Primary Care Clinical Effectiveness Bulletin
April 2011
Edition no. 4
Welcome to the fourth 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 the Website (e.g. NICE) where the complete document(s) are available for reading/downloading.
CONTENTS1. Clinical Guidelines and Care Pathways
· NICE Clinical Guideline on Lung cancer (CG121)
· NICE Clinical guideline on ovarian cancer (CG122)
· SIGN clinical guideline on the management of asthma – an update
· ‘Eyes on Evidence’ (NHS Evidence) April & May 2011
2. NICE Public Health Guidance
· Preventing type 2 diabetes: population and community-level interventions in high-risk groups and the general population (PH34)
· Review of NICE PH3 guidance on Prevention of sexually transmitted infections and under 18 conceptions
3. NICE Technology Appraisals and Interventional Procedure Guidance
4. Other useful information
· South West London Effective Commissioning Initiative (SWLECI) 2011/12
· Surgical Treatment of Carpal Tunnel Syndrome
· NICE Pathways
· NICE consultations for your comments
· NICE News
1. Clinical Guidelines and Care Pathways
NICE Clinical Guideline on Lung cancer (CG121)
(Relevant to primary, secondary acute & tertiary care)
The new recommendations replace those previously published in 2005 and include:
· Re-emphasis of the importance of public awareness of early symptoms and signs, recognising that this remains the key to reducing the number of deaths from lung cancer.
· Diagnosis and staging of the disease
· Different approaches to treatment - including offering surgery to those patients who are medically fit and suitable
· New emphasis on follow-up.
· New section on communicating with the patient.
NICE Clinical Guideline on Ovarian Cancer (CG122)
(Relevant to primary, secondary acute & tertiary care)
This clinical guideline looks at the detection, diagnosis and initial management of epithelial ovarian cancer, the most common type of ovarian cancer. It calls for more initial investigations to take place in primary care settings so that women can be referred to hospital specialists sooner and begin treatment. Recommendations include:
· GPs & other primary care professionals to offer women (particularly those over 50) a blood test to measure the level of CA125 if they present on a regular basis with - bloating, feeling full quickly, lower abdominal pain and needing to urinate urgently or frequently.
· Based on the results of this test, offer women an ultrasound scan of their abdomen and pelvis. If this suggests ovarian cancer, refer them to a hospital specialist within two weeks; the existing national target set by the Department of Health.
· GPs are advised to test women aged 50 or above for ovarian cancer if they have experienced prolonged symptoms within the last 12 months that suggest irritable bowel syndrome (IBS). IBS rarely presents for the first time in women of this age.
(NB the algorithm overleaf is taken directly from NICE CG122 Quick Reference Guide)
SIGN British Guideline on the Management of Asthma No. 101 - An update
Produced jointly by SIGN and the British Thoracic Society (BTS) since 2003, sections of the guideline are updated annually. This version includes updates to monitoring asthma and pharmacological management, and a new section on asthma in adolescents. This asthma guideline is designed to continue to serve as a basis for high quality management of both acute and chronic asthma and a stimulus for research into areas of management for which there is little evidence.
’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 April 2011
Eyes on Evidence May 2011
2. Public Health Guidance
Preventing type 2 diabetes: population and community-level interventions in high-risk groups and the general population (PH35)
(NB This guidance was published in early May.) NICE's 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.
Review of NICE PH3 guidance on Prevention of sexually transmitted infections and under 18 conceptions
The review decision for prevention of sexually transmitted infections and under 18 conceptions has been published and is now available on the NICE website via the hyperlink above. This document describes the review process including updated evidence review and consultation with stakeholders, and concludes that the guidance does not need to be updated at this time.
3. NICE Technology Appraisals and Interventional Procedures Guidance
Technology Appraisals:
Everolimus for the second-line treatment of advanced renal cell carcinoma (TA219)
(Relevant to primary, secondary acute & tertiary care)
Everolimus is not recommended for the second-line treatment of advanced renal cell carcinoma.
Psoriatic arthritis - golimumab (TA220) (Relevant to secondary acute & tertiary care)
Golimumab is recommended as an option for treating active and progressive psoriatic arthritis in adults if:
· It is used as described for the other tumour necrosis factor (TNF) inhibitor treatments - etanercept, infliximab and adalimumab - covered by TA199.
· The manufacturer provides the 100 mg dose of golimumab to the NHS at the cost of the 50 mg dose, as agreed by the manufacturer and the Department of Health as part of a patient access scheme.
Thrombocytopenic purpura - romiplostim (TA221) (Relevant to primary & secondary acute care)
Romiplostim is recommended for the treatment of adults with chronic ITP:
· Whose condition does not respond to standard active treatments and rescue therapies or,
· Who have severe disease, and a high risk of bleeding that requires frequent courses of rescue therapies, and
· If the manufacturer makes romiplostim available with the rebate on the list price agreed under the patient access scheme.
Only a haematologist should initiate and supervise treatment with romiplostim.
Ovarian cancer (relapsed) - trabectedin (TA222) (Relevant to secondary acute & tertiary care)
Trabectedin (Yondelis, PharmaMar) in combination with pegylated liposomal doxorubicin hydrochloride (PLDH) is not recommended as a treatment for ovarian cancer that has returned six months or more after initial treatment with chemotherapy which included platinum, because of concerns over how well it works compared with the most commonly-used treatments.
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)
Carotid artery stent placement for asymptomatic extracranial carotid stenosis (IPG388)
Carotid artery stent placement for symptomatic extracranial carotid stenosis (IPG389)
Endovascular repair of popliteal aneurysms (IPG390)
Extracorporeal membrane oxygenation for severe acute respiratory failure in adults (IPG391)
Stent insertion for bleeding oesophageal varices (IPG392)
4. Other useful Information
South West London Effective Commissioning Initiative (ECI)
An example of the use of evidence in the commissioning of local health services is the South West London Effective Commissioning Initiative (ECI). The aim of 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. The ECI is driven by the need to ensure that NHS funded treatments are effective, evidence-based and provide equality in access and value for money.
ECI is working towards improved engagement of primary and secondary care clinicians as well as patients and the public.
An example of criteria is:
Varicose VeinsThis guidance applies to each leg individually. The techniques that are normally approved are open surgery (ligation and stripping) and the endovenous techniques endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) using VNUS Closure system. Sclerotherapy will not normally be funded. Factors to be taken into account when selecting the most appropriate treatment include local equipment, clinical assessment (including vein tortuosity and anatomy) and patient preference.
Absolute Criteria
PCT's will normally fund surgical or endovenous intervention for varicose veins if they are accompanied by one or more of the following complications:
Intractable ulceration secondary to venous stasis.
OR
Healed venous ulcerations in patients that cannot tolerate compression stockings for clinical reasons.
OR
Significant haemorrhage from a ruptured superficial varicosity (serious enough to warrant transfusion or admission);
OR
After an unsuccessful six month trial of conservative management (compression stockings, exercise and daily elevation several times a day) when varicosities result in either:
· recurrent documented thrombophlebitis (two or more episodes)
· persistent skin changes (eczema, pigmentation or lipodermatosclerosis)
· persistent aching, heaviness, itching or swelling severely affecting the patient’s quality of life (for example the patient is unable to stand throughout the day for their job or they are woken regularly at night by severe discomfort)
The most current full 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 South West London Effective Commissioning Initiative (ECI) please e-mail Dr Josephine Ruwende, Consultant in PH Medicine,
NICE consultations for your comments:
· Hyperglycaemia: guideline consultation
11 May - 8 June 2011
· Clinical Guideline process review consultation
27 April - 19 July 2011
· Self-harm (longer term management): guideline consultation
12 April - 7 June 2011
· Acute kidney injury: draft scope consultation
17 May - 14 June 2011
Details of all NICE consultations can also be accessed here.
NICE News
NICE Pathways
NICE Pathways is an online tool for health and social care professionals that brings together all related NICE guidance and associated products in a set of interactive topic-based diagrams.
Visually representing everything NICE has said on a particular topic, the pathways enable you to see at a glance all of NICE's recommendations on a specific clinical or health topic. They provide an easier and more intuitive way to find, access and use NICE guidance. NICE Pathways will also expand to reflect NICE's new role in providing social care advice and quality standards.
NICE pathways represents a network of NICE information. For example, the diet pathway links up with the physical activity pathway; the COPD pathway links up with the smoking pathway. Over time, all of NICE's guidance, quality standards and related tools will be added to this network of information. For the first time you do not need to understand how NICE classifies different types of guidance to view everything NICE has said on a particular topic.
Shared Learning Awards winner announced
Manchester Royal Infirmary has scooped this year's Shared Learning Award for their work in transforming haemodialysis treatment in Manchester.
Social care heads the new agenda for NICE
Integrating health and social care is fundamental to helping drive up the quality of patient care, as NICE outlines plans to extend its remit into social care guidance for adults and children.
Antibiotic prescribing cut by three-quarters following NICE advice
NICE guidance has helped to cut down on unnecessary antibiotic prescribing for the prevention of infective endocarditis, latest research suggests.
NHS trusts failing to tackle staff obesity
Just 15 per cent of NHS trusts have a policy or plan to help tackle staff obesity, a report by the Royal College of Physicians and the Faculty of Occupational Medicine has revealed.
Experts urge PCTs in England to improve care for high cholesterol condition
The NHS in England is lagging behind the rest of the UK when it comes to indentifying and treating patients with the inherited condition familial hypercholesterolaemia (FH), a leading expert has warned.
Another reminder that NICE provides tools to support the implementation of guidance e.g. audit and costing tools which can be accessed via the NICE website
Editorial team
As always your feedback on the usefulness of this bulletin would be much appreciated.
Dr. Usman Khan, NHS Richmond & NHS Kingston,
Tracy Steadman, NHS Croydon,
Alastair Johnston, NHS Wandsworth,
Livia Royle, NHS Kingston,
Dr John Licorish, NHS Sutton & Merton
SW London Primary Care Clinical Effectiveness Bulletin 4th Edition May11 Page 1 of 7