Recognising value

Sciatica is a common condition. How much better is surgery at relieving pain and disability than non-surgical treatments or steroid injections? Liu and colleagues conducted a systematic review and meta-analysis to answer this question (doi:10.1136/bmj-2022-070730).1 The certainty of the evidence is low, but at least in the medium term discectomy seems better than non-surgical treatments or steroid injections for reducing leg pain and disability. But the differences between groups lessened over time. Editorialists Annina Schmid and colleagues warn against extrapolating these results to patients in primary care settings, most of whom recover in a few months (doi:10.1136/bmj.p791).2 The value of surgery is mainly confined to patients referred to secondary care with clear discogenic sciatica when rapid pain relief is a priority. For those patients, the results of this review “challenge the stepped care approach that offers the least invasive options first to everyone with sciatica.”

Another study has a clearer answer. Conducted in the US Veterans Affairs system, this large study shows benefits from the antiviral drug nirmatrelvir when used early in patients with SARS-CoV-2 (doi:10.1136/bmj-2022-073312).3 Deaths and hospital admissions were reduced in patients who received treatment. The value of treatment was evident regardless of age, gender, comorbidities, or vaccination status.

There has been no assessment of the potential effects on health of the UK’s decision to join the Comprehensive and Progressive Agreement on Trans-Pacific Partnership, say Courtney McNamara and colleagues (doi:10.1136/bmj-2022-073302).4 Trade agreements pose many potential health threats. They can increase the price of drugs, interfere with governments’ ability to enact health regulations, cause economic and health harms among workers who lose their jobs, and increase the influence of industry on setting standards for public health. If the government does not assess the health impacts, write the authors, then public health scholars should do so.

What should you drink if you have type 2 diabetes? Anything but sugar sweetened beverages, it seems. Ma and colleagues followed more than 15 000 US nurses and health professionals with type 2 diabetes for several decades, updating information on beverage intake every two to four years (doi:10.1136/bmj-2022-073406).5 The onset of cardiovascular disease and death from diabetes, as well as overall mortality, were higher in those who consumed more sugar sweetened beverages. Coffee, tea, and plain water were associated with lower risks for those outcomes, especially when they replaced sugar sweetened beverages.

Sustainable healthcare can bring value for patients, healthcare staff, and the planet, reports Florence Wedmore after attending a Royal College of Physicians conference on the topic (doi:10.1136/bmj.p833).6 One presenter suggested talking to patients about climate change in terms of how they manage their disorder. For patients with diabetes, for example, one disease and climate friendly recommendation might be to “use your feet for transport.”

Since 2021 patients in the US have had free and immediate access to their medical records, thanks to passage of the 21st Century Cures Act. Doctors and administrators have worried about the potential for confusion or anxiety if patients receive results before they hear from their doctor. It turns out, though, that patients value this access. This is true even when they receive results indicating something might be wrong and even when they receive results before communicating with their doctor. Nearly all patients (95.7%) who responded to a large survey wanted to continue getting their results as soon as they were ready, reports Joanne Silberner (doi:10.1136/bmj.p789).7 This surprised the survey authors, who had expected only about half of patients would feel this way.

What does the UK public think of the NHS? David Oliver says that the results of the latest British Social Attitudes survey make for “grim reading,” with 40% of respondents very or quite dissatisfied with services (doi:10.1136/bmj.p760).8 It’s not just patients who are unhappy, though. NHS staff are, too. Large percentages of surveyed healthcare workers report feeling undervalued by management or are thinking of leaving their jobs. “Our concerns mirror theirs,” writes Oliver, suggesting that before it’s too late doctors and NHS staff should try to align their efforts to change things with those of the people they serve.

And finally, we mustn’t undervalue women or doctors. Scarlett McNally argues for more emphasis on family planning and better funding (doi:10.1136/bmj.p862).9 “We need to value every woman beyond her role (or potential role) as a mother,” she says, pointing out that “supporting smaller families or valuing child-free lives would help to maximise health for all.” Helen Salisbury considers the introduction of physician associates, paramedics, and other non-physician staff that resulted from the 2019 Additional Roles Reimbursement Scheme (doi:10.1136/bmj.p856).10 Such staff can be useful in dealing with circumscribed clinical scenarios, she writes, since there are not enough doctors in general practice. But medicine is rarely that neat, because many patients have multiple medical problems whose simultaneous management requires a broad, general understanding of medicine: “We should not underestimate the value of our expert generalism.”