Tom Nolan, clinical editor; sessional GP, Surrey
Tom Nolan reviews this week’s research
Replacing aortic valve replacements
Established surgical treatment for people with severe aortic stenosis who have obstructive coronary artery disease is surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG). A new trial, published in the Lancet, suggests that transcatheter aortic valve implantation (TAVI) and fractional flow reserve (FFR) guided percutaneous coronary intervention (PCI) may be a better option. Four of the 91 patients (4%) in the TAVI group of the multicentre European study and 17 of the 77 (23%) in the SAVR group reached the composite primary endpoint of the study of all-cause mortality, myocardial infarction, disabling stroke, clinically driven target vessel revascularisation, valve reintervention, and life threatening or disabling bleeding at one year after treatment (hazard ratio 0.17 (95% confidence interval 0.06 to 0.51)). This was in large part due to none of the TAVI group dying during the one year follow-up, compared with seven (10%) in the SAVR group.
Lancet doi:10.1016/S0140-6736(24)02100-7
Advance care planning and interventions in the last months of life
A cluster randomised trial has found that offering patients access to a trained facilitator in advance care planning (ACP) for discussions led to higher rates of new documentation of ACP (12% compared with 6.6% in the control arm). However, this didn’t seem to translate into lower levels of medical interventions at the end of life. The other primary endpoint was receipt of “potentially burdensome care” (including intubation and CPR) within six months of death in a subsample of patients with severe illness who later died. Rates of potentially burdensome care were higher in the ACP intervention arm of the study, showing that engaging in ACP (and documenting it) doesn’t necessarily lead to lower levels of medical intervention.
JAMA Intern Med doi:10.1001/jamainternmed.2024.6215
Nudge won’t budge
If you can diagnose message overload by the number of WhatsApp groups a person has on mute, then I’ve definitely got it. Message overload may also be a contributing factor to the negative findings of a trial of text message reminders to help medication adherence. The study randomised over 9000 people taking medication for cardiovascular disease to receive text messages or usual care if they were more than seven days late in picking up a new prescription. There were three intervention arms: a generic reminder message, a behavioural nudge, or a behavioural nudge and a chatbot. They found no difference in the “proportion of days covered” by prescriptions over a one year period in the three text message groups compared with usual care. By measuring prescriptions over a year-long period, the study was able to assess the longer term behavioural impact of the nudges, which over time may have become just another message to ignore.
JAMA doi:10.1001/jama.2024.21739
Trigger warning for emergency departments
Speaking of ignoring messages, can someone do a study to quantify how many popup alerts you have to overrule or ignore to get through a day of seeing patients? A new study in JAMA Internal Medicine on electronic triggers (e-triggers) isn’t even about these popups, but it was enough to trigger me. It looks at e-triggers and their potential to be applied retrospectively to look for possible missed diagnoses. Researchers created e-triggers for six high risk presentations and found that there were lots of missed opportunities in diagnosis (so called MODs) when they applied these to patient records. For example, from a sample of 625 records 47 MODs for stroke and 31 MODs for abdominal pain were found, and 20 patients had experienced severe harm from the MOD.
JAMA Intern Med doi:10.1001/jamainternmed.2024.6214
Drug diversion for non-medical use
A 2018 systematic review concluded that there is “little or no organized criminal involvement in the pharmaceutical black market” and that pharmaceutical drugs for non-medical use are mostly obtained through friends and family. But how does ketamine, which is licensed in the UK only as an anaesthetic, find its way into the wrong hands? A research letter in JAMA sheds light on the growing levels of pharmaceutical ketamine diversion in the US. There were 230 reported incidents in 2023 up from 195 in 2017, mostly occurring in hospitals and clinics, and usually stolen by employees or lost in transit.
JAMA doi:10.1001/jama.2024.23014