Primary Care Clinical Effectiveness Bulletin
June 2011
Edition no. 6
Welcome to our South West London-wide 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 is collated each month from National Institute of Health & Clinical Excellence (NICE), NHS Evidence (formerly National Library for Health), Scottish Intercollegiate Guidelines (SIGN), and SW London Effective Commissioning Initiative (ECI). (NB Please note that Clinical Knowledge Summaries (CKS) is no longer updated, but is still browsable.) The title of each piece of guidance is also a hyperlink (just control + click to follow links) to relevant websites where the complete document(s) are available for reading and/or downloading. This month you are invited to give us feedback (see ‘Our Survey’ below).
CONTENTS1. NICE Clinical Guideline
· The management of Hip Fracture in Adults
2. NICE Technology Appraisals and Interventional Procedure Guidance
3. SW London Effective Commissioning Initiative
4. Other useful information
· ‘Eyes on Evidence’
· NICE 'do not do' recommendations – featuring COPD
· Ways of influencing the work of NICE – including consultations
· NICE News – recent news items
5. Our Survey
1. Clinical Guidelines and Care Pathways
Hip fracture (CG124) (of interest to primary care, mainly relevant to secondary care)
Hip fracture refers to a fracture occurring in the area between the edge of the femoral head and 5 centimetres below the lesser trochanter (see figure 1 in the full guideline via hyperlink above). These fractures are generally divided into two main groups. Those above the insertion of the capsule of the hip joint are termed intracapsular, subcapital or femoral neck fractures. Those below the insertion are extracapsular. The extracapsular group is split further into trochanteric (inter- or pertrochanteric and reverse oblique) and subtrochanteric. Hip fracture is a major public health issue due to an ever increasing ageing population. About 70,000 to 75,000 hip fractures occur each year and the annual cost (including medical and social care) for all UK hip fracture cases is about £2 billion. About 10% of people with a hip fracture die within 1 month and about one-third within 12 months. Most of the deaths are due to associated conditions and not to the fracture itself, reflecting the high prevalence of co-morbidity. Because the occurrence of fall and fracture often signals underlying ill health, a comprehensive multidisciplinary approach is required from presentation to subsequent follow-up, including the transition from hospital to community. This guideline covers the management of hip fracture from admission to secondary care through to final return to the community and discharge from specific follow-up.
2. NICE Technology Appraisals and Interventional Procedures Guidance
Technology Appraisals
Rheumatoid arthritis (methotrexate-naïve) - golimumab (terminated appraisal) (TA224) (Relevant to secondary care)
NICE is unable to recommend the use in the NHS of golimumab for the treatment of methotrexate-naive rheumatoid arthritis because no evidence submission was received from the manufacturer or sponsor of the technology.
Rheumatoid arthritis (after the failure of previous anti-rheumatic drugs) - golimumab (TA225) (Relevant to secondary care)
Golimumab in combination with methotrexate is recommended for adults whose rheumatoid arthritis has responded inadequately to conventional disease-modifying antirheumatic drugs (DMARDs) only, including methotrexate. In this case, golimumab is an option if it is used as described for other tumour necrosis factor (TNF) inhibitor treatments - adalimumab, etanercept and infliximab - covered by NICE technology appraisal 130, and the manufacturer provides the 100 mg dose of golimumab at the same cost as the 50 mg dose. For adults whose rheumatoid arthritis has responded inadequately to other DMARDs, including a TNF inhibitor, golimumab in combination with methotrexate is also recommended as a treatment option. In this situation golimumab can be used only as described for other TNF inhibitor treatments in NICE technology appraisal guidance 195 (which covers the use of adalimumab, etanercept, infliximab, rituximab and abatacept after the failure of a TNF inhibitor), and the manufacturer provides the 100 mg dose of golimumab at the same cost as the 50 mg dose.
Lymphoma (follicular non-Hodgkin's) - rituximab (TA226) (Relevant to secondary care)
Rituximab maintenance therapy is recommended as an option for the treatment of people with follicular non-Hodgkin’s lymphoma that has responded to first-line induction therapy with
rituximab in combination with chemotherapy.
Lung cancer (non-small-cell, advanced or metastatic maintenance treatment) - erlotinib (monotherapy) (TA227) (Relevant to secondary care)
Erlotinib monotherapy is not recommended for maintenance treatment in people with locally advanced or metastatic non-small-cell lung cancer who have stable disease after platinum-based first-line chemotherapy.
Interventional Procedures - all mainly relevant to acute care
Key:
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 radical inguinal lymphadenectomy (IPG398)
Special arrangements
Percutaneous endoscopic catheter laser balloon pulmonary vein isolation for atrial fibrillation (IPG399)
Special arrangements
Thoracoscopic exclusion of the left atrial appendage in atrial fibrillation (with or without other cardiac surgery) for the prevention of thromboembolism (IPG400)
Other (see guidance)
3. South West London Effective Commissioning Initiative (ECI)
A good example of the use of scientific evidence in the commissioning of local health services is the SW London Effective Commissioning Initiative (ECI), which 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. 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 has been taken directly from the ECI document:
(see next page)
All referrals should be through an agreed pathway to optimise access to conservative treatment.
Absolute Criteria
The PCT will fund carpal tunnel surgery where:
Symptoms persist for more than three months after conservative therapy with oral/local corticosteroid injections and/or splinting.
OR
There is neurological deficit or median nerve denervation for example sensory blunting, muscle wasting or weakness of thenar abduction.
OR
Severe symptoms significantly interfering with daily activities.
Rationale
§ Carpal Tunnel Syndrome (CTS) presents with symptoms ranging in severity and should be recognised before permanent deficits develop. Risk of nerve damage is low for most patients and the relationship between symptoms and nerve conduction study results is not strong.
§ Conservative treatment offers short-term benefit (0-3 months) and symptom severity can be seen to improve after 2-7 weeks of initial treatment.
§ Conservative treatment offers the opportunity to avoid surgery and have the advantage of being relatively inexpensive and without serious adverse side effects.
§ Steroids (oral and local injection) and nocturnal splinting in the neutral position are considered the most effective conservative therapies.
§ In the mid and longer term (3-18 months), surgery is more effective than conservative treatment.
§ Open carpal tunnel release/decompression is the most common surgical treatment performed. The choice of endoscopic or open technique is usually guided by surgeon’s experience and patient’s preference.
This is one of the new surgical procedures agreed and added to the ECI document from July 2011.
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). For further information on the Effective Commissioning Initiative please e-mail Dr Josephine Ruwende, Consultant in PH Medicine,
4. Other Useful Information
’Eyes on Evidence’ (NHS Evidence)
‘Eyes on Evidence’ is a newsletter which covers major new evidence as it emerges, with an explanation about what it means for current practice. This is a second chance to view the Eyes on Evidence June 2011 issue, which was also mentioned in last month’s CE Bulletin. (Ctrl+Click on the heading of this section to access all back issues.)
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. This month’s example is: Management of COPD
Ways of influencing the work of NICE
NICE tries to be open and transparent in the way it develops its guidance, and there are a number of ways you can get involved. For example, the following list (NB not exhaustive) contains some of NICE consultations currently taking place:
· Anaphylaxis: guideline consultation
11 July - 8 August 2011
· CG64 Prophylaxis against infective endocarditis: review proposal consultation
11 July - 25 July 2011
· NICE advice on healthcare-associated infections: consultation
4 July - 9 August 2011
· Acute coronary syndromes - ticagrelor: appraisal consultation
30 June - 21 July 2011
· Obesity - working with local communities: consultation on the evidence
24 June - 22 July 2011
· End of life care: quality standard consultation
24 June - 22 July 2011
· NHS Evidence Process and Methods Manual consultation
13 June - 16 September 2011
· Diagnostics programme manual: consultation
10 June - 9 September 2011
Details of all NICE consultations can be accessed here.
NICE News
The following is a list of recent news items (not exhaustive) from the NICE website:
§ Parliamentary report calls for dementia care training
Training in dementia care should be offered to all staff working with older people in the health, social care and voluntary sectors, in line with NICE recommendations, the All-party Parliamentary Group on Dementia has said.
§ Psychiatrists call for greater access to NICE-recommended psychological therapies
Access to psychological therapies in hospital wards "falls far short of acceptable standards", according to a new report.
§ NICE annual review 2010/11 published online
NICE has today published its annual review online, providing an overview of our work during 2010/11.
§ Stroke prevention surgery 'not performed in time'
More than half of stroke patients in the NHS are not getting early access to potentially life-saving stroke-prevention surgery, according to a report from the Royal College of Physicians and the Vascular Society.
§ Government accepts changes to the Health and Social Care Bill
The government has agreed to make a series of core changes to its Health and Social Care Bill, following a report by the NHS Future Forum.
5. Our Survey
Thank you for reading this Primary Care Clinical Effectiveness Bulletin. Please complete our reader’s survey to help us to meet your needs more effectively (click on icon below). The survey consists of 6 questions with tick box replies, and should take no longer than a minute or two to complete! There is a link to enable you to easily return your questionnaire. We will collate the results and give feedback in the next edition.
Editorial team
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,
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