Demographic Dividend Divided

Readers of the CLAHRC WM News Blog will be familiar with the concept of the demographic dividend – the opportunity for economic growth when the dependency ratio improves as a result of falling birth rates and before it declines due to an increasing proportion of elderly people. Asian prosperity has been fueled, at least in part, by favourable dependency ratios. However, distorted sex ratios at birth from the usual 105:100 to about 116:100 (males to females) is now resulting in a mismatch in early adulthood and consequent declining marriage rates. This mismatch accumulates over decades and will lead to a 30% imbalance within a few decades – the mathematics were explicated in more detail in a recent article of the Economist.[1] The situation is further aggravated by the “flight from marriage” as more well-educated women delay or eschew the idea of committing themselves to one man. The social effects of all this are hard to foresee, but it is well known that single men are a restless lot, prone to violence and available for army conscription.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. The Economist. Bare branches, redundant males. The Economist. 18th April 2015.
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Further Evidence from Informal Settlements

At last slum health, featured in previous blogs, is starting to receive the attention it deserves. A recent report on the Mathare settlement in Nairobi, Kenya [1] correlates how far a person lives from a public toilet and risk of disease. The further a person lives from the facility, the more likely they are to be chronically unwell, especially with diarrhoeal diseases and childhood stunting. As readers know, poor nutrition and sanitation create a vicious circle. Also, the risk of violence against women rises with distance from a public facility. Clean water and sanitation remain huge challenges for slum dwellers. Improved sanitation would also produce an educational and economic dividend. Meanwhile toilet design has improved, for example, with the invention of the composting toilet, so cost-effective, logistically feasible improvements are possible and likely to be highly cost-effective. The CLAHRC WM Director liked this paper because it integrated disease surveillance, geospatial mapping, and the personal accounts of slum dwellers, to create a rich account of pathways to poor health.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Corburn J & Hildebrand C. Slum sanitation and the social determinants of women’s health in Nairobi, Kenya. J Env Public Health. 2015. [ePub]

Measuring the Quality of Life: Holy Grail

The standard method to measure quality of life (QoL) is to convert a generic quality of life score to a utility value, thus:

Score on a generic quality of life questionnaire X Conversion factor (tariff) = Utility

The QoL score must be generic because it has to cover all ailments, from deafness to paraplegia to depression.

The conversion factor converts this score to a utility that provides a common 1-0 (best health to death) scale, but also allows for negative values (worse than death). The most commonly used QoL questionnaire is the EQ-5D, which has only five dimensions (mobility, ability to care for oneself, ability to perform usual activities, pain/discomfort, and anxiety/depression). There is reason to question whether this is sufficiently broad for health (narrowly defined) use. For instance, it might not fully capture the utility loss from blindness. If it does not fully capture health narrowly defined, then it may be assumed that it falls shorter still for health more broadly defined to include effects of social care, economic independence, and overall happiness. Scales such as the WALY (Wellbeing-Adjusted Life Years) scale try to capture these outcomes. However, it is cumbersome to have two separate scales; ideally we need one, covering the same dimensions, but without introducing distortions by double counting some of them, but not others. Work is ongoing to sort this all out by collating information on many dimensions and eliminating those that largely duplicate information that others capture more specifically.

Enter Amartya Sen, an economist who won the Economics Nobel Prize in 1998 (alright, technically the Svergies Riksbank Prize in Economic Sciences). He emphasised human capabilities and argued that happiness was not enough – it was more important to have the capacity to understand and appreciate what the world has to offer and to be involved politically, than to simply have a hedonic life. Professor Jo Coast, collaborator of CLAHRC WM, has produced a score called ICECAP-A (ICEpop CAPability measure for Adults) for the purpose of measuring capabilities.[1]

Capability-based measures and patient perceived quality of daily life are fundamentally different constructs and pin-point the fundamental philosophical distinctions that lie at the heart of the quality of care debate. Like Candide in Voltaire’s play, I would gladly sacrifice happiness for an intellectual appreciation of the world and what lies beyond.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Al-Janabi H, Flynn T, Coast J. Development of a self-report measure of capability wellbeing for adults: the ICECAP-A. Qual Life Res. 2012; 21(1): 167-76.

Use of Language: Race is to Ethnicity as Sex is to Gender

The CLAHRC WM Director has often puzzled over the use of “gender” vs. “sex”, and “ethnic group” vs. “race” in scientific writing. They are not synonyms; gender and ethnicity are social constructs, while and sex and race are biological. The former are not “polite” terms for the latter. Philip Steer, Emeritus Editor of an exceptionally lively speciality journal BJOG: An International Journal of Obstetrics and Gynaecology, has written a sure-footed article on this topic.[1] Agreeing that race is the appropriate term to describe groups with a similar place of origin, irrespective of culture, he recommends the National Library of Medicine MeSH groupings. Five continental groupings (African, American, Asian, European, and Oceanic) are broken down by sub-region – for example, European into ‘White European’ and ‘Mediterranean’. Gone is the term Caucasian, which was used to describe broader origins than just the Caucasus area and which, the CLAHRC WM Director learned, has eugenic overtones.

The article makes some other interesting points. Africa has the greatest human genetic diversity among the continents, accounting for as much as 80% of all human genetic variation. This is because of the bottleneck created by the exodus from Africa of a relatively small group of Homo sapiens about 70,000 years ago. These migrants mated with Neanderthals and spread out to colonise the rest of the globe. All of this is of interest to CLAHRC Africa, which has an interest in preventing hypertension and stroke. Salt is the prime causal suspect and there is evidence that some African people may be especially prone to salt-induced hypertension as a result of a widespread allele. Since intake of salt has increased rapidly over the past century we are developing protocols to identify the main source of salt in the diet. In due course we will design an intervention to tackle this. We are working closely with colleagues in the African Population Health Research Center (APHRC) and Malawi on this project.

However, the whole question of race will become progressively less important in science and medicine in the future for two reasons. First, gene sequencing will increasingly enable scientists and doctors to hypothecate genetic variation at the individual level, rather than the level of the group/race.[2] [3] The arrival of personalised medicine will reduce the importance of race and it has always been the case that there is far more variation within, than between races. Second, mating across racial boundaries will increasingly dilute correlation between race and genetic configuration and vitiate the effects of Homo sapiens great migration out of Africa.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Steer P. Race and Ethnicity in Biomedical Publications. BJOG. 2015: 122(4): 464-7.
  2. Burchard EG, Ziv E, Coyle N, et al. The Importance of Race and Ethnic Background in Biomedical Research and Clinical Practice. New Engl J Med. 2003; 348: 1170-5.
  3. Jeffers C. The Cultural Theory of Race: Yet Another Look at Du Bois’s “The Conservation of Races”. Ethics. 2013; 123(3): 403-26.

Risk adjusted outcomes – again!

This interesting paper [1] shows that risk-adjusted Patient Reported Outcome Measures (PROMs) produce more outliers by surgeon than Standardised Mortality Ratios (SMRs). Presumably the distribution of PROMs was more skewed than the distribution of SMRs. However, surgeons accounted for only a small proportion of all unexplained variance in the distribution of PROMs, so little could be achieved by weeding out a few individual surgeons. In addition, risk adjustment can under-adjust so that a true positive becomes a false negative. For example, controlling for hospital type could obscure poor performance in types of hospital that attract poorly performing surgeons. A better way to scrutinise surgical performance might be to analyse surgical skill by observing recordings of operations and analysing them by experts or automated systems.[2] These results could be correlated with PROMs to identify truly excellent surgeons who could give proctorship to those whose processes and outcomes were less good. We think the future of quality monitoring lies in triangulating ‘performance data’ and using it in local improvement programmes.[3] [4] — Richard Lilford, CLAHRC WM Director References:

  1. Varagunam, M; Hutchings, A, Black, N. Do patient-reported outcomes offer a more sensitive method for comparing the outcomes of consultants than mortality? A multilevel analysis of routine data. BMJ Qual Saf. 2015; 24(3): 195-202.
  2. Hampton T. Efforts seek to develop systematic ways to objectively assess surgeons’ skills. JAMA. 2015; 313(8): 782-4.
  3. Department of Health. Guidance on the routine collection of Patient Reported Outcome Measures (PROMs). London: Department of Health. 2009. [Online].
  4. Lilford R, & Rosser D. What’s Up Doc? Health Serv J. 2013; 123:19-21.

Very Fresh Blood for Transmission: Probably Not Worth the Effort

This is the largest trial (over 1,200 patients per group) to compare extremely fresh (less than a week old on average) with standard (about three weeks old) blood transfusion in sick adult patients.[1] ‘Old’ blood has lower oxygen carrying capacity than fresh blood, and accumulates potentially harmful metabolites. However, there are costs associated with trying to give everyone fresh blood. In the end this study showed a null result with the point estimate favouring old blood. The death rate was high (over one third) so the trial ‘excluded’ the rather large adverse effect of a 16% increased death rate found in observational studies.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Lacroix J, Hébert PC, Fergusson DA, et al. Age of Transfused Blood in Critically Ill Adults. New Engl J Med. 2015;372:1410-8.

An Apple a Day…

The old adage, “an apple a day keeps the doctor away” has been put to the test by Davis et al. in a recently published cross-sectional study.[1] The authors studied over 8,000 US adults, comparing those who ate “an apple a day” (based on a dietary recall questionnaire), with those who did not, on the primary outcome of “keeping the doctor away” – no more than one self-reported visit to a physician in the previous year.

The study identified 753 adults who ate at least one apple a day, and, compared to non-apple eaters, they had higher levels of education, were less likely to smoke, and were more likely to be from a racial or ethnic minority (P<0.001). However, after adjusting for socio-demographic and health-related characteristics, there was no statistically significant difference in physician visits (OR 1.19, 0.93-1.53, P=0.15); though they did appear to use fewer prescription medicines (OR 1.27, 1.00-1.63). So maybe we should start using “an apple a day keeps the pharmacist away”?

— Peter Chilton, Research Fellow

Reference:

  1. Davis MA, Bynum JPW, Sirovich BE. Association Between Apple Consumption and Physician Visits Appealing the Conventional Wisdom That an Apple a Day Keeps the Doctor Away. JAMA Intern Med. 2015. [ePub].

Who Would Want to Work in a University?

Many people like to be self-employed – they don’t have to defer to a boss they might not like, they are independent, and they can make their own decisions. But make no mistake, they pay a high price for these freedoms – people working independently earn about 25% less than matched counterparts in employment.[1] Those who leave their companies to start consultancies likewise experience a drop in earnings. And the freedoms they gain are only partial – they are heavily constrained by their clients and the commissions they can secure. Of course, they have to do all their maintenance – IT, pension, legal advice, accountancy, etc. Working as an academic in a research-intensive university provides the best of both worlds. Considerable discretion over which projects to pursue. Opportunities to make strategic and tactical decisions and to display entrepreneurship. The opportunity to secure funding and build a small team. Opportunities to make discoveries and a name for yourself, and to work in an intellectually rich and not-that-badly paid environment. What’s not to like? Yet academics often seem discontented. Why? First, fear of failure. The freedom to make the calls on what to study comes at a price – the ever present risk of failure. Publishing in top papers and securing grants is a tough, competitive business. Most of us encounter difficult patches and some scholars start to panic or slowly sink and become disaffected. Second, success takes a long time to build – the delay between an idea and a paper in the New England Journal of Medicine is about five years on average, but can be as much as two decades. Gone is the immediate gratification that comes from a well-executed procedure or a skilfully conducted consultation, for example. Third, the administration in all universities is very tricky because academics and administrators are managing different risks – for the academic, the risk is failure to secure or deliver on a grant, while for administrators the risk is bureaucratic or legal challenge relating to contracting employment, finance, and so on. The more remote (centralised) the management, the worse the problem. My fourth reason is speculative and I hope it does not cause (too much) offense. Academics, being a non-random sample of the population, may be quite brittle people, tending towards introspective and somewhat narcissistic personality types – or maybe I am just describing myself! In any event, having tried the health and civil services, and lacking the courage to start a company, I plan to stay in a university for as long as I can cut the mustard.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. Dellot B, & Reed H. Boosting the Living Standards of the Self-Employed. London: RSA Action and Research Centre. 2015.

First the Heart, Now the Brain

I always wondered whether it may be possible that just as clot-busting medicine preceded clot-removing endovascular surgery for acute heart attack, so the same sequence of events would unfold for acute stroke caused by a clot in the proximal artery. And so it has – endovascular clot removal improved functional outcomes following thrombolytic stroke in two recent trials.[1] [2] Survival also improved in the larger trial, while the other was under-powered for this end-point. The larger trial also showed an improvement in the visual-analogue scale of the EQ-5D. The favourable effects confirmed the result of a previous trial in the Netherlands,[3] and both trials were stopped earlier than planned as a result of the weight of positive evidence. In order to be eligible for this treatment a patient must have good collateral flow distal to the block and a relatively small infarct. Time is of the essence and the interval between CT scan and endovascular clot removal in the trials was little over an hour; a logistic challenge.

How should the NHS respond to this information? NICE has already considered the issue,[4] but this preceded the above results that are hot off the press. Nevertheless NICE advocated that the treatment may be used with appropriate safeguards. This decision was informed by safety evidence from numerous, mostly non-experimental, studies along with ‘proof of principle’ evidence that recanalisation of thrombosed arteries is enhanced by endovascular treatment. It is clear that some UK centres are offering this therapy and participating in a UK-based RCT.[5] One suspects that the data-monitoring committee of this RCT will be reconvened. The treatment has the potential to be cost-effective, based on a previous study that pieced information together from multiple sources.[6] This can now be updated with direct evidence from RCTs. The survival rate was improved by eight percentage points in the above trial, and if this is taken at face value, and if the mean duration of each life gained is 7 years, then the (undiscounted) DALY gain is (7 x 0.08) = 0.56. So even before considering quality of life, the treatment is cost-effective if it costs less than about £11,000 at the NICE willingness-to-pay threshold. The stage seems set for phased introduction of this therapy, since the main areas of uncertainty are likely to migrate from clinical effectiveness to appropriate service delivery. I hesitate to say it, but this technical development is likely to add to the argument for further consolidation of stroke units.

How should the NHS in England proceed? We propose an integrated and co-ordinated response between NICE and NHS England as follows:

DCB - Heart and Brain

— Richard Lilford, CLAHRC WM Director

References:

  1. Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection. N Eng J Med. 2015; 372: 1009-18.
  2. Goyal M, et al. Randomized Assessment of Rapid Endovascular Treatment of Ischemic Stroke. N Eng J Med. 2015. 372: 1019-30.
  3. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015; 372: 11-20
  4. National Institute for Health and Care Excellence. Mechanical clot retrieval for treating acute ischaemic stroke. NICE interventional procedure guidance IPG458. 2013.
  5. The University of Glasgow. Pragmatic Ischaemic Stroke Thrombectomy Evaluation: PISTE. 2015. [Online].
  6. Nguyen-Huynh MN, & Johnston SC. Is mechanical clot removal or disruption a cost-effective treatment for acute stroke? AJNR Am J Neuroradiol. 2011; 32(2): 244-9.

Lay Community Health Workers

In discussing possible solutions to health problems in CLAHRC Africa, the role of Lay Community Health Workers (LCHWs) often comes up. In fact, there is seldom a large-scale health problem that someone does not suggest can be laid at the door of LCHWs.

What are LCHWs?

  1. LCHWs (sometimes referred to as Lay Health Workers or Community Health Workers) cover a range of functions. However, LCHWs tend to have the following features:
  2. They are of the community in the sense that they live among the people they serve. They tend to be nominated/selected by their local community.
  3. They have a connection to the health service – for example, they have established lines of communication and can refer.
  4. They are not full-time and generally have other roles/jobs in the community.
  5. They may receive some monetary payment from health services, but this is small in amount relative to substantive health care workers.

What is the history of LCHWs?

The CLAHRC WM Director finds it difficult to follow the evolution of present day LCHWs, but he fancies that some people have differentiated themselves to provide services to their community from the beginning of time, for example, providing birth assistance. The present day CHW:

  1. is differentiated from traditional healers and hews, to some extent at least, to an Enlightenment-based scientific model;
  2. performs a role that forms part of, or complements, the local health service.

Recent examples of initiatives that relied on LCHWs include:

  1. The “barefoot doctor” programme in China.[1]
  2. An extensive reproductive health programme in Iran associated with a steep drop in fertility.[2]
  3. An extensive child health programme in Brazil that was associated with a large (over 50%) and precipitate drop in childhood mortality.[3]
  4. The anti-retroviral programme in Africa where LCHWs played a part in identifying cases and helping clients adhere to exacting treatment regimes. [4]

Lay workers are also found in high-income countries and may even be making something of a come-back. Our CLAHRC, for instance, has evaluated the role of such volunteer support workers in the case of vulnerable women over the perinatal period.[5]

Are LCHWs effective?

This question invites the response “compared to what?” They played a large (arguably essential) part in the above programmes and the programmes were themselves successful. LCHWs make a small call on the public purse and so there are good reasons to think they are cost-effective compared to health service personnel who might be deployed to perform the same function. There is empirical support for the theoretical idea that being part and parcel of the local community and being selected by local people provides credibility and enhances the effectiveness of LCHWs. A collaborator of the CLAHRC WM Director, Dr Alex Plowright, argues that the empathy they display is especially important where health systems are weak and staff are often disaffected. Summative evaluations (82 RCTs) show that LCHWs are effective on average, but the results, as with many service interventions, are heterogeneous.[6] This reflects, at least in part, the fact that LCHWs are deployed in very different social and political environments that might be neutral, supportive, or antipathetic to their efforts.[7] [8] Salient questions include the education of LCHWs (how much, in what form, over what time periods), whether LCHWs should specialise, and what functions they should perform.

Towards a theory of LCHWs deployment

The argument proposed here has two premises:

  1. LCHWs do not tend to have detailed theoretical knowledge, nor a deep understanding of patho-physiological pathways. If they did, they would not be LCHWs.
  2. Most health gains in deprived communities in low- and middle-income countries turn not on intensive medical practice, but on a small number of conceptually straightforward processes – basic nutrition, bed nets, oral rehydration, vaccination, access to contraception, and so on.

Putting these two ideas together can help shape an answer to the above question relating to role definitions. First, it would suggest that LCHWs should not become a type of “dumping ground” for all ills – mental health, untreated ear disease, skin infections, etc. Rather, they should learn what the red flags are and have a generally low threshold of referral to a health facility. A corollary of this idea is that LCHWs should not be required to specialise, though this is not to say that they should not develop a special interest. Childbearing might be an exception, since a type of CHW called a traditional birth attendant can improve outcomes of labour, at least where trained midwives are not available.[9] Once the above fundamentals are covered, then one can imagine a role in health promotion – for example, discouraging salt and sugar and perhaps checking for the silent killer that is hypertension, as recommended by Margaret Thorogood.[10]

— Richard Lilford, CLAHRC WM Director

References:

  1. Rosenthal MM, & Greiner JR. The Barefoot Doctors of China: From Political Creation to Professionalization. Hum Organ. 1982; 41(4): 330-341.
  2. Hoodfar H, & Assadpour S. The Politics of Population Policy in the Islamic Republic of Iran. Stud Family Plann. 2000; 31(1): 19-34.
  3. UNICEF. The State of the World’s Children 2008. New York, NY: UNICEF. 2007.
  4. Hermann K, Van Damme W, Pariyo GW, Schouten E, Assefa Y, Cirera A, Massovon W. Community health workers for ART in sub-Saharan Africa: learning from experience – capitalizing on new opportunities. Hum Resour Health. 2009; 7: 31.
  5. Lilford R. Improve long-term development of children. 20 Feb 2015. [Online].
  6. Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev. 2010; 3: CD004015.
  7. Glenton C, Colvin CJ, Carlsen B, Swartz A, Lewin S, Noyes J, Rashidian A. Barriers and facilitators to the implementation of lay health worker programmes to improve access to maternal and child health: qualitative evidence synthesis. Cochrane Database Syst Rev. 2013; 10: CD010414.
  8. Kok MC, Kane SS, Tulloch O, et al. How does context influence performance of community health workers in low- and middle-income countries? Evidence from the literature. Health Res Policy Syst. 2015; 13(1): 1.
  9. Jokhio AH, Winter HR, Chang KK. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. N Engl J Med. 2005; 352(20): 2091-9.
  10. Thorogood M, Goudge J, Bertram M, et al. The Nkateko health service trial to improve hypertension management in rural South Africa: study protocol for a randomised controlled trial. Trials. 2014; 15: 435.