Swiss Re Ag · SIX:SREN
Swiss Re — Investor Presentation (2017)
38 slides from Swiss Re's investor presentation, 2017
Slide 1: Dr Aseem Malhotra, Honorary Consultant Cardiologist
Dr Aseem Malhotra, Honorary Consultant Cardiologist, Lister Hospital Stevenage Academy of Medical Royal Colleges Choosing Wisely Steering Group King’s Fund – Member of Board of Trustees Special thanks to Professor Sir Muir Gray, Professor Simon Capewell, Professor Terence Stephenson, Professor Dame
Slide 2: The Evidence-Based Medicine triad
The Evidence-Based Medicine triad (see D.L. Sackett et al, BMJ 1996; 312: 71-72) ‘~ ~-_ | ‘ N
Slide 3: Half of what you learn in medical school quote
“ Half of what you learn in medical school will be shown to be either dead wrong or out of date within 5 years of your graduation; the trouble is nobody can tell you which half. The most important thing to learn is how to learn on your own” David Sackett
Slide 4: Efficient Health Care Requires Informed Doctors and Patients
Efficient Health Care Requires Informed Doctors and Patients Seven Sins that contribute to Lack of knowledge Biased funding of research (research funded because it is likely to be profitable, not because it is likely to be beneficial for patients) Biased reporting in medical journals Biased pa
Slide 5: Financial conflicts of interest/ culture to do more
Financial conflicts of interest/ culture to do more Financial influence of individual doctors to earn more based upon the number of investigations and procedures can sometimes put profits before patients One US Cardiologist admitted to ordering $19 million dollars worth of unnecessary investigat
Slide 6: Technological drive
Technological drive Intra-Aortic Balloon Pumps Designed for use in cardiogenic shock complicating myocardial infarction Decades of use based upon industry sponsored Observational studies £40,000 per pump, catheter per patient £800 140,000 used worldwide Financial costs and potential harm t
Slide 7: BMJ
BMJ BA4J 201334745741 dol: 10.1136/omj15741 (Published 24 September 2013) I Too much angioplasty Stenting offers no prognostic benefit over drugs in stable coronary disease Aseem Malhotra interventional cardiology specialist registrar, Royal Free Hospital, London Often a gulf exists between cardiolo
Slide 8: More informed consent can reduce potential harms
More informed consent can reduce potential harms Would making it mandatory on the consent form that stents do not improve prognosis be a reasonable default to reduce patient anxiety, reassure of the benefits of medical therapy and encourage a more informed discussion about equally if not more impo
Slide 9: NEWS: Call for better information before heart operations
NEWS = Health Call for better information before heart operations By Adam Brimelow Health Correspondent, BBC News © 24 June 2014 f
Slide 10: 'Legitimate debate'
‘Legitimate debate' A spokesman for the British Cardiovascular Intervention Society said there was no evidence in the UK that patients has been treated inappropriately. He said changing the consent form was not the best way of ensuring patients understood their treatment. But Prof Terence Stephenson
Slide 11: When patients were told the lack of prognostic benefit for PCI
When patients were told the lack of prognostic benefit for PCI, only 45.7% elected to go ahead with the procedure versus 69.4% who were not explicitly given this information Ref:Rothberg MB, Scherer L, Kashef M, et al. The Effect of Information Presentation on Beliefs About the Benefits of Elective
Slide 12: More is not better!
More is not better! US regions with higher utilisation and expensive care reveal slightly worse mortality outcomes, lower perceived access, and less patient satisfaction Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder ÉL. The Implications of Regional Variations in Medicare Spending.
Slide 13: Statistics- A risk factor for misinformation?
Doctors Understanding of Health Statistics- A risk factor for misinformation? Many doctors do not understand health statistics and therefore cannot evaluate the evidence for or against a treatment. In a study of 150 gynaecologists, one third did not understand the meaning of a 25% risk reduction
Slide 14: Misleading health statistics
Misleading health statistics There are many ways of presenting a benefit. RRR, ARR or NNT Communicating relative risks as opposed to absolute risk or NNT ( numbers needed to treat) can lead laypeople and doctors to overestimate the benefit of medical interventions. For example in high risk typ
Slide 15: WHO Bulletin 2009
WHO Bulletin 2009 “ It is an ethical imperative that every doctor and patient understand the difference between absolute and relative risks to protect patients against unnecessary anxiety and manipulation” Gerd Gigerenzer, Director of Harding center for risk literacy, Berlin.
Slide 16: Case Study
Case Study 49 year old type 2 diabetic and overweight man is reviewed in OPD 9 months following emergency coronary stenting Reports disabling and persistent chest pain in recent weeks which is atypical in nature for having a cardiac origin After checking there is no acute problem, no new ECG c
Slide 17: Abramson J, Rosenberg H, Jewell N, Wright JM, BMJ 2013
Abramson J, Rosenberg H, Jewell N, Wright JM, BMJ 2013;347:f6123 doi: 10.1136/bmj.f6123 (Published 22 October 2013)
Slide 18: BMJ
BMJ BMJ 2013;347:f6340 doi: 10.1136/bmj.f6340 (Published 22 October 2013) Page 1 of 2 ————EFE>E—E—E>E=—>—E>=—~—~E>E=Z{Z{ZZ| OBSERVATIONS FROM THE HEART Saturated fat is not the major issue Let's bust the myth of its role in heart disease Aseem Malhotra interventional cardiology specialist registrar,
Slide 19: Call for retraction
Call for retraction “ there are only one or two well- documented (problematic) side effects” Myopathy and muscle weakness occurred in one in 10,000 people he said and there was a small increase in diabetes - Professor Rory Collins –Guardian, March 2014
Slide 20: Statin controversy
Statin controversy Statins – letter to Health Secretary signed by leading doctors including the President of the RCP, Sir Richard Thompson, past chair of the RCGP, Clare Gerada, Chair of National Obesity Forum David Haslam, Prof Simon Capewell rejecting NICE move to lower threshold to offer treatm
Slide 21: Loss of professional confidence
Loss of professional confidence GPC “In light of the Cochrane review of the effectiveness of antiviral influenza treatments, the GPC will request that NICE refrain from recommending a reduction to the current treatment threshold for primary prevention of cardiovascular disease with statin therapy
Slide 22: Harvard Researcher Wins Round in Brawl With Oxford Peer
Harvard Researcher Wins Round in Brawl With Oxford Peer Over Benefits of Cholesterol Drugs The verdict is in on a bruising spat between researchers at Harvard University and the University of Oxford over a paper questioning the value of prescribing cholesterol- lowering drugs to people at low risk o
Slide 23: Statin controversy…
Statin controversy… MJA, June 2015- up to 2900 people may have suffered a heart attack or died as a result of stopping their statin after Catalyst Heart of the matter programme A month earlier, editor Professor Stephen Leeder sacked January 2016- Re-analysis by reputed French Cardiologist Dr M
Slide 24: Peter Wilmshurst – Centre of Evidence Based Medicine, Oxford 2014
Peter Wilmshurst – Centre of Evidence Based Medicine, Oxford 2014 Pharmaceutical companies and medical device companies have a fiduciary obligation as businesses to make a profit and declare a shareholder dividend by selling their product. They are not required to sell consumers ( patients and d
Slide 25: The Illusion of "innovation"
The IIlusion of “innovation” Of 667 new drugs approved by the FDA between 2000 and 2008 only 11% truly innovative. 75% essentially copies of old ones. Drug companies spend twice as much on marketing than they do on research and development “ It is no longer possible to trust much of the clinical
Slide 26: Statin Usage Survey
Statin Usage Survey statinusage.com nearly 75% of new users discontinue statins within a year of prescription 1. Side effects were the leading reason why patients stopped taking statins More than six in ten respondents (62%) said they discontinued their statin due to side effects, with the sec
Slide 27: Sunday Times Investigation, 18th September 2016
Sunday Times Investigation, 18th September 2016 Sir Rory Collins, a professor of medicine and epidemiology at Oxford University, led a review into statins, published in The Lancet earlier this month, which found that not more than one in 50 people will suffer side effects. Collins, who believes
Slide 28: Dear Mr Ungoed-Thomas,
Dear Mr Ungoed-Thomas, Thank you for your freedom of information request dated 4 October 2016. Item 1 — (a) Has any revenue from the licensing of the patent for the test for SLCO1B1 been used to fund research at CTSU? (b) If so, what research projects has it funded and do any these relate to statins
Slide 29: UK: The fat man of Europe?
UK: The fat man of Europe? • 2/3 adults obese or overweight • obesity will double by 2050 • 1/3 children obese or overweight • Obesity costs NHS £5billion+ ↑ ↑£10 billion by 2050
Slide 30: It's OK. I'm on statins
It’s OK. ’m on statins
Slide 31: Choosing Wisely in the UK
BMJ 2015;350:h2308 doi: 10.1136/bmj.h2308 (Published 12 May 2015) Page 1 of 4 ANALYSIS Choosing Wisely in the UK: the Academy of Medical Royal Colleges’ initiative to reduce the harms of too much medicine [EBS] oP EN Access A Malhotra and colleagues explain how and why a US initiative to get doctors
Slide 32: Academy of Medical Royal Colleges/BMJ Choosing Wisely/Too Much Medicine Initiative
Academy of Medical Royal Colleges/BMJ Choosing Wisely/Too Much Medicine Initiative Overdiagnosis can be said to occur when “individuals are diagnosed with conditions that will never cause symptoms or death” often as a “consequence of the enthusiasm of early diagnosis.” Overtreatment includes tre
Slide 33: AoMRC: doctors have an ethical responsibility to reduce wasted use
AoMRC: “doctors have an ethical responsibility to reduce this wasted use of clinical resource because, in a healthcare system with finite resources, one doctor’s waste is another patient’s delay”
Slide 34: Call to action/next steps
Call to action/next steps To ensure the development of a Choosing Wisely culture in clinical practice, the academy suggests: Doctors should provide patients with resources that increase their understanding about potential harms of interventions and help them accept that doing nothing can often b
Slide 35: NNTs for treatment of heart disease - Death
NNTs for treatment of heart disease - Death Aspirin ( high risk) 100 Statins (high risk) 83 Aspirin and statins ( low risk) – infinity… Coronary stents during heart attack 40 Coronary stents at any other time? MEDITERRANEAN DIET!!!! 30 Ref: theNNT.com
Slide 36: Dr Aseem Malhotra
Dr Aseem Malhotra * @DrAseemMalhotra For low risk YES or NO ? to taking a given new analysis revealing no mortality benefit via NO 143 votes - Final results 12/11/2017, 11:39
Slide 37: John Adams quote
“ The preservation of the means of knowledge among the lowest ranks is of more importance to the public than all the property of all the rich men in the country” John Adams, 2nd US President, 1775.
Slide 38: Basic Copyright Notice & Disclaimer
Basic Copyright Notice & Disclaimer ©2017 This presentation is copyright protected. All rights reserved. You may download or print out a hard copy for your private or internal use. You are not permitted to create any modifications or derivatives of this presentation without the prior written permiss