Correspondence
for a key component of any such service arrangement in low-income countries with scare specialist resources for mental health—the use of non-specialist health workers to supplement care usually delivered by specialists. In our understanding, to treat people with moderate-to-severe forms of schoziphrenia staff need training in psychiatric skills, which is seen in usual care for patients in India, irrespective of location. Not providing these staff skilled in psychiatric care for this population would not be ethical. Furthermore, a large number of participants with ongoing treatment met the trial inclusion criteria. At the rural Tamil Nadu site, many participants were not receiving treatment and as a result, the intervention effect size was more substantial, showing the value of community health workers in low-resource settings to deliver psychosocial interventions for people with moderate-to-severe schizophrenia. We believe that at 12 months of treatment, a 20% reduction in overall symptom and disability ratings in people with schizophrenia is a reasonable and substantial change to achieve. Finally, we agree with the authors that more rigorous trials with different populations are needed to ascertain the role of community health workers in helping to address the treatment gap of people with schizophrenia in low-resource settings. We declare no competing interests.
*Graham Thornicroft, Sudipto Chatterjee, Rangaswamy Thara, Vikram Patel [email protected] King’s College London, Institute of Psychiatry, London SE5 8AF, UK (GT); Sangath, Goa, India (SC, VP); Schizophrenia Research Foundation, Chennai, India (RT); Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, London, UK (VP); and Public Health Foundation of India, New Delhi, India (VP) 1
1574
Chatterjee S, Naik S, John S, et al. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial. Lancet 2014; 383: 1385–94.
2
3
World Health Organization. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings. http://www.who.int/mental_ health/publications/mhGAP_intervention_ guide/en/ (accessed March 4, 2014). Government of India Ministry of Health and Family Welfare. National Mental Health Programme (NMHP). http://mohfw.nic.in/ index1.php?lang=1&level=2&sublinkid=2381&l id=1962 (accessed Sept 25, 2014).
Survival in acute myocardial infarction In their Article (April 2, p 1305),1 Sheng-Chia Chung and colleagues establish a comparison between Sweden and the UK in which only 2·3% (95% CI 2·2–2·3) of patients in the UK and 1·3% (1·3–1·4) of patients in Sweden had been recorded as being admitted to hospital after out-of-hospital cardiac arrest. In our Viewpoint,2 we pointed out that resuscitation from cardiac arrest had prevented 4 times as many deaths than the then prevalent method for reperfusion (streptokinase) and that in the studies on which these estimates were based,3,4 the percentage of patients who had survived out-of-hospital arrest was 5·0% for The United Kingdom Heart Attack Study Collaborative Group and 4·4% for the Southern Heart Attack Response Project. These patients have a high hospital fatality rate (odds ratio for deaths is 4·55 in Sweden and 4·78 in the UK, as stated in their supplementary appendix).1 It is difficult to escape the conclusion that patients surviving out-of-hospital cardiac arrest were under-reported in the registries of both countries and that fuller reporting would have increased the fatality rates, more so in Sweden than in the UK. Survival from out-of-hospital cardiac arrest varies widely among ambulance districts5 and in one district was improved markedly after rigorous retraining of paramedics.6 Resuscitation from cardiac arrest is still a very important but neglected specialty in audits of treatment for the acute coronary syndromes.
I declare no competing interests.
Robin Norris [email protected] 17 Aberdeen Rd, Castor Bay, Auckland 0620, New Zealand 1
2
3
4
5
6
Chung S-C, Godeborg R, Nicholas O, et al. Acute myocardial infarction: a comparison of short-term survival in national outcome registries in Sweden and the UK. Lancet 2014; 383: 1305–12. Julian DG, Norris RM. Myocardial Infarction: is evidence-based medicine the best? Viewpoint. Lancet 2002; 359: 1515–16. The United Kingdom Heart Attack Study Collaborative Group. Effect of time from onset to coming under care on fatality of patients with acute myocardial infarction: effect of resuscitation and thrombolytic treatment. Heart 1998; 80: 114–20. Norris RM, for the Southern Heart Attack Response Project (SHARP) investigators. A new performance indicator for acute myocardial infarction. Heart 2001; 85: 395–401. Perkins GD, Cooke MW. Variability in cardiac arrest survival: the NHS Ambulance Service Quality Indicators. Emerg Med J 2012; 29: 3–5. Fletcher D, Chamberlain D, Handley A, et al. Utstein-style audit of Protocol C: a non-standard resuscitation protocol for healthcare professionals. Resuscitation 2011; 82: 1265–72.
Authors’ reply We thank Robin Norris for his comments on our study, 1 and we strongly agree with him that resuscitation after out-of-hospital cardiac arrest is an important aspect of the quality of care of patients with acute coronary syndromes. We propose linkage of electronic health records across primary care, the ambulance service, and national quality registries for cardiac arrest and cardiac diseases to better understand, and improve management and outcome. Norris is correct in stating that the national acute coronary syndrome (ACS) registry data that we report only includes patients admitted to hospital, and therefore excludes patients who died before reaching hospital. Specifically, for acute myocardial infarction patients with out-of-hospital cardiac arrest, only patients who were resuscitated and admitted to hospital were included. In our study,1 such patients had an increased 30-day mortality in Sweden (25%) and the UK (32%) than the overall acute myocardial infarction www.thelancet.com Vol 384 November 1, 2014
Correspondence
We declare no competing interests.
*Sheng-Chia Chung, Adam Timmis, Tomas Jernberg, Harry Hemingway on behalf of the authors [email protected] The Farr Institute of Health Informatics Research, Department of Epidemiology & Public Health, University College London, 222 Euston Road, London NW1 2DA, UK (SCC, HH); National Institute for Health Research, Biomedical Research Unit, Bart’s Health, London, UK (AT); and Department of Cardiology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden (TJ) 1
2
Chung S-C, Godeborg R, Nicholas O, et al. Acute myocardial infarction: a comparison of short-term survival in national outcome registries in Sweden and the UK. Lancet 2014; 383: 1305–12. Stromsoe A, Svensson L, Claesson A, Lindkvist J, Lundstrom A, Herlitz J. Association between population density and reported incidence, characteristics and outcome after out-of-hospital cardiac arrest in Sweden. Resuscitation 2011; 8: 1307–13.
www.thelancet.com Vol 384 November 1, 2014
3
4
Watson L, Virdi G, Donohoe R. Cardiac Arrest Annual Report: 2009–10. London: London Ambulance Service; 2010. Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 2011; 8: 1479–87.
Bridging medical education and clinical practice Medical students in the UK welcomed Richard Horton’s call for social accountability in medical education (Sept 13, p 940). 1 Meeting his challenge—”what can we achieve right now?”—students nationwide are establishing collaborative networks to broaden and supplement their learning. The Student Members Group at the Royal Society of Medicine in 2014 started an initiative to promote student-driven change in national health policy and training. Open to pre-registration students of all health-care professions, representatives from across the UK connect with health-service leaders and patients to produce policy reviews and recommendations, acquiring insight into diversity, governance, and leadership. Reports have been submitted to Sir Robert Francis‘ Freedom to Speak Up review2 and informed the Royal College of Nursing’s response to Health Education England’s Shape of Caring consultation.3 Similarly, Student Audit and Research in Surgery (STARSurg) provides an annual, multicentre observational cohort study, designed, managed, and deployed by a tiered network of student leaders.4 Supported by senior clinician oversight, student collaborators develop research and quality improvement skills, for sustainable, evidence-based change. The group engaged 258 students, representing 31 UK medical schools, in collecting outcome data for 1503 patients over 109 hospital sites, and proposed strategies to improve clinical practice.5
Through exposure to different clinical settings during training, students are well equipped to identify health-system problems and develop solutions. Disregarding institutional and geographical boundaries, student-led collaborations empower students to diversify their skill sets through sustainable, high quality, extracurricular experiential learning. We implore educationalists worldwide to foster similar initiatives, recognising students’ capacity to directly improve patient care.
Ghislain & Marie David De Lossy/Science Photo Library
30-day mortality of 7·7% in Sweden and 10·6% in the UK. However, these data were unlikely to explain the recorded 30-day-mortality difference between the two countries for three reasons. First, based on previous findings using other sources of data, the proportion of patients admitted to hospital alive after an out-of-hospital cardiac arrest of presumed cardiac aetiology were similar in Sweden2 and the UK,3 and there is some evidence that shows the incidence might be higher in England and Wales than in Sweden.4 Second, if there was an important difference in the proportion of patients with out-of-hospital cardiac arrest included in the registries, then one would expect more differences in death rates soon after admission; this was not reported in our study (figure 1 of the Article).1 Third, although it is possible that out-of-hospital cardiac arrest in cases of acute myocardial infarction were under-reported in national ACS quality registers (RIKS-HIA and MINAP), we do not yet have evidence of which country has the more complete reporting in their ACS registries. If Norris is correct, and the reporting is more complete in Sweden, then the true underlying mortality difference between the two countries would be even greater than we reported.
We declare no competing interests.
*Nick Cork, Oliver Llewellyn, James Glasbey, Chetan Khatri, on behalf of the Royal Society of Medicine Student Members Group and the STARSurg Collaborative [email protected] Royal Society of Medicine, London, UK (NC, OL); and STARSurg Collaborative, Research Department, Royal College of Surgeons of England, London WC2A 3PE, UK (JG, CK) 1 2
3
4
5
Horton R. Offline: The case for a medical school revolution. Lancet 2014; 384: 940. Sir Robert Francis. Freedom to Speak Up: An independent review into creating and open and honest reporting culture in the NHS. 2014. http://freedomtospeakup.org.uk (accessed Sept 26, 2014). Royal College of Nursing. Royal College of Nursing response to Health Education England’s and the Nursing and Midwifery Council’s call for evidence on the Shape of Caring review. 2014. http://www.rcn.org.uk/__ data/assets/pdf_file/0004/595282/66.14_ Shape_of_Caring_RCN_submission.pdf (accessed Oct 13, 2014). Nepogodiev D, Chapman SJ, Glasbey JC, et al. Multicentre observational cohort study of NSAIDs as risk factors for postoperative adverse events in gastrointestinal surgery. BMJ Open 2014; 4: e005164. STARSurg Collaborative. Impact of postoperative non-steroidal anti-inflammatory drugs on adverse events after gastrointestinal surgery. Br J Surg 2014; 101: 1413–23.
Save a Child’s Heart project in Israel We would like to emphasise the efforts of many Israeli doctors who care for patients from Arab countries and other countries, despite the belligerent situation in the Middle East. Hospitals in Northern Israel such as Rambam in Haifa, Rebecca Sief in Tzfat, Naharia Western 1575
for a key component of any such service arrangement in low-income countries with scare specialist resources for mental health—the use of non-specialist health workers to supplement care usually delivered by specialists. In our understanding, to treat people with moderate-to-severe forms of schoziphrenia staff need training in psychiatric skills, which is seen in usual care for patients in India, irrespective of location. Not providing these staff skilled in psychiatric care for this population would not be ethical. Furthermore, a large number of participants with ongoing treatment met the trial inclusion criteria. At the rural Tamil Nadu site, many participants were not receiving treatment and as a result, the intervention effect size was more substantial, showing the value of community health workers in low-resource settings to deliver psychosocial interventions for people with moderate-to-severe schizophrenia. We believe that at 12 months of treatment, a 20% reduction in overall symptom and disability ratings in people with schizophrenia is a reasonable and substantial change to achieve. Finally, we agree with the authors that more rigorous trials with different populations are needed to ascertain the role of community health workers in helping to address the treatment gap of people with schizophrenia in low-resource settings. We declare no competing interests.
*Graham Thornicroft, Sudipto Chatterjee, Rangaswamy Thara, Vikram Patel [email protected] King’s College London, Institute of Psychiatry, London SE5 8AF, UK (GT); Sangath, Goa, India (SC, VP); Schizophrenia Research Foundation, Chennai, India (RT); Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, London, UK (VP); and Public Health Foundation of India, New Delhi, India (VP) 1
1574
Chatterjee S, Naik S, John S, et al. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): a randomised controlled trial. Lancet 2014; 383: 1385–94.
2
3
World Health Organization. mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings. http://www.who.int/mental_ health/publications/mhGAP_intervention_ guide/en/ (accessed March 4, 2014). Government of India Ministry of Health and Family Welfare. National Mental Health Programme (NMHP). http://mohfw.nic.in/ index1.php?lang=1&level=2&sublinkid=2381&l id=1962 (accessed Sept 25, 2014).
Survival in acute myocardial infarction In their Article (April 2, p 1305),1 Sheng-Chia Chung and colleagues establish a comparison between Sweden and the UK in which only 2·3% (95% CI 2·2–2·3) of patients in the UK and 1·3% (1·3–1·4) of patients in Sweden had been recorded as being admitted to hospital after out-of-hospital cardiac arrest. In our Viewpoint,2 we pointed out that resuscitation from cardiac arrest had prevented 4 times as many deaths than the then prevalent method for reperfusion (streptokinase) and that in the studies on which these estimates were based,3,4 the percentage of patients who had survived out-of-hospital arrest was 5·0% for The United Kingdom Heart Attack Study Collaborative Group and 4·4% for the Southern Heart Attack Response Project. These patients have a high hospital fatality rate (odds ratio for deaths is 4·55 in Sweden and 4·78 in the UK, as stated in their supplementary appendix).1 It is difficult to escape the conclusion that patients surviving out-of-hospital cardiac arrest were under-reported in the registries of both countries and that fuller reporting would have increased the fatality rates, more so in Sweden than in the UK. Survival from out-of-hospital cardiac arrest varies widely among ambulance districts5 and in one district was improved markedly after rigorous retraining of paramedics.6 Resuscitation from cardiac arrest is still a very important but neglected specialty in audits of treatment for the acute coronary syndromes.
I declare no competing interests.
Robin Norris [email protected] 17 Aberdeen Rd, Castor Bay, Auckland 0620, New Zealand 1
2
3
4
5
6
Chung S-C, Godeborg R, Nicholas O, et al. Acute myocardial infarction: a comparison of short-term survival in national outcome registries in Sweden and the UK. Lancet 2014; 383: 1305–12. Julian DG, Norris RM. Myocardial Infarction: is evidence-based medicine the best? Viewpoint. Lancet 2002; 359: 1515–16. The United Kingdom Heart Attack Study Collaborative Group. Effect of time from onset to coming under care on fatality of patients with acute myocardial infarction: effect of resuscitation and thrombolytic treatment. Heart 1998; 80: 114–20. Norris RM, for the Southern Heart Attack Response Project (SHARP) investigators. A new performance indicator for acute myocardial infarction. Heart 2001; 85: 395–401. Perkins GD, Cooke MW. Variability in cardiac arrest survival: the NHS Ambulance Service Quality Indicators. Emerg Med J 2012; 29: 3–5. Fletcher D, Chamberlain D, Handley A, et al. Utstein-style audit of Protocol C: a non-standard resuscitation protocol for healthcare professionals. Resuscitation 2011; 82: 1265–72.
Authors’ reply We thank Robin Norris for his comments on our study, 1 and we strongly agree with him that resuscitation after out-of-hospital cardiac arrest is an important aspect of the quality of care of patients with acute coronary syndromes. We propose linkage of electronic health records across primary care, the ambulance service, and national quality registries for cardiac arrest and cardiac diseases to better understand, and improve management and outcome. Norris is correct in stating that the national acute coronary syndrome (ACS) registry data that we report only includes patients admitted to hospital, and therefore excludes patients who died before reaching hospital. Specifically, for acute myocardial infarction patients with out-of-hospital cardiac arrest, only patients who were resuscitated and admitted to hospital were included. In our study,1 such patients had an increased 30-day mortality in Sweden (25%) and the UK (32%) than the overall acute myocardial infarction www.thelancet.com Vol 384 November 1, 2014
Correspondence
We declare no competing interests.
*Sheng-Chia Chung, Adam Timmis, Tomas Jernberg, Harry Hemingway on behalf of the authors [email protected] The Farr Institute of Health Informatics Research, Department of Epidemiology & Public Health, University College London, 222 Euston Road, London NW1 2DA, UK (SCC, HH); National Institute for Health Research, Biomedical Research Unit, Bart’s Health, London, UK (AT); and Department of Cardiology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden (TJ) 1
2
Chung S-C, Godeborg R, Nicholas O, et al. Acute myocardial infarction: a comparison of short-term survival in national outcome registries in Sweden and the UK. Lancet 2014; 383: 1305–12. Stromsoe A, Svensson L, Claesson A, Lindkvist J, Lundstrom A, Herlitz J. Association between population density and reported incidence, characteristics and outcome after out-of-hospital cardiac arrest in Sweden. Resuscitation 2011; 8: 1307–13.
www.thelancet.com Vol 384 November 1, 2014
3
4
Watson L, Virdi G, Donohoe R. Cardiac Arrest Annual Report: 2009–10. London: London Ambulance Service; 2010. Berdowski J, Berg RA, Tijssen JG, Koster RW. Global incidences of out-of-hospital cardiac arrest and survival rates: systematic review of 67 prospective studies. Resuscitation 2011; 8: 1479–87.
Bridging medical education and clinical practice Medical students in the UK welcomed Richard Horton’s call for social accountability in medical education (Sept 13, p 940). 1 Meeting his challenge—”what can we achieve right now?”—students nationwide are establishing collaborative networks to broaden and supplement their learning. The Student Members Group at the Royal Society of Medicine in 2014 started an initiative to promote student-driven change in national health policy and training. Open to pre-registration students of all health-care professions, representatives from across the UK connect with health-service leaders and patients to produce policy reviews and recommendations, acquiring insight into diversity, governance, and leadership. Reports have been submitted to Sir Robert Francis‘ Freedom to Speak Up review2 and informed the Royal College of Nursing’s response to Health Education England’s Shape of Caring consultation.3 Similarly, Student Audit and Research in Surgery (STARSurg) provides an annual, multicentre observational cohort study, designed, managed, and deployed by a tiered network of student leaders.4 Supported by senior clinician oversight, student collaborators develop research and quality improvement skills, for sustainable, evidence-based change. The group engaged 258 students, representing 31 UK medical schools, in collecting outcome data for 1503 patients over 109 hospital sites, and proposed strategies to improve clinical practice.5
Through exposure to different clinical settings during training, students are well equipped to identify health-system problems and develop solutions. Disregarding institutional and geographical boundaries, student-led collaborations empower students to diversify their skill sets through sustainable, high quality, extracurricular experiential learning. We implore educationalists worldwide to foster similar initiatives, recognising students’ capacity to directly improve patient care.
Ghislain & Marie David De Lossy/Science Photo Library
30-day mortality of 7·7% in Sweden and 10·6% in the UK. However, these data were unlikely to explain the recorded 30-day-mortality difference between the two countries for three reasons. First, based on previous findings using other sources of data, the proportion of patients admitted to hospital alive after an out-of-hospital cardiac arrest of presumed cardiac aetiology were similar in Sweden2 and the UK,3 and there is some evidence that shows the incidence might be higher in England and Wales than in Sweden.4 Second, if there was an important difference in the proportion of patients with out-of-hospital cardiac arrest included in the registries, then one would expect more differences in death rates soon after admission; this was not reported in our study (figure 1 of the Article).1 Third, although it is possible that out-of-hospital cardiac arrest in cases of acute myocardial infarction were under-reported in national ACS quality registers (RIKS-HIA and MINAP), we do not yet have evidence of which country has the more complete reporting in their ACS registries. If Norris is correct, and the reporting is more complete in Sweden, then the true underlying mortality difference between the two countries would be even greater than we reported.
We declare no competing interests.
*Nick Cork, Oliver Llewellyn, James Glasbey, Chetan Khatri, on behalf of the Royal Society of Medicine Student Members Group and the STARSurg Collaborative [email protected] Royal Society of Medicine, London, UK (NC, OL); and STARSurg Collaborative, Research Department, Royal College of Surgeons of England, London WC2A 3PE, UK (JG, CK) 1 2
3
4
5
Horton R. Offline: The case for a medical school revolution. Lancet 2014; 384: 940. Sir Robert Francis. Freedom to Speak Up: An independent review into creating and open and honest reporting culture in the NHS. 2014. http://freedomtospeakup.org.uk (accessed Sept 26, 2014). Royal College of Nursing. Royal College of Nursing response to Health Education England’s and the Nursing and Midwifery Council’s call for evidence on the Shape of Caring review. 2014. http://www.rcn.org.uk/__ data/assets/pdf_file/0004/595282/66.14_ Shape_of_Caring_RCN_submission.pdf (accessed Oct 13, 2014). Nepogodiev D, Chapman SJ, Glasbey JC, et al. Multicentre observational cohort study of NSAIDs as risk factors for postoperative adverse events in gastrointestinal surgery. BMJ Open 2014; 4: e005164. STARSurg Collaborative. Impact of postoperative non-steroidal anti-inflammatory drugs on adverse events after gastrointestinal surgery. Br J Surg 2014; 101: 1413–23.
Save a Child’s Heart project in Israel We would like to emphasise the efforts of many Israeli doctors who care for patients from Arab countries and other countries, despite the belligerent situation in the Middle East. Hospitals in Northern Israel such as Rambam in Haifa, Rebecca Sief in Tzfat, Naharia Western 1575
