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Irwig L, Irwig J, Trevena L, et al. Smart Health Choices: Making Sense of Health Advice. London: Hammersmith Press; 2008.

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Smart Health Choices: Making Sense of Health Advice.

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Chapter 1This book could save your life

In the past, information was the real bottleneck, so any improvement in information would lead to an improvement in thinking and in the quality of decisions. Information access and handling (by computers) have widened that bottleneck. So we move on to the next bottleneck. This is ‘thinking’. What do we do with the information?

Edward de Bono1

Every day we make decisions about our health – some big and some small, some conscious and some subconscious. What we eat, how we live and even where we live can affect our health. We make decisions about where to source information about maintaining good health, as well as about whom to see for treatment when we are ill.

We are bombarded with information about health on a daily basis. ‘Good health’ is highly valued and some people will go to great lengths to achieve it. Sometimes we worry whether we are making the right decisions and we seek assurances that we are receiving the best possible care. We often want answers to questions about a specific health condition. We might wonder about the meaning of certain test results, whether there are other treatment options and, if so, how effective they are. More and more people are also beginning to question whether tests and treatments might have side effects or involve risks.

Public confidence in traditional sources of health care has been understandably shaken in recent years by a number of high-profile hospital scandals and claims of negligence. In the UK, a major enquiry found three heart surgeons guilty of professional misconduct when 29 babies died between 1988 and 1995, more than double the rate in the rest of England.2 An enquiry into 29 deaths in Campbelltown and Camden Hospitals in New South Wales in Australia also found mismanagement, poor communication and under-resourcing.

Despite the intense publicity that usually surrounds such cases of medical negligence, these account for a relatively small proportion of the problems with people’s health care. A much broader problem arises from the care provided by well-meaning professionals in a system that is so fragmented and complicated that it is all too easy for things to go wrong. It is estimated that as many as 30,000 people die in the UK each year as a result of medical errors3 and that tens of thousands of Australians die or are seriously injured as a result of their healthcare. Seventeen per cent of hospital admissions are associated with an adverse event caused by healthcare management.4 In the USA, it has been estimated that about 180,000 people die each year partly as a result of their healthcare – the equivalent of three jumbo jet crashes every 2 days. These figures suggest that there is a great deal of room to improve the healthcare that many people receive.

Some people assume that complementary or ‘natural’ therapies provide a safer alternative to conventional options. However, there are many examples of people suffering side effects or complications from such therapies, whether from herbal products, acupuncture or chiropractic. In Australia in 2003 hundreds of vitamin and other products had to be recalled after 19 people were hospitalised and 87 reported feeling ill after taking a ‘natural’ travel sickness pill. Some alternative therapies can also interact with other medicines. Prince Charles sparked debate in May 2006 when he advocated greater access to complementary therapies at the World Health Assembly in Geneva and through the Smallwood report, which was commissioned by him. Some of Britain’s leading doctors followed with a letter to NHS trusts urging them to fund only therapies that were based on scientific evidence. They were particularly concerned about NHS funds being used for homeopathic treatments, given that research has not shown them to be effective and patients were not being told this.5 Early in 2007, a £200,000 pilot project of complementary therapies in Northern Ireland general practice had doctors complaining that the limited government health funds could be better spent on breast cancer drugs that have been shown to be effective in scientific studies.

This book will help you to evaluate the potential benefits and harms of various therapies, whether they are part of western medicine or a traditional or complementary practice. When making smart health choices, you should bear in mind what we don’t know as well as what we do know about the pros and cons associated with use.

Although many cases of harm result from human and/or system errors, there are many other ways in which harm can be done. Sometimes, bad things simply happen by chance and are unavoidable. In other cases, they are caused by the well-meaning, but ill-informed, use of treatments and tests that do more harm than good. In addition to this, there are tens of thousands of people who, although not being harmed by their care, are not receiving the best possible treatment for their situation. Studies in many countries have shown that the way the same condition is treated can vary dramatically, depending on where the patient lives or on which type of doctor or health practitioner they see. Much remains unknown about how best to prevent or treat many common conditions; however, there is widespread evidence that the information that is already available is often not put to best use.6

This situation has come about for many reasons. Historically, the medical and health professions have not placed sufficient emphasis on the proper evaluation of health practices, although evidence-based practice has become much more common in recent times. Commercial interests, such as pharmaceutical and medical technology companies, often drive the introduction of new practices before their harms and benefits have been carefully investigated. (More about that through the rofecoxib arthritis drug story later.) The media often disseminate misleading and even dangerous health information. And consumers themselves often seek out and recommend the use of ineffective and even harmful remedies, perhaps encouraged by misleading advertising, websites or the advice of well-intentioned friends and family.

This book aims to help consumers and practitioners develop the skills to assess health advice – and hopefully to make decisions that will improve the quality of their care. For some people, making better-informed decisions could be life saving. We hope that it will be useful if you are struggling to come to terms with an illness or injury, and the best ways of managing it. Or you may simply want to lead a healthier life, and may be wondering how to make sense of the often conflicting flood of health information that deluges us every day, through the media, and from our friends and health practitioners.

Medicine has a long history of introducing new treatments and other interventions before they have been properly evaluated and proved beneficial. In the late 1950s, American surgeons began introducing a new treatment for people with stomach ulcers that involved freezing the stomach. The first few patients so treated showed a dramatic improvement in ulcer symptoms, and the technique was enthusiastically adopted and used on tens of thousands of ulcer patients. When a proper evaluation was finally conducted, it found that subsequent surgery for ulcers, bleeding from the stomach or hospitalisation for severe pain occurred in 51 per cent of the patients randomly allocated to stomach freezing – compared with 44 per cent of patients randomly allocated to a sham treatment (placebo). (The quality of research is increased by random allocation of patients – for example, by the flip of a coin – to either an active treatment or a placebo treatment, or a comparative treatment.) Needless to say, the stomach freezing procedure was rapidly abandoned, but only after tens of thousands of people with ulcers received the wrong treatment because of insufficient evidence.

Sometimes, the widespread introduction of unproven treatments has had disastrous consequences. In the 1980s, a new treatment for a heart disorder is estimated to have killed tens of thousands of people. This disaster, described by Thomas Moore in his book Deadly Medicine,7 might have been prevented if the drug, flecainide, had been properly evaluated before its widespread use to control irregular heartbeats after a heart attack. It might have been prevented if more practitioners and consumers had been prepared to ask ‘What is the evidence to support the use of this new drug?’ The drug was approved for marketing after its manufacturer showed that it stopped several kinds of irregular heartbeats. However, it was introduced before studies had investigated whether this meant that it would also prevent deaths. When this research was finally done, it showed that the treatment had the opposite effect to that expected: it caused deaths.8

Unfortunately there are more recent examples of widely used treatments proving to be harmful after more rigorous evaluation has been conducted. Two examples that we will consider in more detail later in this book are the withdrawal of rofecoxib, an anti-inflammatory medicine used for arthritis, which was found to increase the risk of heart attacks and strokes, and the change in use of hormone replacement therapy after the results of a large randomised trial called the Women’s Health Initiative (WHI).

This book is in no way intended as a do-it-yourself guide to becoming your own doctor. It is hoped, however, that it will help you to assess health advice better by showing you how to recognise useful evidence and reject that which is likely to be harmful. Its underlying argument – that we should remain cautious about any intervention that has not been thoroughly investigated and proved to do more good than harm – applies to all health advice, whether it comes from mainstream medicine or complementary/alternative practitioners.

The book is based on the philosophy that consumers have a right to develop a health partnership with their practitioner, so that all decisions take account of their personal preferences, as well as being based on accurate information about the beneficial and harmful effects of interventions. We hope that it will enlighten and empower those who may be feeling disgruntled with their healthcare, or who are confused by all the conflicting opinions and information that they are given, or who feel that their practitioners are not taking their viewpoints into account. The book will also be useful to readers making health decisions on their own, without consulting a practitioner.

We believe that the information in this book could have a profound impact on your health by offering simple tools to distinguish between good advice and potentially harmful advice. This knowledge could mean the difference between choosing the most effective treatment or choosing one that may be useless or even life threatening. Perhaps this book will save your life – or that of someone close to you.

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References

1.
de Bono E. Parallel Thinking. London: Penguin; 1994.
2.
The Bristol Royal Infirmary Inquiry. 2001. www​.bristol-inquiry.org.uk/
3.
Weingart SN, Wilson RMcL, Gibberd RW, Harrison B. Epidemiology of medical error. BMJ. 2000;320:774–777. [PMC free article: PMC1117772] [PubMed: 10720365]
4.
Wilson R, Runciman W, Gibberd R, Harrison B, Newby L, Hamilton J. The quality in Australian Health Care Study. Med J Australia. 1995;163:458–71. [PubMed: 7476634]
5.
Doctors attack ‘bogus’ therapies. BBC News. May 23, 2006.
6.
Antman M, Lau J, Kupelnick B, Mosteller F, Chalmers T. A comparison of results of meta-analyses of randomised trials and recommendations of clinical experts. JAMA. 1992;268:240–8. [PubMed: 1535110]
7.
Moore T. Deadly Medicine: Why tens of thousands of patients died in America’s Worst drug disaster. New York: Simon & Shuster; 1995.
8.
CAST (Cardiac Arrhythmia Suppression Trial (CAST) Investigators) Preliminary report: Effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med. 1989;321:406–12. [PubMed: 2473403]
Copyright © 2008, Professor Les Irwig, Judy Irwig, Dr Lyndal Trevena, Melissa Sweet.

All rights reserved. No part of this publication may be reproduced, stored in any retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publishers and copyright holder or in the case of reprographic reproduction in accordance with the terms of licences issued by the appropriate Reprographic Rights Organisation.

Bookshelf ID: NBK63656

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