The research shaping the health of a nation

“What I would say is a marker for healthcare quality is availability of research,” Professor Colin Berry declares, from his office at the University of Glasgow.

“When patients are given the opportunity to take part in a research study, the fact that they are taking part in the study raises the quality of their healthcare without regard to what the study is about.”

It’s perhaps no surprise that Berry speaks so emphatically about medical research.

He is, after all, a funded researcher with the British Heart Foundation, as well as being Director of Research and Development at the Golden Jubilee National Hospital in Glasgow. Not to mention his positions as a Chair in Cardiology and Imaging in the University of Glasgow and Consultant Cardiologist at the Golden Jubilee and Queen Elizabeth University Hospital.

But despite his obvious professional interest, Berry’s words give food for thought about research being the backbone to all medical procedures that are carried out in our hospitals every single day.

Berry is contemplating the impact of Brexit on research in our hospitals, particularly after clinical trials of a new heart drug were stopped in three UK hospitals – including the Golden Jubilee – because of concerns over Brexit.

Medical research firm Recardio was due to try the drug dutogliptin on patients, but suspended all UK activities due to uncertainty about how new medicines will be approved after Brexit.

“If Brexit reduces the opportunities for patients to take part in research then that will make optimised healthcare a little bit more challenging to implement in the NHS in Scotland,” explains Berry.

“Of course, research brings the latest in new medicines, new tests and new treatments so again, if the research studies are meeting barriers through Brexit or the companies who run and support research projects are being more cautious about the United Kingdom because of Brexit, then that’s a shame with respect to the opportunities for our patients to take part in studies.”

And the opportunity for patients to take part in studies is one of Berry’s main raison d’êtres.

He is involved in a host of important projects designed to significantly change – and of course, save – the lives of patients with heart problems.

One of the projects looks at small vessel disease.

“If you imagine the main arteries in the heart as being tree trunks, then we’re really focused on the small vessels, or the branches,” Berry explains. “They are tiny wee branches, less than half a millimetre in size. They cannot be seen by standard tests, yet in many ways they are the most important vessels.”

Berry continues: “If we look at chest pain, there are about a million chest pain attendances in the UK each year at chest pain clinics. Only one in five of these patients have got a blocked heart artery so the majority have chest pain that is not well explained under tests, so a high proportion of patients – perhaps half of the patients – may have small vessel problems and they may be falsely reassured.

“In other words, the CT scan, which is now recommended to image blocked heart arteries, shows the arteries are not blocked and patients get advice that it may be something else. But, actually, if we study these patients – and there’s hundreds of thousands of them – these patients actually have chest pain due to the small vessel problems because of high blood pressure, ageing, and there’s associations with the female sex. Small vessel problems are preponderant in women whereas the large vessel problems are preponderant in men.

“The long-term impact is psychological distress, frustration, impaired quality of life and potentially cardiovascular consequences such as a heart attack and heart failure.”

Berry’s research team has been looking at other types of tests other than the CT scan which does not pick up on the small vessel problems.

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He says: “There are two types of test – an MRI scan which is currently not recommended in the NHS, so we are actually paying for this through research funds. Through research protocols we are able to develop information or evidence then we make that information available publicly and it’s for those who develop guidelines and NHS management to form views about how tests are made available.

“The other tests that we are employing are at the time of coronary angiography. For someone with chest pain, ultimately the best test is an angiogram to see if there is a blocked heart artery which can be opened up with a balloon and a stent placed, or indeed bypass surgery.

“We know from our British Heart Foundation funded research and a study called CorMicA that half of patients referred for an angiogram have clear or unobstructed heart arteries. Now there’s 250,000 coronary angiograms performed in the UK each year. Half of these are potentially unnecessary or things might have been done differently, or additional measurements can be made to actually measure small vessel function using a guidewire that’s sensitive to resistance.

“We can measure blood vessel resistance and correlate that to patients’ symptoms. We’ve been able to show that using these tests as an additional step during a standard coronary angiogram has changed the diagnosis in more than half of the patients and we are able to therefore recommend different treatments.

“The patients receive this information at the time and they get greater clarity on their health problems – if any, because some of the results are normal, sometimes we’re confirming that actually, your blood vessels have got normal function – and we followed the patients up in the CorMicA study. This study ran from November 2016 to 2017 and we found that these tests had led to improvements in quality of life and reduction in angina and chest pain.

“That was done in the Golden Jubilee in the west of Scotland and we are now seeking to run this study nationally or indeed internationally.”

Another important piece of work Berry has been working on is the creation of an electronic registry which has, once again, been developed in the west of Scotland.

Berry tells Holyrood: “When patients are in our hospitals or indeed when they get transferred between hospitals – which is increasingly the case – often the clinicians involved in the care will have no sight or knowledge of what happens next to the patients.

“Actually, that gap in knowledge leads to uncertainty and sometimes inefficiency in healthcare and how patients are being managed, whereas through the electronic patient records that now exist increasingly, and with the electronic systems that are now in place, we are able to link patient journeys and this becomes enabling.

“We have undertaken a pilot proof of concept project where we are able to link the journeys that a single patient will have through hospitals back and forward, but at scales over all patients in Glasgow who have a heart attack and then to look at the medicines they receive or don’t receive, and the stents they might receive or don’t receive and then look at their outcomes – are they still alive a year after having a heart attack or in the longer term?

“Looking into this, we can see about the efficiencies in health and the potential for improvement in healthcare through the information that starts to come together.

“The hospitals are distinct organisations so they do not necessarily share the information. We have these health boards in Scotland but there are – dare I say the word – barriers to information transfer between hospitals and organisations. That creates gaps and loss of information as to how patients are being looked after and what there outcomes are.

“The information exists but it’s not linked and it becomes all the more relevant if there might be differences between health boards and regions.”

Berry adds: “Some patients in certain parts of the country get more efficient or direct healthcare than other parts and why might that be? Actually, we don’t know.”