Procedures of Limited Clinical Effectiveness Phase 1
Consolidation and repository of the existing evidence-base
Meeyin Lam, Public Health Trainee
Jennie Mussard, Assistant Director (PCT Intelligence)
Updated to include procedure codes and information on outliers, October 2010
This report was produced with the support of the London Health Observatory team, which is part of the Clinical Health Intelligence Directorate, CSL.
Key Points
· This table includes a list of 70 potentially avoidable procedures under 41 main procedure groupings, based on the master list provided in the DFI report. The DFI codes have been included.
· A total of 26 of the main procedure groups are listed by at least five London sectors (14 procedures), have NICE guidance (16 procedures) or both (4 procedures). This suggests that there is a reasonable evidence-base, or a strong foundation for consensus, for developing pan-London referral guidance. These are shaded blue or green.
· The remaining 15 procedures are listed by less than five London sectors and do not have NICE guidance, indicating that more extensive evidence appraisal and clinical consultation is needed.
· Three procedures have been identified as having higher potential or stretch savings across London as a whole AND are on less than five London sector lists. These procedures are a priority for further evidence appraisal, as the savings may be greater. These are shaded yellow.
· The Appendix reviews an additional list of procedures that are not included in commissioners’ list and include some outpatient procedures
Local reviews of evidence and referral guidance – London
ETR: Exceptional treatment reviews: procedures. Reviewer PCT listed in brackets
INEL: Inner North East London Low Priority/Excluded Restricted Procedures 2010-2011 (draft list)
NCL: North Central London Policy for Low Priority Treatments (draft 2)
NWL Policy: North West London’s ‘Interventions Not Normally Funded’ Policy. Includes hierarchy of evidence and grading of recommendation (A -D).
A: Based on evidence from systematic reviews, meta-analysis of randomised controlled trials or at least one randomised controlled trial
B: Based on evidence from at least one controlled study without randomisation or at least one other type of quasi experimental study
C: Based on evidence from non experimental descriptive studies, such as comparative studies, correlation studies and case control studies
D: Directly based on evidence from expert committee reports or opinions and/or clinical experience of respected authorities or extrapolated from hierarchy evidence from above
ONEL: Outer North East London Procedures of Limited Clinical Effectiveness. April 2010 (draft policy). Provides evidence review. Does not include most cosmetic procedures.
SEL: South East London Exceptional Treatments Commissioning Policy (not including dental and orthodontic)
Section 1 treatments require review and approval by the relevant group and prior funding agreed
Section 2 treatments do not require prior agreement; however they must be notified to the PCT along with details of how the access criteria were met.
SWL: South West London Effective Commissioning Initiative 2009/10. Provides evidence review.
Local reviews of evidence and referral guidance – outside London
C&M: Draft Cheshire and Merseyside Prior Approval Scheme, Incorporating Procedures of Lower Clinical Priority. A review and compilation of the policies of the 8 PCTs in Cheshire and Merseyside. Criteria were also informed by a review undertaken by the South West London Public Health Network on behalf of 5 PCTs in London and the London Health Observatory. Criteria have been classified as either ‘not contentious’ as all current policies are very similar or ‘requires discussion to agree criteria’ if there is significant variation between policies.
Brighton: NHS Brighton and Hove PCT policies - Procedures which require prior approval from the PCT
Evidence reviews and guidance in green text have been referenced by others (including Dr Foster Intelligence), but not cross-checked for this project. They may have reviews of evidence.
- Berkshire NHS Priorities Website
- Brent PCT
- Hampshire & Isle of Wight PCTs (South Central Priorities Committee) Policy
- Norfolk Policy for Low Priority Procedures and Thresholds
- Oxfordshire PCT
- Suffolk Low Priority Treatment Policy
- Waltham Forest Exceptional Treatments Policy 2008
- West Essex PCT Surgical Threshold Policy
- West Essex PCT Priorities Policy
- West Sussex PCT Low Priorities Procedures and Other Procedures and Restrictions
- Western Cheshire
- Westminster PCT, 2007, Low priority procedures policy
Stratification of areas for further work
Procedures have been highlighted in the table in the following colours:
BLUE: all or most (5/6) London sectors have referral guidance for the procedure, though they may not be identical, and/or there is NICE guidance
YELLOW: the procedure has been identified to have a higher potential or stretch saving level across London as a whole (this may vary for different sectors and PCTs). The levels of saving were identified by Dr Foster Intelligence.
GREEN: procedure meets both of the above criteria
WHITE: Four or less London sectors have referral guidance for the procedure AND there is no relevant NICE guidance
Procedure / DFI Code / HRG, OPCS, ICD codes / Published evidence and reviews eg original studies, systematic reviews, meta-analyses, journal articles, text books / Formal recommendations (NICE, professional bodies, etc) / Local review of evidence (by sector or PCT) / Referral guidance / London PCTs and providers with significantly high SAR 2009/10: /Balance of clinical evidence: a planned procedure where evidence of clinical- and/or cost-effectiveness is either absent, or too weak for reasonable conclusions about efficacy and long term benefits/harms to be reached
Apicectomy / A01 / OPCS
F121 / British Association Oral and Maxillofacial Surgeons. Referral guidelines. Apical surgery. Previously available at http://www.baoms.org.uk/CD-ROM/guidelines/Apical%20surgery.pdf (accessed 3rd October 2007)
Royal College of Surgeons of England. Guidelines for surgical endodontics. http://www.rcseng.ac.uk/fds/clinical_guidelines/documents/surg_end_guideline.pdf (accessed 1st Oct 2007) / NWL Policy (D) / NWL with exceptions
NCL[1] / Barnet, Bromley, Croydon, Enfield, Haringey, Waltham Forest
Barnet & Chase Farm, Ealing, Homerton, Mayday, South London, UCLH, Whipps Cross
Autologous chondrocyte implantation
(Blue) / A02 / OPCS
W853 / NICE Technology appraisal TA89 / C&M criteria
Western Cheshire / No PCT
No provider
Injections and fusion for back pain
(Blue) / A03 / HRG4
HC01Z, HC02B, HC02C, HC03A, HC03B, HC03C, HC04A, HC04B, HC04C, HC05B, HC05C, HC07Z, HC08Z, HC09Z
OPCS
V221, V231, V241, V251, V253 ,V261, V333, V335, V336, V371, V372, V373, V374, V378, V379, V381, V382, V383, V384, V388, V389, V391, V392, V393, V394, V395, V398, V399, / Gibson JNA, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database of Systematic Reviews 2007, Issue 2.
Ibrahim T; Tleyjeh IM; Gabbar O. Surgical versus non-surgical treatment of chronic low back pain: a meta-analysis of randomised trials. International Orthopaedics, February 2008, vol./is. 32/1(107-13), 0341-2695
Mirza SK; Deyo RA Systematic review of randomized trials comparing lumbar fusion surgery to non-operative care for treatment of chronic back pain. Spine, April 2007, vol./is. 32/7(816-23), 1528-1159
Rivero-Arias O, Campbell H, Gray A et al. Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial. BMJ. 2005 May 28;330(7502):1239
Van Tulder M, Koes B, Seitsalo S, Malmivaara A. Outcome of invasive treatment modalities on back pain and sciatica: an evidence-based review. Volume 15, Supplement 1 / January, 2006 Can be purchased from http://www.springerlink.com/content/718525118748783t/fulltext.pdf
For discectomy:
Butterman GR. Treatment of lumbar disc herniation: epidural steroid injection compared to discectomy. J Bone and Joint Surgery 2004; 86-a: 670-9
Greenfield K, Nelson RJ et al. Microdiscectomy and conservative treatment for lumbar disc herniation with back pain and sciatica: a randomized clinical trial. Proceedings of the International Society for the Study of the Lumbar Spine, 2003: 245
Hoffman RM, Wheeler KJ, Deyo RA. Surgery for herniated lumbar discs: a literature synthesis. J Gen Int Med 1993; 8: 487-96
Malter AD, Larson EB et al. Cost effectiveness of lumbar discectomy for the treatment of herniated invertebral disc. Spine 1996; 21: 1048-55
Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine 1983 8(2): 131-40
Weinstein JN, Torteson TD, Lurie JD et al. Surgical vs Nonoperative Treatment for Lumbar Disk Herniation. JAMA 2006 296
Also see listing for Lumbar disc prolapse (A09) / NICE Clinical Guidance CG 88 (published May 2009) / ONEL
SWL / ONEL[2]
SWL critieria[3]
Brighton[4]
Suffolk / Enfield, Lewisham, Tower Hamlets, Waltham Forest
Barnet & Chase Farm, Barts, ESH, GSTT, Imperial, King’s, St George’s, UCLH, Whipps Cross
Bilateral bone anchored hearing aid (BAHA) / A04 / OPCS
D131, D132, D133, D134, D135, D136, D138, D139 / Tower Hamlets provided the following sources (to support funding?)
Dutt, S, et al, Patient satisfaction with bilateral bone-anchored hearing aids: the Birmingham experience, J Laryngol Otol, 2002, 116, 37-45, p 41.
Snik, A, et al, Candidacy for the bone-anchored hearing aid, Audiol Neurotol, 2004, 9, 190-96, p196.
Snik, A, et al, Consensus statements on the BAHA system: where do we stand at present?, Ann Otol, Rhinol Laryngol, 2005, Dec, 114, 12, 2-12, p7.
REFER, Department of Health Research Findings Register, The use of bone-anchored hearing aids, REFER Summary, 2001, 1-3, p2. http://www.refer.nhs.uk/ViewRecord.asp?id=505
Proops, D, The evidence base for aural rehabilitation with the bone-anchored hearing aid, J Laryngol Otol, 2002, 28, p1.
Dutt, S, et al, The Glasgow Benefit Inventory in the evaluation of patient satisfaction with the bone anchored hearing aid: quality of life issues, J Laryngol Otol, 2002, June, 116, Supplement 28, 7-14, p10. / NICE, “Press release – guidance on hearing aids”, 2000 / ETR (Tower Hamlets)[5] / Hampshire & Isle of Wight PCTs
South Gloucester-shire PCT[6]
Croydon list
Bedfordshire and Hertfordshire[7]
Doncaster Primary Care Trust[8] / No PCT
GSTT, Royal Free
Dilatation and curettage
(Blue) / A05 / HRG4
MA10Z, MA13A, MA13B,
OPCS4
Q103, Q108, Q109
ICD10
N920, N921, N924, N925, N926, N938, N939
Age <45 only / Coulter A, Kelland J, Long A. The management of menorrhagia. Effective Health Care Bulletin 1995; (9).
Emanuel MH, Wamsteker K, Lammes FB. Is dilatation and curettage obsolete for diagnosing intrauterine disorders in premenopausal patients with persistent abnormal uterine bleeding? Acta Obstet Gynecol Scand 1997; 76: 65.
BMJ Clinical Evidence: Menorrhagia. Sept 06. / NICE Clinical Guideline on heavy menstrual bleeding CG44
Royal College of Obstetricians and Gynaecologists. Management of Menorrhagia in Secondary Care. 1999
NHS Institute for Innovation and Improvement. NHS Better Care, Better Value Indicators: Surgical thresholds indicators. 10 October 2007 At http://www.productivity.nhs.uk/Definitions.aspx Accessed 26.3.08 / ONEL
NWL Policy (D) / ONEL
NWL with exceptions
SEL criteria/ notification
INEL
NCL
C&M (req discussion)
Brighton
Croydon list
Berkshire
West Essex / Enfield
Barnet & Chase Farm, Dartford & Gravesham, Imperial, North Middlesex
Ganglia
(Blue) / A06 / OPCS4
T591, T592, T593, T594, T598, T599, T601, T602, T603, T604, T608, T609
ICD10
M674 / Vroon P, Scholten RJ, van Weert HCPM. Interventions for ganglion cysts in adults (Protocol). Cochrane Database of Systematic Reviews 2005, Issue 2. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005327/pdf_fs.html [Accessed 2nd Oct 2007]
Burke FD, Melikyan EY, Bradley MJ, Dias JJ. Primary care referral protocol for wrist ganglia. Postgrad Med J 2003 79:329-331
Bandolier. Wrist ganglia. Webpage. [Cited 19th Sept 2007]. Available at: http://www.jr2.ox.ac.uk/bandolier/booth/miscellaneous/wristgang.html
Wildin C,Dias J,Heras-Palou C,Bradley M,Burke FD. Trends in elective hand surgery referrals from primary care. Annals of The Royal College of Surgeons of England 2006; 88 [6]: 543-546
Dias J, Buch K. Palmar wrist ganglion: does intervention improve outcome? A prospective study of the natural history and patient-reported treatment outcomes. J Hand Surg (Br) 2003;2: 172-6. / NWL Policy (A)
ONEL / NWL with exceptions
SEL notification
ONEL
INEL
NCL
Revised Croydon list / Bromley, Croydon, Islington
Ashford & St Peter’s, Chelsea & Westminster, Darftord & Gravesham, Homerton, Mayday, Newham, North Middlesex, South London, Whittington, West Middlesex
Grommets
(Blue) / A07 / OPCS
D151, D158, D159, D202, D203, D208, D209 / Langton Hewer CD, McDonald S, Nunez DA. Grommets (ventilation tubes) for recurrent acute otitis media in children. Cochrane Database of Systematic Reviews 2004, Issue 2. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004741/pdf_fs.html [Accessed 2nd Oct 2007]
Lous J, Burton MJ, Felding JU, Ovesen T, Rovers MM, Williamson I. Grommets (ventilation tubes) for hearing loss associated with otitis media with effusion in children. Cochrane Database of Systematic Reviews 2005, Issue 1. Available at: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001801/pdf_fs.html [Accessed 2nd Oct 2007]
Maw, R., Wilks, J., Harvey, I. et al (1999) Early surgery compared with watchful waiting for glue ear and effect on language development in preschool children: a randomised trial [published erratum appears in Lancet 1999 Oct 16;354(9187):1392]. Lancet 353(9157), 960-963
Oomen k et al (2005) Effect of adenotonsillectomy on middle ear status in children. Laryngoscope Apr;115(4):731-4
Paradise JL (2005) Developmental outcomes after early or delayed insertion of typanostomy tubes. NEJM (353);6:576-589
Rosenfeld et al (2004) Clinical Practice Guideline: Otitis Media with Effusion. Otolaryngology – Head and Neck Surgery (130);5;s95-s118
Williamson I. Otitis media with effusion. Treatment. Surgery (ventilation tubes, adenoidectomy, or both). BMJ Clinical Evidence 2006. Available http://clinicalevidence.bmj.com/ceweb/about/index.jsp [Accessed 19th Sept 2007] / NICE Clinical Guideline on surgical management of otitis media with effusion CG60
SIGN Guideline 66 (2003) Diagnosis and management of childhood Otitis Media in Primary Care
NHS Institute for Innovation and Improvement. NHS Better Care, Better Value Indicators: Surgical thresholds indicators. 10 October 2007 At http://www.productivity.nhs.uk/Definitions.aspx Accessed 26.3.08
Centre for Reviews and Dissemination. The treatment of persistent glue ear in children. 1992. http://www.york.ac.uk/inst/crd/projects/glueear.htm / NWL Policy (A)
ONEL
SWL / NWL
SEL with exceptions
ONEL
INEL
SWL criteria
NCL
C&M criteria (req discussion)
West Essex / Bromley
ESH, Kingston, Royal Free, Lewisham, West Middlesex, Whipps Cross
Grommets (adults) / Yung MW, Arasaratnam R. Adult-onset otitis media with effusion: results following ventilation tube insertion. J Laryngol Otol. 2001 Nov;115(11):874-8