Tag Archives: HRC

Major government health directive monitored for efficacy and safety

Last year I was fortunate to become part of a team at Christchurch hospital led by emergency care physician, Dr Martin Than. About 7 years ago in response to some local issues with how patients presenting with chest pain were being evaluated for potential heart attacks, Dr Than began a research program that investigated what clinical, demographic, and biological (blood) factors could best be used to safely and efficiently rule-out a heart attack.

Someone turning up at the doors of the Emergency Department with chest pain desperately wants to hear those reassuring words “You are not having a heart attack.” Unfortunately, for the ED staff this a very difficult conclusion to come to rapidly. As a result, around the world, as many as 90% of patients being assessed for possible heart attack end up being admitted to hospital overnight or longer, although only 20% of them end up being diagnosed with a heart attack. Obviously this is not good for the patient or the hospital – especially given tight budgets and lack of bed space. Dr Than’s work addressed the problem with a large multi-national observational study which assessed if a decision making pathway (called an accelerated diagnostic pathway or ADP for short) could increase the proportion of patients who could potentially not be admitted to hospital instead referred for some outpatient testing(1). This was further refined in another observational study which reduced the number of blood biomarkers that needed testing(2). Finally, and uniquely a randomised controlled trial of the new ADP verse standard practice was run at Christchurch Hospital. This was very successful, nearly doubling the proportion of patients who could be discharged to outpatient care within 6 hours of arriving in the ED(3). More has been done since on refining the ADP … but that is for another post.

The Ministry of Health liked what they saw as did ED physicians and Cardiologists throughout the country. This has resulted in the MOH asking all EDs within New Zealand to implement an accelerated diagnostic protocol. In doing so they will join all of Queensland, and a sprinkling of hospitals throughout the world that have recently adopted an ADP. This kind of positive outcome to local research is what every scientist dreams of, and Dr Than and his team have a right to be proud. But wait, as they say, there is more. Thanks to a Health Innovation Partnership grant from the Health Research Committee we are able to put in place a mechanism to monitor the effect and safety of an ADP at eight hospitals around New Zealand. This is where I come in, as I am collecting, collating and analysing the data for this project.   It is very exciting to be involved not only in helping implement a change of practice, but to be able to assess if that change is effective across a range of New Zealand hospitals from major inner-city hospitals to small rural hospitals, each of which has to adapt an ADP to meet their own particular circumstances. As I write Middlemore, North Shore, Wellington, Hutt Valley, Nelson and Christchurch hospitals all have new ADPs in place. Most if not all EDs will have them by the end of the year.

Some of where accelerated diagnostic pathways have been implemented.

Some of where accelerated diagnostic pathways have been implemented.

The model of observational research -> randomised controlled trial -> local implementation with further research -> mandatory national implementation -> research the effect of that change on local and national levels -> refine processes etc, is I believe a very good one and one that should be standard practice for major health initiatives. The MOH, HRC, and various district health boards that have bought into this process should be commended. There are other similar initiatives happening around the country and a look forward to when as a health consumer I can have confidence in any procedure I may face as been similarly thoroughly assessed.

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Thanks to my Acute Care Fellowship sponsors: Sponsors

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and to the grant funding body:

HRC

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References

  1. Than, M. P., Cullen, L., Reid, C. M., Lim, S. H., Aldous, S., Ardagh, M. W., et al. (2011). A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet, 377(9771), 1077–1084. doi:10.1016/S0140-6736(11)60310-3
  2. Than, M. P., Cullen, L., Aldous, S., Parsonage, W. A., Reid, C. M., Greenslade, J., et al. (2012). 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. Journal of the American College of Cardiology, 59(23), 2091–2098. doi:10.1016/j.jacc.2012.02.035
  3. Than, M. P., Aldous, S., Lord, S. J., Goodacre, S., Frampton, C. M. A., Troughton, R., et al. (2014). A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Internal Medicine, 174(1), 51–58. doi:10.1001/jamainternmed.2013.11362
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$20bn for Medical Research!

Alas, not in New Zealand, but close … our Australian counterparts in medical research appear on the face of it to have scored big in what appears otherwise to be a grim Australian budget.  An AUD$20bn medical research “future fund” is to be established. This effectively means that by 2022-3 there will be twice the current budget available for medical research per annum (i.e. about $1bn).  How this will be divided up remains to be seen, but I note that Prof Mike Daub of Curtin University is suspicious that it is “Medical Research” not “Health and Medical Research.”

If this truly is a massive boost to medical research in Australia, what could it mean to New Zealand?

A negative possibility is that because there are already issues with recruiting medical specialists who wish to undertake research in New Zealand and because the Australian NHMRC already has successful contestable grant funding rates about twice that of New Zealand’s HRC (~16% cf ~7%), I expect there would be more one-way traffic of scientists to Australia. It is imperative that this be avoided, for all our health’s sake.

If, though, the funding recognises the value of collaborative research then it may be possible for New Zealand scientists to work more closely with their Australian counterparts on projects of mutual interest.  To that end, the New Zealand Government has (now) a great opportunity under CER to facilitate collaboration.  Perhaps, a dedicated fund that would support New Zealand researchers financially to play a role in Australian led research.  Apart from the high quality of NZ researchers (!), New Zealand should appeal to Australia because of the better integration of our health systems, especially with respect to tracing patient hospital events nationally, and because of the lower costs of doing research here.  Furthermore, health consumers in New Zealand demand the best (I know I do!) and the best is only available through research – ultimately more research across the ditch will benefit us here.  Thanks Tony.

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ps. Catching the early flight to Sydney tomorrow to share some Trans-Tasman love and collaborate with my medical research colleagues at the Prince of Wales Hospital and the Royal Brisbane & Women’s Hospital.

What the HRC should have done

The system is broke.  It is no better than a lottery.  The Health Research Council tacitly acknowledged this last year when they introduced a lottery to their grant funding round.  The lottery was for three grants of $150,000 each.  These “Explorer Grants” are available again this year.  The process went thus: HRC announced the grant and requested proposals;  proposals were required to meet simple requirements of transformative, innovative, exploratory or unconventional, and have potential for major impact;  proposals were examined by committees of senior scientists;  all that met the criteria were put in a hat and three winners were drawn out.

116 grants were received, 3 were awarded (2.6%!!!). There were several committees of 4-5 senior scientists. Each committee assessed up to 30 grants.  I’m told it was a couple of days work for each scientist. I’m also told that, not surprisingly given we’ve a damned good science workforce, most proposals met the criteria. WHAT A COLOSSAL WASTE OF TIME AND RESOURCES.

Here is what should have happened:  All proposals should have gone immediately into the hat.  Three should have been drawn out.  Each of these three should have been assessed by a couple of scientists to make sure they meet the criteria.  If not, another should be drawn and assessed.  This would take about a 10th of the time and would enable results to be announced months earlier.

Given that the HRC Project grants have only about a 7% success rate and that the experience of reviewers is that the vast majority of applications are worthy of funding  I think a similar process of randomly drawing and then reviewing would be much more efficient and no less fair.  Indeed, here is the basis of a randomised controlled trial which I may well put as a project proposal to the HRC.

Null Hypothesis:  Projects assessed after random selection perform no differently to those assessed using the current methodology.

Method:  Randomly divide all incoming project applications into two groups. Group 1: Current assessment methodology.  Group 2: Random assessment methodology.  Group 1: assess as per normal aiming to assign half the allocated budget.  Group 2: Randomly draw 7% of the Group 2 applicants;  assess;  draw more to cover any which fail to meet fundability (only) criteria;  fund all which meet this criteria in order they were drawn until half the allocated budget is used.

Outcome measures:  I need to do a power calculation and think about the most appropriate measure, but this could be either a blinded assessment of final reports or a metric like difference in numbers of publications.

Let’s hope that lessons are learnt when it comes to the processes used to allocate National Science Challenges funds.