African centres for Service Delivery Research

The CLAHRC WM Director returned yesterday from a three week trip to African centres for Service Delivery Research (see here for a map).* He visited:

The launch of the CHSSRD
The launch of the CHSSRD

CLAHRC WM is establishing collaborations with these centres of excellence in South and East Africa. Some of the health problems that African centres are tackling are very different from those in the West Midlands (malaria and infant malnutrition), while others are similar (type 2 diabetes and hypertension). However, although the specific problems may vary, at the generic level there is startling similarity in objectives (improving access, identifying problems before harm is done, improving implementation of care standards and so on – examples are given in Table 1). Likewise the methodological issues in carrying out evaluations are, if not identical, then very similar across continents. These observations reinforce the idea that we have a lot to learn from each other and that the North-South divide is a barrier more in our minds and on maps than in the problems we face and methods used to address them.

One very generic issue concerns the question of whether hospitals and hospital departments fail in the specific or in the general – that is to say are rates of adherence to the tenets of good practice correlated within hospitals and their departments? This is a crucial issue for managers, since if they are only very poorly correlated, as found in some studies,[1] [2] then efforts at improvement may need to be focussed on each standard, one at a time. However, if they are strongly correlated, then a generic approach might get more purchase. The issue is also important scientifically, since high correlation within hospitals/departments reduces precision in comparative studies (the so-called “design effect”) meaning that larger numbers of clusters are needed to achieve a given level of statistical power. CLAHRC WM is proposing to investigate this issue in primary and secondary research studies. This project will be greatly enriched by collaboration across high- and low-income countries, allowing the role of context to be more thoroughly explored.

We would be grateful for comments from readers, along with enquiries about future collaborations, which can be made “without prejudice.”

*As an aside, he also completed the gruelling 109km Cape Argus Cycle Tour for the Amy Biehl Foundation, riding alongside famous cricketer Allan Lamb, and finishing the course in 4:21:51 despite dealing with a late puncture and headwinds of up to 45km/h.

Table 1

Topic CLAHRC WM
Example
CLAHRC Africa
Example
Triage Surges in demand for admission to labour ward Sick children may wait up to 3 hours to be seen in long queues outside health facilities
Workforce training and continuing
education
Physician assistants, nurse and doctors Clinical officers, nurses and doctors
Case-finding Undetected high-risk in the community Nutritional deficiency and hypertension in villages and urban
informal settlements
Implementation of
effective care
– identifying and then overcoming barriers
Uptake of home haemodialysis /
improving holistic trauma care for elderly people
Management of adult
diabetes and paediatric emergencies
Cost-effectiveness of Service Delivery Interventions ePrescribing systems and increasing
consultant cover over weekends
Increasing high-
dependency bed
availability under
different constraints
Non-allopathic care for mental illness Providing a platform (“YouthSpace”) for young adults with
mental illness
Exploring the role of the traditional healer

–Richard Lilford, Director of CLAHRC WM

References

[1] Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals — the Hospital Quality Alliance program. N Engl J Med. 2005;353:265-74.

[2] Wilson B, Thornton JG, Hewison J, Lilford RJ, Watt I,  Braunholtz D, et al. The Leeds University Maternity Audit Project. Int J Qual Health Care. 2002;14:175-81.

Unfinished business

Readers of this News Blog will know that the NIHR CLAHRC WM has a strong mental health theme. Professor Swaran Singh (University of Warwick) drew the Director’s attention to a recent provocative paper by Wunderink et al.[1] This is a seven year follow-up of a randomised controlled trial (RCT) comparing standard maintenance antipsychotic chemotherapy with an early dose reduction/ discontinuation strategy in patients with first-episode psychosis. While the reduction/ discontinuation strategy resulted in a higher relapse rate within two years, this difference had disappeared at seven years and patients in the reduction/ discontinuation arm had better functional status. Since exposure to antipsychotic drugs has been shown to be associated with reduced brain volume in humans (even after trying to control for illness severity),[2] and in normal primates,[3] [4] this study has potentially massive implications for the future research agenda in schizophrenia. For instance, it would be informative to understand the effect of these medicines, which cross the placental and blood-brain-barriers with ease,[5] on the foetal brain.[6]

–Richard Lilford, Director of CLAHRC WM

References

[1] Wunderink L, Nieboer RM, Wiersma D, Sytema S, Nienhuis FJ. Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy: Long-term Follow-up of a 2-Year Randomized Clinical Trial. JAMA Psych. 2013; 70(9): 913-20.

[2] Ho B, Andreasen NC, Ziebell S, Pierson R, Magnotta V. Long-term Antipsychotic Treatment and Brain Volumes: A Longitudinal Study of First-Episode Schizophrenia. Arch Gen Psychiatry. 2011;68(2):128-137.

[3] Dorph-Petersen KA, Pierri JN, Perel JM, Sun Z, Sampson AR, Lewis DA. The influence of chronic exposure to antipsychotic medications on brain size before and after tissue fixation: a comparison of haloperidol and olanzapine in macaque monkeys. Neuropsychopharmacology. 2005;30(9):1649-61.

[4] Konopaske GT, Dorph-Petersen KA, Sweet RA, et al. Effect of chronic antipsychotic exposure on astrocyte and oligodendrocyte numbers in macaque monkeys. Biol Psychiatry. 2008; 63(8): 759-65.

[5] Masud Iqbal M, Aneja A, Rahman A, et al. The Potential Risks of Commonly Prescribed Antipsychotics. Psych. 2005; 2(8): 36-44.

[6] Bodén R, Lundgren M, Brandt L, Reutfors J, Kieler H. Antipsychotics During Pregnancy: Relation to Fetal and Maternal Metabolic EffectsArch Gen Psychiatry. 2012;69(7):715-721

Changing Human Behaviour Through the Fast-Thinking Part of the Mind

Culture change improvements target the slow-thinking conscious mind. But human behaviour can also be influenced subliminally in the fast-thinking mind – by making the “right thing to do the easy thing to do“.

For an excellent account of the state of the science on unconscious influences on behaviour, the Director recommends a recent article in Scientific American. (Bargh JA. How Unconscious Thought and Perception Affect Our Every Waking Moment. Scientific American. January 2014:22-7.)

–Richard Lilford, Director of CLAHRC WM

On the high prevalence of mental disorders

There are a very large number of different mental disorders, at least according to the recent American Psychiatric Association diagnostic classification. More to the point of this blog, certain mental disorders are also extremely common – in particular, depression.

A recent study compared exercise treatments with anti-depressants or cognitive behaviour therapy in a meta-analysis of head-to-head trials.[1] Each of these modalities has been shown to be better than nothing, but they appear to be of similar effectiveness.

What are we to make of this? Presumably, people should be given the choice. Also, the dose of the medication is reasonably well standardised. That of exercise is very variable. I am training for the world’s largest bike race (the Cape Argus Cycle Tour) and have been doing a lot of exercise at the limits of my endurance. This has a euphoric effect, which was probably not replicated for the average person in the trials. Exercise also has other health benefits, apart from the mind.[2]

But what if we stand back from these rather instrumental results, and consider the matter from a more anthropological perspective? The really interesting thing at this distance is the observation that mental illness is so extraordinarily common and depression affects approximately a quarter of all human beings at some point in their life.[3] Of course, the 25% incidence threshold is a choice – society could use a higher or lower cut off if it wished. Nonetheless 25% of people endure one or more extended periods where their answers on a pro forma indicate that they feel pretty miserable.

This invites the question as to why such a feeling is so common. There seem to be two possible aetiologies for this phenomenon. Firstly, it may be the case that being a human being is very hard, irrespective of the society or time in which one dwells. Alternatively, living in a modern market economy, for all the comforts it gives us, may be particularly psycho-toxic. I think this question is near unanswerable. However, I offer the hypothesis that some societies offer their citizens greater opportunities than others, but these opportunities come at a price. This price is exacted because opportunity entails the risk of failure. The United States, at the moment, is a wonderful habitat for the liberal cognitive elite, sitting in Boston, Chicago or Palo Alto, but the meritocracy has a down side. It seems plausible that people brought up to have no great aspirations, perhaps in a communist or feudal world, might be at lower risk of depression than those exposed to competition with their peers. I would be very grateful if anyone can supply some empirical evidence on this point, though I suspect the results will always be contestable. My observation is that people will always tend to migrate from less free to freer societies, even though they are not so poorly informed as to think that this will necessarily take them to the top. It is hope that projects them into the liberal maelstrom. Like Candide,[4] I would certainly make such a trade-off.

All this reminds me of an article in the Times Higher written by the Vice-Chancellor of the University of Buckingham (Prof Terence Kealey), which likened people in a competitive society to a herd of wildebeest – yes, the gnu of the African plain. Male wildebeest compete to become the alpha male. They try hard, and then most eventually fail. At some point, survival of the herd is dependent upon the contest ending with the unambiguous emergence of the leader. At that point, the unsuccessful bulls become subdued; they lower their heads and graze quietly while the Vice-Chancellor among the gnu procreates to his heart’s content. Biochemically, the cerebral serotonin metabolism of the remaining herd has been altered – in short, they are depressed. But hey, they had their chance.

So let’s get back to treatment. Whether because our society is meritocratic or because it is just part of the human condition, many people will cross the threshold of clinical depression. If they do, they can be given the choice between exercise, anti-depressant drugs, or talking therapy. They can try one, and then switch to the other, although I suspect that cognitive behavioural therapy is by some margin the most expensive and might have to be rationed for that reason. I mean, if a quarter of the population get depressed, it would take a mighty big mental health workforce to provide behavioural therapy for all of them. As for prevention, even if the human condition is such that many people will warrant the label depression, it may be worth trying to mitigate the problem through public health means, such as tackling bullying in schools and targeting high risk groups, such as children who have recently been in care. Finding out whether or not these measures are effective is an aim of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for West Midlands.

–Richard Lilford

References:

[1] Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Sys Rev. 2013; 9: CD004366.

[2] Larson EB, Bruce RA. Health Benefits of Exercise in an Aging Society. Arch Intern Med. 1987; 147(2):353-6.

[3] WebMD. Depression Health Center. Available at: http://www.webmd.com/depression/guide/major-depression. 2013 [accessed 17 Dec 2013].

[4] Voltaire. Candide, ou l’Optimisme. Available at: http://www.gutenberg.org/ebooks/19942. 1759 [accessed 18 Dec 2013].

Business management

We are familiar with randomised controlled trials (RCTs) in healthcare, education, criminology, and social policy, but what about business management?

Many management interventions are generic,[1] covering the whole of an organisation. I came across a really interesting RCT of such an intervention recently where whole factories were randomised.[2] The factories were textile organisations in India, and the intervention was to have, or not have, management consultant support. I have always had a rather nihilistic impression of the consultancy industry, but it looks as though I might have been wrong, as the intervention sites performed slightly better than the control sites in terms of an increase in productivity in the first year (17%), and the opening of more production plants (0.259 on average) within three years.

–Richard Lilford, Director of CLAHRC WM

References:

[1] Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. BMJ. 2010;341:c4413.

[2] Bloom N, Eifert B, Mahajan A, McKenzie D, Roberts J. Does Management Matter? Evidence from India. Q J Econ. 2013; 128(1):1-51.

New type of health professional

There is an international trend to create a new type of health professional to provide front line diagnostic and therapeutic care. Such clinicians are called Physician Assistants in the US, and Clinical Assistants in Africa, but there are many synonyms for this job. The motivations for creating this professional grade vary, but, in essence, the post has been designed make good a shortfall in medical manpower at lower unit cost. From a low-income country perspective such posts have the advantage that certification is not internationally recognised, thereby mitigating a potential ‘brain drain’.

A CLAHRC ambition is to study the role of such personnel, with special reference to continuing education, support and specialisation, and to measuring impact and safety. We would be interested to hear from other people who are undertaking similar work.

–Richard Lilford, Director of CLAHRC WM