Category Archives: Health and Medicine

More on the PBRFs new clothes

A few of weeks ago I outed the multi-million-dollar exercise that is the Quality Evaluation component of the performance based research fund (PBRF) as a futile exercise because there was no net gain in research dollars for the NZ academic community.  Having revealed the Emperor’s new clothes, I awaited the call from the Minister in charge to tell me they’d cancelled the round out of futility.  When that didn’t come, I pinned my hope on a revolt by the University Vice-Chancellors. Alas, the VCs aren’t revolting.  This week, my goal is for there to be mass resignations from the 30 or so committees charged with assessing the evidence portfolios of individual academics and for individual academics to make last minute changes to their portfolios so as to maintain academic integrity.

I love academic metrics – these ways and means of assessing the relative worth of an individual’s contribution to academia or of the individual impact of a piece of scholarly work are fun.  Some are simple, merely the counting of citations to a particular journal article or book chapter, others are more complex such as the various forms of the h-index. It is fun to watch the number of a citations of an article gradually creep up and to think “someone thinks what I wrote worth taking notice of”.  However, these metrics are largely nonsense and should never be used to compare academics.  Yet, for PBRF and promotions we are encouraged to talk of citations and other such metrics.  Maybe, and only maybe, that’s OK if we are comparing how well we are performing this year against a previous year, but it is not OK if we are comparing one academic against another.  I’ve recently published in both emergency medicine journals and cardiology journals.  The emergency medicine field is a small fraction the size of cardiology, and, consequently, there are fewer journals and fewer citations.  It would be nonsense to compare citation rates for an emergency medicine academic with that of a cardiology academic.

If the metrics around individual scholars are nonsense, those purporting to assess the relative importance (“rank”) of an academic journal are total $%^!!!!.  The most common is the Impact Factor, but there are others like the 5-year H-index for a journal.  To promote them, or use them, is to chip away at academic integrity.  Much has been written elsewhere about impact factors.  They are simply an average of a skewed distribution.  I do not allow students to report data in this way.  Several Nobel prize winners have spoken against them.  Yet, we are encouraged to let the assessing committees know how journals rank.

Even if the citation metrics and impact factors were not dodgy, then there is still a huge problem that faces the assessing committee, and that is they are called on to compare apples with oranges.  Not all metrics are created equal.  Research Gate, Google Scholar, Scopus and Web of Science all count citations and report h-indices.  No two are the same.  A cursory glance at some of my own papers sees a more than 20% variation in counts between them.  I’ve even paper with citation counts of 37, 42, 0 and 0.  Some journals are included, some are not depending on how each company has set up their algorithms. Book chapters are not included by some, but are by others. There are also multiple sites for ranking journals using differing metrics.  Expecting assessing committees to work with multiple metrics which all mean something different is like expecting engineers to build a rocket but not to allow them to use a standard metre rule.

To sum up, PBRF Evidence Bases portfolio assessment is a waste of resources, and encourages use of integrity busting metrics that should not be used to rank individual academic impact.


Cheesecake Files: The ICare-Acute Coronary Syndrome (heart attack) study

Hundreds of nurses, Emergency Department doctors, Cardiologists and other specialists, laboratory staff, administrators and managers from every hospital in New Zealand with an emergency department have come together to implement new, effective, and safe pathways for patients who think they may be having a heart attack.  Today, Dr Martin Than (CDHB, Emergency Department) presented to the American Heart Association results of our research into the national implementation of clinical pathways that incorporate an accelerated diagnostic protocol (ADP) for patients with possible heart attacks.  Simultaneously, a paper detailing that research is appearing in the academic journal Circulation.

The headlines, are that in the 7 hospitals we monitored (representing about 1/3rd of all ED admissions in NZ a year), there was a more than two fold increase in the numbers of patients who were safely discharged from the ED within 6 hours of arrival and told “It’s OK, you are not having a heart attack”.

Improving Care processes for patients with a possible heart attack.

Why is this important?

About 65,000 of the 1 million presentations to EDs each year in New Zealand are for patients whom the attending doctors think may be having a heart attack.  However, only 10-15% of those 65,000 are actually having a heart attack.  The traditional approach to assessment is long, drawn out, involves many resources, and means thousands of people are admitted into a hospital ward even thought it turns out they are not having a heart attack.  Of course, this means that they and their families have a very uncomfortable 24 hours or so wondering what is going on.  So, any method that safely helps to reassure and return home early some of those patients is a good thing.

What is a clinical pathway?

A clinical pathway is a written document based on best practice guidelines that is used by physicians to manage the course of care and treatment of patients with a particular condition or possible condition.  It is intended to standardise and set out the time frame for investigation and treatment within a particular health care setting – so it must take into account the resources available for a particular hospital.   For example, each hospital must document how a patient is assessed and if, for example, they are assessed within the ED as having a high-risk of a heart attack, where they must go.  In a large metropolitan hospital, this may mean simply passing them into the care of the cardiology department.  In a smaller setting like Taupo, where there is  no cardiology department, it may mean documenting when and how they are transported to Rotorua or Waikato hospital.

What is an accelerated diagnostic protocol?

An accelerated diagnostic protocol (ADP) is a component of the clinical pathway that enables the ED doctors to more rapidly and consistently make decisions about where to send the patient.  In all cases in New Zealand the ADPs for evaluating suspected heart attacks have 3 main components: (i) an immediate measurement of the electrical activity of the heart (an ECG), (ii) an immediate blood sample to look for the concentration of a marker of heart muscle damage called troponin, and a second sample 2 or 3 hours later, and (iii) a risk score based on demographics, prior history or heart conditions, smoking etc., and the nature of the pain (ie where it hurts and does it hurt when someone pushes on the chest, or when the patient takes deep breaths etc).   Importantly, these components enable a more rapid assessment of patients than traditionally and, in-particularly, enable patients to be rapidly risk stratified into low-risk, intermediate risk, and high-risk groups.  Usually the low-risk patients can be sent home.

What was done?

The Ministry of Health asked every ED to put in place a pathway.  Over an ~18 month period, a series of meetings were held at each hospital which were led by Dr Than, the clinical lead physician for the project.  Critically, at each meeting there were multiple members of the ED (doctors and nurses), cardiology, general wards, laboratory staff, and hospital administrators.  The evidence for different ADPs was presented.  Each hospital had to assess this evidence themselves and decide on the particularly ADP they would use.  Potential barriers to implementation and possible solutions were discussed.  Critically, champions for different aspects of the pathway implementation process were identified in each hospital.  These people led the process internally.

Oversight of the implementation was an adhoc advisory board put together by the Ministry of Health and with MoH officials, Dr Than, Cardiologists, and myself.

The Improving Care processes for patients with suspected Acute Coronary Syndrome (ICare-ACS) study was a Health Research Council sponsored study with co-sponsorship of staff time by participating hospitals.  Its goal was to measure any changes in each hospital to the proportions of patients who were being discharged home from ED early and to check whether they were being discharged safely (ie to check that there were not people with heart attacks were being sent home).  Dr Than and I co-led this project, but there were many involved who not only set up the pathways in each of the 7 participating study hospitals, but who also helped with attaining the data for me to crunch.

What were the study results?

In the pre-clinical pathway implementation phase (6 months for each hospital) there were 11,529 patients assessed for possible heart attack. Overall, 8.3% of them were sent home within 6 hours of arrival (we used 6 hours because this is a national target for having patients leave the ED).  The proportions of patients sent home varied considerably between hospitals – from 2.7% to 37.7%.  Of those sent home early, a very small proportion (0.52%) had what we call a major adverse event (eg a heart attack, a cardiac arrest, or death for any reason) within 30 days.  This is actually a very good number (it is practically impossible to be 0%).

We monitored each hospital for at least 5 months after pathway implementation and a median of 10.6 months.  Of the 19,803 patients, 18.4% were sent home within 6 hours of arrival.  ie the pathway more than doubled the number of patients who were sent home early.  Importantly, all 7 of the hospitals sent more patients home earlier.  The actual percentages sent home in each hospital still varied, showing there are more further improvements to be made in some hospital than others.  Very importantly, the rate of major adverse events in those sent home remained very low (0.44%).  Indeed, when we looked in detail at the few adverse events, in most cases there was a deviation from the local clinical pathway.  This suggests that some ongoing education and “embedding in” of the pathways may improve safety even more.

The study also showed that amongst all patients without a heart attack the implementation of the pathway reduced the median length of stay in hospital by nearly 3 hours.  Using crude numbers for the cost of an acute event in a hospital I estimate that this is a saving to the health system of $9.5Million per year.  These types are calculations are difficult and full of assumptions, nevertheless, I can be confident that the true savings are in the millions (pst… Government… I wouldn’t mind a fraction of this saving to carry on research please).

How did this come about?

This study and the pathway implementation is the result of a decade long series of studies in Christchurch hospital and some international studies, particularly with colleagues in Brisbane.  These studies have involved ED staff, cardiologists, research nurses, University of Otago academics (particularly those in the Christchurch Heart Institute) and many others.  They began with an international onbservational study which measured troponin concentrations at earlier than normal time points to see whether they gave information that would enable earlier discharge of some patients.  This was followed by the world’s first randomised trial of an ADP verse standard (then) practice.  That showed that the ADP resulted in more patients being safely sent home.  It was immediately adopted as standard practice in Christchurch.  The ADP was refined with a more “fit for purpose” risk assessment tool (called EDACS – developed locally and with collaboration of colleagues in Brisbane).  The EDACS protocol was then compared to the previous protocol (called ADAPT) in a second randomised trial.  It was at least as good with potential for discharging safely even more patients.  It is currently standard practice in Christchurch.

As a consequence of the Christchurch work, the Ministry of Health said, effectively,  ‘great, we want all of New Zealand to adopt a similar approach’, and the rest, as they say, is history.  Now, all EDs have a clinical pathway in place, all use an evidence based ADP – two use the ADAPT and all the rest use EDACS with one exception which uses a more ‘troponin centric’ approach (still evidence based) which I won’t go into here.  Meanwhile, all of Queensland has adopted the ADAPT approach and we know of many individual hospitals in Australia, Europe and Iran (yes) which have adopted EDACS.

Other help

As mentioned already, the Health Research Council and the Ministry of Health along with all those medical professionals were integral to getting to where we are today.  Also integral, were all those patients who in the randomised trials agreed to participate.  Medical research is build on the generosity of the patient volunteer.  Behind the scenes is our research manager, Alieke, who ensures doctors run on time.  Finally, I am very fortunate to be the recipient of a research fellowship that enables me to do what I do.  I thank my sponsors, the Emergency Care Foundation, Canterbury Medical Research Foundation, and Canterbury District Health Board.  Some of the earlier work has also been done in part with my University of Otago Christchurch hat on.  Thank you all.

Half a million Kiwis suddenly have high blood pressure

At 10am 14 November 2017 NZST millions of people around the world suddenly had high blood pressure. This will come as a shock to many and may precipitate a crisis in hand wringing and other odd behaviour, like over medication and jogging.

The American Heart Association and American College of Cardiology have just announced a redefinition of High blood pressure.

High blood pressure is now defined as readings of 130 mm Hg and higher for the systolic blood pressure measurement, or readings of 80 and higher for the diastolic measurement. That is a change from the old definition of 140/90 and higher, reflecting complications that can occur at those lower numbers. (link)

Announced at the annual American Heart Association conference, this is bound to cause some consternation.  It shifts 14% of the US adult population into the “High blood pressure” category and I estimate that it will do something similar for the NZ population meaning half a million New Zealanders who didn’t have High blood pressure at 9am now have high blood pressure (assuming NZ cardiologists follow their US colleagues).

While this is, of course, absurd.  It also highlights the seriousness with which the cardiologists take elevated blood pressure – maybe we all should take it a bit more seriously, perhaps park the care further from work and walk a little (likely to be cheaper too).

Have you got high blood pressure. (c) American Heart Association


Christchurch meet the future; Zach meet Christchurch

It would have struggled to be more low key.  There was no Champaign.  No flashy graphics.  No celebrity speakers.  But it was probably one of the most radical and important announcements made in Christchurch and in the technology space in decades.  You see, Zach is coming to town and we have all been invited.

Zach is an A.I.  Zach belongs to the Terrible Foundation  – indeed, Zach runs the foundation and their business.  Zach calls itself the Chief Executive.

Terrible are bringing Zach and one of the most powerful super-computers on the planet to Christchurch.  True to their ethos of challenging inequalities by helping great ideas to thrive, they are not seeking to make money out of it – though they potentially could make many truck loads, rather they want the people of Christchurch to interact with Zach and learn what an AI is and to develop uses for it.  The key figure behind all this told me that the decision it was for the “future generation”.

What astounded me with Zach is that you don’t need to code to work with it.  Zach message, email or talk to Zach in English (or indeed from the sounds of it several other languages so far).  Zach will respond the same way.  If you don’t like what the response is you can train Zach by telling it what you like or what you’d like to change.  For a few weeks a Christchurch GP has been working with Zach and already it is able to listen into a medical consultation and write up a concise summary as well as the doctor & in the format the doctor wants, thus enabling the doctor to spend more time with the patient and less on paper work.

You may have noted that I’ve not mentioned any people by name… they have their own story to tell and it is not for me to try and tell it for them.  What I am excited about is how Zach may help our group to improve care processes for people who come to the emergency department.  Hopefully, we will have our own Zach story to tell in the not too distant future.

Update: Christchurch Press article here.

A vision of kiwi kidneys

Sick of writing boring text reports.  Take a leaf out of Christchurch nephrologist Dr Suetonia Palmer’s (@SuetoniaPalmer) book and make a visual abstract report.  Here are two she has created recently based on data collected about organ donation and end stage renal failure by ANZDATA (@ANZDATARegistry). Enjoy.

Suetonia C-18RfJXUAApRcU

Suetonia C-16lBZXsAERoeM

ps. The featured image is of the Kidney Brothers.  Check out the great educational resources at The OrganWiseGuys.

An even quicker way to rule out heart attacks

The majority of New Zealand emergency departments look for heart muscle damage by taking a sample of blood and looking for a particular molecule called a high-sensitivity troponin T (hsTnT).  We have now confirmed that rather than two measurements over several hours just one measurement on arrival in the ED could be used to rule out heart attacks in about 30% of patients.

What did we do?

We think this is a big deal. We’ve timed this post to meet the Annas of Internal Medicine timing for when our work appears on their website – here.  What we did was to search the literature to find where research groups may have measured hsTnT in the right group of people – namely people appearing in an emergency room whom the attending physician thinks they may be having a heart attack. We also required that the diagnosis of a heart attack, or not, was made not by just one physician, but by at least two independently.  In this way we made sure we were accessing the best quality data.

Next I approached the authors of the studies as asked them to share some data with us – namely the number of people who had detectable and undetectable hsTnT (every blood test has a minimum level below which it is said to be “undetectable” in hsTnT’s case that is just 5 billionths of a gram per litre, or 5ng/L).  We also asked them to check in these patients if the electrical activity of the heart (measured by an electrocardiogram or “ECG”) looked like there may or may not be damage to the heart (a helpful test, but not used on its own to diagnose this kind of heart attack).  Finally, we asked the authors to identify which patients truly did and did not have a heart attack.

What did we find?

In the end research groups in Europe, UK, Australia, NZ, and the US participated with a total of 11 studies and more than 9000 patients.  I did some fancy statistics to show that overall about 30% of patients had undetectable hsTnT with the first blood test and negative ECGs.  Of all those who were identifiable as potentially “excludable” or “low-risk” only about 1 in 200 had a heart attack diagnosed (we’d like it to be zero, but this just isn’t possible, especially given the diagnosis is not exact).

VisualAbstract AnnalsIM 170411

Pickering, J. W.*, Than, M. P.*, Cullen, L. A., Aldous, S., Avest, ter, E., Body, R., et al. (2017). Rapid Rule-out of Myocardial Infarction With a High-Sensitivity CardiacTroponin T Measurement Below the Limit of Detection: A Collaborative Meta-analysis. Annals of Internal Medicine, 166(10). *joint first authors.

What did we conclude?

There is huge potential for ruling out a heart attack with just one blood test.  In New Zealand this could mean many thousands of people a year can be reassured even more swiftly that they are not having a heart attack. By excluding the possibility of a heart attack early, physicians can put more effort into looking for other causes of chest-pain or simply send the patient happily home.   While not every hospital performed had the same great performance, overall the results were good.  By the commonly accepted standards, it is safe.  However, we caution that local audits at each hospital that decides to implement this “single blood measurement” strategy are made to double check its safety and efficacy.

Acknowledgment: This was a massive undertaking that required the collaboration of dozens of people from all around the world – their patience and willingness to participate is much appreciated. My clinical colleague and co-first author, Dr Martin Than provided a lot of the energy as well as intelligence for this project. As always, I am deeply appreciative of my sponsors: the Emergency Care Foundation, Canterbury Medical Research Foundation, Canterbury District Health Board, and University of Otago Christchurch. There will be readers who have contributed financially to the first two (charities) – I thank you – your generosity made this possible, and there will be readers who have volunteered for clinical studies – you are my heroes.




Aunty Cecily

This international women’s day I read a re-post of a wonderful article about Otago University women in science.  I thought I’d add another one, my Aunt Cecily, or to the rest of the world Dame Cecily Pickerill.

Aunty Cecily was clever, determined, and, yes, a tough woman.   It was those qualities that helped her to help many people.

She was born, Cecily Mary Aroha Wise Clarkson in Taihape in 1903 less than 18 months after her parents had arrived from England. Taihape in those days was forests, mud, a building boom and horses.  It appears to have also been a place she could get a good education.  At a young age, just 18, she made it all the way to Dunedin to attend Otago Medical School.  By then her family was in Auckland.  I don’t know what drew her to medicine. Perhaps it was through world war 1 or the flu epidemic that followed that influenced her. Her own Father had been at Gallipoli as a chaplain with the NZ armed forces during the war and invalided home in late 1915.  Just a year after Cecily started University her parents took her two younger sisters and left New Zealand permanently, ending up in Laguna Beach in California.  Her two, slightly older, brothers remained in New Zealand. She needed to be independent at a young age.

She first came across the art and science of plastic surgery while a house surgeon under the tutelage of Professor Henry Pickerill.  Pickerill was the first director of the Otago dental school. During world war I he became one of the pioneers in facial and reconstructive surgery while with the New Zealand Medical Corp.  Many of the men being treated were transferred to Dunedin at the end of the war.

Cecily spent a few years in California working and living with her family before joining Henry in Sydney in about 1933.  She married Henry at the end of 1934.  Later they moved back to Wellington and both worked as plastic surgeons in Wellington and at Middlemore.   In 1942 they set up Bassam hospital in Lower Hutt for plastic surgery on children – mainly repairing cleft palates and the like.

One of the remarkable features of their work in Bassam was the elimination of hospital cross-infection in children.  They wrote of this in the Lancet in 1954  (Pickerill, C. M., & Pickerill, H. P. (1954). Elimination of hospital cross-infection in children: nursing by the mother. Lancet, 266(6809), 425–429.)

In that article they wrote “what chance of success has a plastic operation on the plate or lip if the child contracts a mixed viral and bacterial infection of the field of operation …”  They noted the lavish use of chromium plating, enamel and wearing of masks… but still there was infection.  The Pickerill’s solution was both simple and innovative – they brought the mother in to nurse the child and gave mother and infant a room to themselves. “Not only do they live together in their own room, but nobody except the mother bathes, dresses, or feeds the patient or changes his nappies.”  This, and other measures, resulted in the remarkable result that after 11 year’s work they had “no single case of cross-infection.”

Aunt Cecily was intelligent, and caring, but also strict (ask my mother about the spider in the bathroom if you want a story about just how strict).  It was that strictness which meant Bassam could be a tight ship and produce such remarkable results.

She was also a woman who loved to travel and garden.  She brought rocks home from travels overseas which ended up as part of her fireplace in a house, Beechdale, designed by my grandfather, in Silverstream.  Her beautiful garden featured in magazines and TV shows.

I recall visiting her in the mid ‘80s at Beechdale when I was in my first job after graduating with a BSc(Hons).  I wasn’t particularly happy with the job at the time.  She was sitting in a comfortable chair in her lounge with a magnifying glass and an open scientific journal.  I realised then, that science and the love of science are for life.

Later when I was doing my PhD on the use of a copper vapour laser to remove birthmarks, I felt even closer to her when one of the patients we treated had had the birthmark partly removed by her surgically.  Many years later a little of it had regrown around the edges which we were able to treat with the laser.

My last memory of her was when she was in her last few weeks of life.  She was in a room in Bassam hospital which was had by then been turned into a hospice.  She had the radio going with some very modern music – which we joked about.  It was fitting that she spent her final days being cared for in the place that she had spent so many days caring for others.