology review the evidence from published studies.

In an analysis of randomised controlled trials on behavioural treatments, they found that most studies were too small to be informative, although statistically significant improvements were recorded across some groups of offenders.

The largest, longest trial compared group therapy with no group therapy for 231 men guilty of child abuse, exhibitionism, or sexual assault. During the subsequent 10 years, a greater proportion of those allocated to group therapy were re-arrested, but this did not reach statistical significance.

However, evidence from these types of trials provides only a fraction of the knowledge needed, particularly on recidivism (used here to mean a repeat sexual offence), say the authors.

Treatment failure is associated with higher rates of recidivism, and offenders who successfully complete a treatment programme reoffend less often and less seriously (that is non-sexual reoffending) than those who do not show that they have understood and worked through the relevant psychological issues.

Paedophilia cannot always be successfully treated, they write. Better understanding of the outcomes of treatments – either controlling and moderating or harming and worsening behaviour – could at least focus on the most beneficial and cost effective interventions.

There is enormous political and institutional pressure to prove that treatment works. Assessment of all outcomes must take the expectations of researchers into account, and also offenders’ and therapists’ perceptions of treatment.

It should be possible to combine the strength of randomised controlled trials with the collection of good qualitative data and to ensure that psychological interventions for sexual offenders are assessed effectively, they conclude.

Contact:

Belinda Brooks-Green, Lecturer in Psychology, School of Psychology, Birkbeck, University of London, UK
Email: b.brooks-gordon{at}bbk.ac.uk

(3) SHOULD PATIENTS HAVE TO OPT OUT OF ELECTRONIC RECORDS?

(For and Against: Patients should have to opt out of national electronic care records)
http://bmj.com/cgi/content/full/333/7557/39

(Commentary: What’s all the fuss about?)
http://bmj.com/cgi/content/full/333/7557/42

(Soft paternalism and the ethics of shared electronic patient records)
http://bmj.com/cgi/content/full/333/7557/2

(The NHS programme for information technology)
http://bmj.com/cgi/content/full/333/7557/3

The potential benefits of sharing patient electronic records within health systems are broadly agreed, but concerns remain over patient consent and security. Experts in this week’s BMJ discuss how patients should consent to use of electronic records in the NHS and how the data can be kept secure.

There are two broad schools of thought. The first (the opt-out model) is for the public to be informed of the NHS care records service and to be given a chance to opt out if they do not want their clinical records shared within the NHS. The second model is for no sharing to occur until people have expressed their desire to share their clinical records within the NHS (the opt-in model).

Nigel Watson, Chief Executive of Wessex Local Medical Committees, has experienced an opt-out approach and believes that this is the way forward.

He cites existing opt-out schemes that have been widely accepted by health professionals and the public, and points out that the health service in Alberta, Canada, changed from the opt-in position to an opt-out one in 2003 after consultation with both patients and clinicians.

In his own area of Hampshire and the Isle of Wight, only 1150 out of the 1.3 million patients have decided not to have their records included in the repository.

In terms of security, access to a patient record in the repository requires a user name and password, he adds. User names are only issued to staff with confidentiality clauses in their employment contracts, and before accessing the patient record the user is asked to confirm that the patient has given consent.

He believes an opt-out model should be used for the NHS care record service, as it allows patients to benefit from earlier availability of information, reduces the workload on hard pressed services, and cuts the bureaucracy for both practices and patients.

However, he stresses the need for a large publicity campaign six months before the start of the service, telling patients what is going to happen, the potential benefits and dangers, and most importantly how they can opt out of having their records shared.

But Dr John Halamka, Chief Information Officer at Harvard Medical School, argues that opting in is the only way to ensure confidentiality.

He discusses regional data sharing in the US and believes that patients are best served by prospectively seeking their permission to include data in the regional index. This approach acknowledges patient control and ownership of medical information.

Both opt-in and opt-out approaches have risks and benefits, he says. The key disadvantage of an opt-in system is that records populate the regional index slowly, making adoption of data sharing slow. Another is that a clinician may prescribe a drug that has an important interaction with the patient’s undisclosed mental health prescriptions.

With the opt-out approach, historical records could be used to populate the regional index rapidly, but if the index is compromised, information about all institutions, including mental health providers, could be leaked. This could cause much anxiety and may affect patient confidence in the system, since they did not prospectively approve participation.

“We have only one opportunity to build a healthcare information superhighway that patients and providers can trust. We should let the patients decide if they want to drive on it,” he concludes.

Two editorials also published in this issue discuss the ethics of shared electronic patient records and the need for rigorous evaluation and regulation.

Contacts:

Nigel Watson, Chief Executive, Wessex Local Medical Committees, Winchester, Hampshire, UK
Email: nigel.watson{at}wessexlmcs.org.uk

Dr John Halamka, Chief Information Officer, Harvard Medical School, Boston, Massachusetts, USA
Email: jhalamka{at}caregroup.harvard.edu

(4) PARENTS ADVISED TO USE MINIMUM DOSE TO TREAT CHILDHOOD FEVER

(Editorial: Antipyretic drugs for children)
http://bmj.com/cgi/content/full/333/7557/4

Parents should be advised to use the minimum dose necessary when treating a child with fever, say researchers in an editorial in this week’s BMJ.

Fever is common in children and can often cause distress, parental anxiety, and – in some parents – “fever phobia” (undue fear and overly aggressive treatment of fever).

Non-drug treatments include loosening clothing, reducing the ambient temperature, and encouraging the child to take fluids. The drug options are paracetamol and ibuprofen, and parents commonly give both drugs to a child with fever.

But should these drugs be used together, or alternately, for which children, and at what dose and frequency? Advice is inconsistent, leading to confusion and frustration among parents, nurses, and doctors.

To try to answer these questions, researchers in Bristol searched the scientific literature, but found very little evidence to support prescribing paracetamol and ibuprofen in combination or alternately.

They also found other important gaps in the evidence, including limited safety data and no clear definition of what is a clinically important temperature difference after treatment.

Until such evidence is available, the role of combined anti-fever drugs is uncertain, they warn.

Given that the absence of evidence from trials is at odds with strongly held parental beliefs in many cases, and given the desire among parents and clinicians to do something when faced with febrile children, it seems churlish to conclude that combined treatment should be withheld from all children, say the authors.

But parents should be advised to use the minimum treatment necessary, they conclude.

Contact:

Contact authors via Cherry Lewis, Research Communications Manager, University of Bristol, UK
Email: Cherry.Lewis{at}bristol.ac.uk

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