Wishing you a rational new year

Let’s start the year as we mean to go on—by promoting rational healthcare decisions based on the best available evidence. Des Spence, who has now written a weekly column for the BMJ for four years, ended 2010 with a head-on challenge to paediatric ear, nose, and throat surgeons. He said they were practising bad medicine by continuing to remove tonsils and insert grommets in children’s ears (BMJ 2010;341:c6560, doi:10.1136/bmj.c6560). In a string of subsequent correspondence, which one contributor says is essential teaching material for registrars (http://bit.ly/i8gkXS), Spence has apologised for offending ENT surgeons and for the sweeping nature of his critique. But he sticks to his guns that these still common procedures do permanent harm and, at most, only temporary good.

This week we publish letters from the president and former president of the British Association of Paediatric Otorhinolaryngology (doi:10.1136/bmj.c7292). Rates of tonsillectomy and grommet operations have fallen, they say. Two randomised controlled trials have just been completed. National guidelines exist to prevent inappropriate surgery. But yes, there is still uncertainty about the diagnosis of tonsillitis, which relies on clinical assessment. In his reply Spence concludes, “with respect”—a phrase that former BMJ editor Stephen Lock said usually meant quite the reverse—“that both grommet surgery and tonsillectomy are counterintuitive and unnecessary operations in children” (doi:10.1136/bmj.7302). Feel free to weigh in with your views while we commission an updated review of the evidence.

And so to diabetes. As Deborah Cohen and Philip Carter report (doi:10.1136/bmj.c7139), there is clear evidence that the new analogue insulins are not significantly better for patients than the cheaper human ones. And yet analogues now account for about 80% of insulin prescriptions in the UK, 70% in the United States, and 60% in Europe. How has this happened? Fierce competition between insulin manufacturers has inspired clever marketing tactics, say Cohen and Carter. Claims of greater weight loss on analogues have been questioned by regulators, but equally persuasive for GPs and patients are the nice new pen devices, specialist diabetic nurses, and training for health professionals, all funded by industry to help patients switch. “No company will provide nurses to start people on generic isophane insulin,” says Norman Waugh, quoted in the article.

NICE has concluded that the incremental cost of analogues is more than £100 000 per quality adjusted life year, and that this is not clinically justified. Canadian and German health technology assessors agree. According to figures from the University of Cardiff collated for the BMJ and Channel 4 News, if only half of those using analogues had been put on human insulin instead, the NHS would have saved close to £250m over the past five years.

Finally, aspirin. At the close of 2010, the Lancet published a meta-analysis of individual patient data from randomised controlled trials (Lancet 2010, doi:10.1016/S0140-6736(10)62110-1). It found a 21% reduction in deaths from cancer in people who took aspirin for almost six years. The news that aspirin prevented cancer hit the headlines, and no doubt prescriptions of aspirin in healthy people over a certain age are now on their way up. We asked Paul Moayyedi and Janusz Jankowski to look at the new data. In their editorial (doi:10.1136/bmj.c7326) they conclude that, with a number needed to treat of 200 but a 50% increased risk of serious gastrointestinal and extracranial bleeding, it is not clear that the benefits outweigh the risks, even when factoring in the cardioprotective effects of aspirin. Have a good, and rational, 2011.