Primary Care Clinical Effectiveness Bulletin
May 11
Edition no. 5
Welcome to the fifth edition of South West London Primary Care Clinical Effectiveness Bulletin, a digest of information focusing on primary care and public health evidence, guidelines and new research with the aim of informing and enabling best practice. The information has been collated from National Institute of Health & Clinical Excellence (NICE), NHS Evidence (formerly National Library for Health), Scottish Intercollegiate Guidelines (SIGN) and Clinical Knowledge Summaries (CKS). The title of each piece of guidance is also a hyperlink (just control + click to follow links) to relevant websites (e.g. NICE) where the complete document(s) are available for reading and/or downloading.
CONTENTS1. Clinical Guidelines and Care Pathways
· Common mental health disorders (CG123)
· ‘Eyes on Evidence’ (NHS Evidence) June 2011
2. Local Guidelines and Shared care prescribing guidelines
3. NICE Public Health Guidance
· Preventing type 2 diabetes: population and community-level interventions in high-risk groups and the general population
4. NICE Technology Appraisals and Interventional Procedure Guidance
5. Other useful information
· South West London Effective Commissioning Initiative (SWLECI) 2011/12
o Example of SWLECI criteria - ENT - (Adeno)Tonsillectomy
· NICE 'do not do' recommendations
· Useful search tool – TRIP Database
· NICE consultations for your comments
· NICE News
1. Clinical Guidelines and Care Pathways
Common mental health disorders (CG123)
(Relevant to primary & secondary care mental health)
This new guideline aims to help GPs provide quick, cost-effective treatment to improve the lives of millions of people experiencing common mental health disorders. It offers evidence-based advice on the care and treatment of adults who have common mental health disorders, with a particular focus on primary care. It brings together advice from existing guidelines and combines it with new recommendations on access to care, assessment and developing local care pathways for common mental health disorders. Common mental health disorders include depression, generalised anxiety disorder, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder and social anxiety disorder.
Recommendations include:
· How patients are assessed and a diagnosis made
· When and how they are referred to other services for treatment
· How to develop local referral and care pathways in their local area
· Communication with patients, carers and between health professionals and services.
NB The diagram on the following page is taken directly from the NICE Quick Reference Guide. This can be accessed by clicking on the hyperlink at the top of this page. The QRG contains further useful algorithms covering the stepped care model, including:
· Step 1: Identification and assessment
· Step 2: Treatment and referral advice for sub-threshold symptoms and mild to moderate disorders
· Step 3: Treatment and referral advice for persistent sub-threshold symptoms, mild to moderate disorders with inadequate response to initial interventions, or moderate to severe disorders
SW London Primary Care Clinical Effectiveness Bulletin 5th Edition NHSW June11 Page 1 of 8
SW London Primary Care Clinical Effectiveness Bulletin 5th Edition NHSW June11 Page 1 of 8
’Eyes on Evidence’ (NHS Evidence)
This monthly bulletin covers major new evidence as it emerges, with an explanation about what it means for current practice: Eyes on Evidence June 2011
2. Local Guidelines and Shared care prescribing guidelines
NHSW Clinical Effectiveness and Medicines Management Group (CEMMaG) met at the beginning of June and approved the following local guidelines:
· Shared care prescribing guideline for Alzheimer’s disease drugs (incorporating NICE TA217 on cholindterase inhibitors & memantine for Alzheimer’s disease, March 2011)
· Anti-platelet guidelines for primary care
These guidelines can be accessed directly via this hyperlink to the CEMMaG webpage on the NHS Wandsworth Website (NB scroll down the page to find ‘Resources’).
3. Public Health Guidance
As mentioned in the previous edition in May, the following Public Health Guidance was published:
Preventing type 2 diabetes: population and community-level interventions in high-risk groups and the general population (PH35)
NICE recommendations aim to help prevent type 2 diabetes among populations and communities of adults who are at high risk. Risk factors include being overweight or obese and whether or not someone is physically active. In addition to these individual risk factors, certain ethnic communities and people from lower socioeconomic groups are particularly at risk.
The 11 recommendations advise on:
· Integrating national strategy on type 2 diabetes with national activities to prevent other non-communicable diseases (such as cardiovascular disease and certain cancers).
· National action to promote a healthy diet and physical activity.
· Local needs assessments and strategies, including local action to promote a healthy diet and physical activity among communities at high risk.
· Training for those involved in helping to spread awareness of the risks and how to prevent the condition.
A second piece of guidance on type 2 diabetes, looking at interventions aimed at individuals at high risk, is due to be published in May 2012.
4. NICE Technology Appraisals and Interventional Procedures Guidance
Technology Appraisals
Peripheral arterial disease - cilostazol, naftidrofyryl oxalate, pentoxifylline and inositol nicotinate (TA223) (Relevant to secondary care)
NICE recommends naftidrofuryl oxalate as an option for the treatment of people who have intermittent claudication caused by peripheral arterial disease and for whom vasodilator therapy is considered appropriate after taking into account other treatment options.
Self-help measures, including lifestyle changes such as quitting smoking, taking regular exercise and eating a healthy diet, are the most important components in reducing the chance of developing peripheral arterial disease. However, for some people the severe pain that is often associated with intermittent claudication means that their ability to engage in regular exercise, particularly walking, can be severely limited. Although it does not halt the progress of peripheral arterial disease, naftidrofuryl oxalate has been shown to be the most clinically and cost effective treatment option for people with the condition in terms of improving maximum walking distance.
Interventional Procedures - all mainly relevant to acute care
Normal arrangement / Apply normal consent, audit and clinical governance arrangements plus any additional recommendations, for example, on training, service delivery or data collection.Special arrangement / Notify clinical governance leads, ensure patients understand the uncertainties referred to in the guidance, and audit and review clinical outcomes of all patients having the procedure plus any additional recommendations, for example, on training, service delivery or data collection.
Other (see guidance) / Guidance recommends a combination of normal or special arrangements.
Research only / Use only in the context of a formal research protocol.
Do not use / The procedure should not be used in the National Health Service (NHS)
Endoscopic radiofrequency therapy of the anal sphincter for faecal incontinence (IPG393)
Special arrangements
External aortic root support in Marfan syndrome (IPG394)
Special arrangements
Percutaneous tibial nerve stimulation (PTNS) for faecal incontinence (IPG395)
Special arrangements
Trabecular stent bypass micro-surgery for open angle glaucoma (IPG396)
Special arrangements
Trabeculotomy ab interno for open angle glaucoma (IPG397)
Normal arrangements
5. Other Useful Information
South West London Effective Commissioning Initiative (SWLECI)
An example of the use of scientific evidence in the commissioning of local health services is the South West London Effective Commissioning Initiative (ECI). The aim of the ECI is to develop a set of criteria for access to a range of elective surgical procedures throughout South West London which is updated on a regular basis. This work is driven by the need to ensure that NHS funded treatments are effective and evidence-based and provide value for money, and that access to them is equitable. It also attempts to define more clearly and openly the limits of NHS funding for procedures with social but not physical benefits e.g. cosmetic procedures. These criteria have been devised by local clinicians under the aegis of the South West London Public Health Network, and have been approved by the Boards of all five SW London PCTs and four local Acute Trusts.
The following set of patient criteria for (adeno)tonsillectomy is included here as an example, and has been taken directly from the ECI document:
These criteria refer to tonsillectomies with or without adenoidectomies. Adenoidectomies, for clinical reasons, are routinely funded.
Absolute Criteria - Suspected malignancy.
Indicative Criteria
Recurrent sore throat where the majority of episodes required antibiotic treatment and have been adequately treated and who meet all of the criteria within one of the following groups:
Group 1
· 5 or more episodes in the last year, OR 4 or more episodes in each of the last two successive years, OR 3 or more episodes in each of the last 3 years;
AND
· There has been significant severe impact on quality of life indicated by
at least one of the following:-
(i) Documented evidence of absence from school, work or playgroup*;
OR
(ii) Failure to thrive.
OR
Group 2
Documented evidence of 2 or more episodes of tonsillitis or quinsy requiring admission to hospital.
OR
Group 3
Tonsillitis exacerbating existing disease such as febrile convulsions, guttate psoriasis, glomerulonephritis or rheumatic fever.
*Note: Documented evidence of attendance to general practice or other health care settings, and documented evidence of periods of time off work, school and playgroup may be considered as an episode of tonsillitis.
The PCT will only consider funding for (adeno) tonsillectomy as a treatment for sleep apnoea syndrome in children who meet the criteria in one of the following Groups.
Group 1
The patient must meet two out of the three following criteria:
§ Witnessed episodes of apnoea (breathing pause of 10 seconds are longer)
§ Choking episodes during sleep
§ Daytime neurobehavioural abnormalities or sleepiness
OR
Group 2
If the patient has habitual snoring with laboured breathing and falls into one of the following complex high risk category for sleep apnoea:
§ Down’s syndrome
§ Cerebral palsy
§ Craniofacial disorders
§ Chronic lung disease
§ Sickle cell disease
§ Neuromuscular disorders
§ Genetic/metabolic/storage disease
§ Central hyperventilation syndromes
Note: The case is much more likely to be approved where there is supporting evidence such as sleep studies, growth charts, letters from GPs and letters from employer and school.
New criteria for the following procedures have been agreed and added to the ECI document recently: apicectomy, asymptomatic gallstones, autologous chondrocyte implantation, carpal tunnel, circumcision, dilation and curettage (D&C), female genital prolapse/stress incontinence, hip arthroplasty (revision of), hyperbaric oxygen therapy, hysteroscopy, knee arthroscopy, knee arthroscopy (revision of), knee washout, manual lymphatic drainage, orthodontic treatments, spinal cord stimulation for neuropathic pain and uterine fibroids.
The up-to-date list of ECI procedures and criteria can be accessed via the NHS Wandsworth (WPCT) Website (front page, then scroll down to ECI icon). It is also available via the South West London Public Health Network (choose library tab and then ‘E’ from the alphabetical list).
SW London ECI is working towards improved engagement of primary and secondary care clinicians as well as patients and the public. For further information on the Effective Commissioning Initiative please e-mail Dr Josephine Ruwende, Consultant in PH Medicine,
NICE 'do not do' recommendations
During the process of guidance development NICE often identify clinical practices that they recommend should be discontinued completely or should not be used routinely due to evidence that the practice is not on balance beneficial or a lack of evidence to support its continued use. These type of recommendations, since 2007, have been pulled together into the 'do not do' recommendations on the NICE website. An example is:
CG88 Early management of persistent non-specific low back pain, May 2009
Do not offer X-ray of the lumbar spine for the management of non-specific low back pain.
Do not offer injections of therapeutic substances into the back for non-specific low back pain.
Useful search tool
The TRIP Database isa clinical search engine designed to allow clinicians to quickly find answers to their clinical questions using the best available evidence. The Database started in 1997 as a result of the work of the founders in answering clinical questions. They recognised that searching multiple websites separately for relevant information was time-consuming. The creation of the Database allowed the simultaneous searching of multiple sites, hence speeding up the question answering process. It has been externally evaluated by the Centre for Evidence-Based Medicine.
NICE consultations for your comments:
· CG74 Surgical sight infection: review proposal consultation
13 June - 25 June 2011
· CG58 Prostate cancer: diagnosis and treatment
13 June - 26 June 2011
· CG9 Eating disorders: review proposal consultation
13 June - 26 June 2011
· Diagnostics programme manual: consultation
10 June - 9 September 2011
· CG82 Schizophrenia (update): review proposal consultation
7 June - 21 June 2011
· Varicose veins: scope consultation
9 June - 7 July 2011
· Sickle cell acute episode: scope consultation
7 June - 5 July 2011
Details of all NICE consultations can also be accessed here.
NICE News
GPs following NICE LUTS guidance
Nearly half of GPs are following NICE advice on the management of lower urinary tract symptoms (LUTS) in men, one year on from the launch of the guideline, a survey has found.
NICE guideline process earns international praise
NICE guidelines are among the most "trustworthy" in the world and meet a series of rigorous standards, a leading journal has concluded.
Fresh calls to cut the use of chemical cosh drugs
Experts have renewed calls for action to curb the use of antipsychotic drugs for people with dementia.
NICE to develop new guideline on acute painful sickle cell episode
NICE is in the early stages of developing a short guideline on the management of an acute painful sickle cell episode in hospital.
Editorial team
As always your feedback on the usefulness of this bulletin would be much appreciated.
Dr. Usman Khan, Richmond Borough Team,
Tracy Steadman, Croydon Borough Team,
Alastair Johnston, Wandsworth Borough Team,
Livia Royle, Kingston Borough Team,
Dr John Licorish, Sutton & Merton Borough Team,
SW London Primary Care Clinical Effectiveness Bulletin 5th Edition NHSW June11 Page 1 of 8