This week in the BMJ
Volume 330, Number 7502, Issue of 28 May 2005Chronic low back pain: surgery isn't conclusively better...
Chronic low back pain: surgery isn't conclusively better...
Surgery does not clearly achieve better results than an intensive rehabilitation programme for treating patients with chronic low back pain, and the potential risks of surgery also need to be considered. Fairbank and colleagues (p 1233) randomised 349 patients who had had low back pain for at least one year before recruitment to lumbar spine fusion or to an intensive rehabilitation programme that included exercises and cognitive behaviour therapy. After two years, all patients reported improvement and the researchers found no significant differences in outcomes between the groups, except for a marginally better score on the Oswestry disability index in favour of surgery (P = 0.045).
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... and intensive rehabilitation is cheaper
Surgical stabilisation of the spine for treating chronic low back pain is not cost effective when compared with an intensive rehabilitation programme from the perspective of health providers and patients. In a cost utility analysis based on a randomised controlled trial, Rivero-Arias and colleagues (p 1239) found that the estimated mean total cost per patient was £7830 in the surgery group and £4526 in the rehabilitation group, with the mean quality adjustment life years 1.004 and 0.936 respectively. The authors warn, however, that surgery could become cost effective if, for example, the proportion of rehabilitation patients who subsequently have surgery continues to increase.
Do tracheostomies sooner rather than later
Critically ill adults needing prolonged mechanical ventilation may benefit from tracheostomy sooner rather than later. In a systematic review that included 12 randomised or quasi-randomised controlled trials, Griffiths and colleagues (p 1243) conducted a meta-analysis on five trials that included 406 participants. When compared with tracheostomy performed or more days after admission to an intensive care unit, early tracheostomy significantly reduced duration of artificial ventilation and length of stay in intensive care (weighted mean difference –8.5 days and –15.3 days respectively).
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Some British South Asians don't trust pills for diabetes
British Pakistani and British Indian patients are prone to self regulating their tablet intake to control type 2 diabetes. Lawton and colleagues (p 1247) used in-depth interviews with 32 patients to explore their perceptions and experiences of taking oral hypoglycaemic drugs. Most of the interviewees trusted their doctors' expertise and considered the medicines available in Britain to be better than those available in the Indian subcontinent. They perceived drugs in general to be harmful, however, if taken for long periods of time, with other medicines, or without traditional foods.
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Feedback tool assessed junior doctors reliably
The Sheffield peer review assessment tool (SPRAT), a multisource feedback questionnaire, is a feasible and reliable tool for assessing performance of paediatric senior house officers and specialist registrars. Archer and colleagues (p 1251) used SPRAT to record peers' opinions of 112 paediatricians in training and used the results to assess participants' clinical performance. SPRAT seems to be a feasible way of assessing behaviours that are traditionally difficult to capture, say the authors.
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No need to pay if a drug doesn't work?
Møldrup argues (p 1262) that not paying for a drug unless it works would not only benefit patients and healthcare funders, but it could also benefit drug manufacturers. He discusses the main tensions in the current marketing situation, explains the "no cure, no pay" strategy, and gives examples of some ways in which it has been implemented in the past decade. The strategy would also encourage therapeutic evaluations and reduce use of ineffective treatments, says the author, but he also acknowledges the need for more evidence and wider debate of the proposal.
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