Download SWL CE Bulletin 10th Edition Oct 2011

Primary Care Clinical Effectiveness Bulletin
October 2011
Edition no. 10
Welcome to your 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 and local sources and referenced
below. The bulletin contains hyperlinks to guidance – simply [control+click] to follow the link to
the website where the complete document is available.
CONTENTS – Control & click on underlined titles below to go to sections of interest
1. SW London Effective Commissioning Initiative
 This month’s example criteria – Hysterectomy for heavy menstrual bleeding
2. Clinical Guidelines & Care Pathways
 NICE guideline on Hyperglycaemia in acute coronary syndromes
 NICE guideline on Colorectal cancer
 PRODIGY updated topics
3. NICE Technology Appraisals
 Acute coronary syndromes - Ticagrelor
 Osteosarcoma - Mifamurtide
4. Other useful information
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Are you one of a growing number of GPs using NICE Pathways?
‘Eyes on Evidence’
Measuring implementation of NICE guidance - advice for practices
NICE’s update briefing for
NICE 'do not do' recommendations – featuring lower urinary tract symptoms in men
Ways of influencing the work of NICE – including consultations
NICE News – recent news items
To subscribe to NICE’s monthly newsletter for primary care Update for Primary Care , send an
email with your name, job title and email address to: [email protected]
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1.
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), 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
South West London PCTs and four local Acute Trusts. This month’s example is hysterectomy for
heavy menstrual bleeding, and the following criteria are taken directly from the ECI document:
Hysterectomy for Heavy Menstrual Bleeding
Absolute Criteria - PCTs will fund hysterectomy for heavy menstrual bleeding only when:
o
There has been an unsuccessful trial (of at least 6 cycles) with a levonorgestrel intrauterine
system (e.g. Mirena®) unless medically contraindicated.(1) (1st line pharmaceutical treatment)
AND
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A second pharmaceutical treatment (unless contraindicated) has been tried and has also
failed. These pharmaceutical treatments include:
 Tranexamic acid (2nd line pharmaceutical treatment)
 Non-steroidal anti-inflammatory drugs (NSAIDs) (2nd line pharmaceutical treatment)
 Combined oral contraceptives (2nd line pharmaceutical treatment)
 Oral progesterone ((3rd line pharmaceutical treatment))
 Injected progesterone (3rd line pharmaceutical treatment)
AND
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Endometrial ablation has been tried (unless the patient has fibroids >3cm, an abnormal
uterus or other contraindications)
Note: endometrial ablation is suitable for women who do not want to conceive in the future and
should only be offered after full discussion of risks and benefits and other treatment options.
2.
Clinical Guidelines and Care Pathways
Hyperglycaemia in acute coronary syndromes (CG130)
This guidance applies to primary and secondary care
The guideline covers the role of intensive insulin therapy in managing hyperglycaemia within the
first 48 hours in people admitted to hospital. NICE recommendations include:
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Hyperglycaemia should be managed by keeping blood glucose levels below 11.0 mmol/litre
while avoiding hypoglycaemia, which is where blood glucose levels are below normal, usually
less than 4 mmol/litre.
In the first instance healthcare professionals should consider a dose-adjusted insulin infusion
with regular monitoring of blood glucose levels.
Intensive insulin therapy, which is an intravenous infusion of insulin and glucose with or
without potassium, should not be routinely offered to manage hyperglycaemia unless clinically
indicated.
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All patients with hyperglycaemia after ACS and without diabetes should be offered tests for
HbA1c levels before discharge and fasting blood glucose levels no earlier than 4 days after the
onset of ACS.
Healthcare professionals advise patients without known diabetes that they are at risk of
developing type 2 diabetes, if they have had hyperglycaemia after ACS.
Patients who have had hyperglycaemia after ACS without known diabetes should receive
ongoing monitoring and be given lifestyle advice on eating healthily, physical exercise, weight
management, quitting smoking and alcohol consumption.
A number of tools have also been published to help implement the recommendations including
Baseline assessment tool, Clinical audit tool, Costing statement, Electronic audit tool, Slide set
Colorectal cancer (CG131)
This guidance applies to primary and secondary care
The guideline will help health professionals to provide consistent care for patients with colorectal
cancer, supporting patients with the disease and ensuring equal access to services across England
and Wales.
Recommendations emphasise the importance of ensuring patients have all the information they
need, to enable them to make better informed decisions about their care, improving their quality
of life during and after treatment.
Key recommendations cover:
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Diagnostic investigations
Staging of colorectal cancer
Chemotherapy for advanced and metastatic colorectal cancer:
Follow-up after surgery to remove cancer tumours
Information on all treatment options available to patients
NICE have provided a number of tools to help implement the recommendations including Baseline
assessment tool, Case studies, Clinical audit tool, Costing report, Costing template, Electronic audit
tool, Slide set
PRODIGY (formerly CKS)
Is a reliable source of evidence-based information and practical 'know how' about the common
conditions managed in primary care. See new and updated topics, which this month include
diagnosis and treatment of warts and verrucas, dementia and emergency contraception.
3. NICE Technology Appraisals
Osteosarcoma - mifamurtide (TA235)
This guidance applies to primary and secondary care
Mifamurtide in combination with postoperative multi-agent chemotherapy is recommended within
its licensed indication as an option for the treatment of high-grade resectable non-metastatic
osteosarcoma after macroscopically complete surgical resection in children, adolescents and young
adults and when mifamurtide is made available at a reduced cost to the NHS under the patient
access scheme.
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Acute coronary syndromes - ticagrelor (TA236)
This guidance applies to primary and secondary care
Ticagrelor in combination with low-dose aspirin is recommended for up to 12 months as a
treatment option in adults with acute coronary syndromes (ACS) that is, people:
 With ST-segment-elevation myocardial infarction (STEMI) – defined as ST elevation or new left
bundle branch block on electrocardiogram – that cardiologists intend to treat with primary
percutaneous coronary intervention (PCI) or
 With non-ST-segment-elevation myocardial infarction (NSTEMI) or
 Admitted to hospital with unstable angina – defined as ST or T wave changes on
electrocardiogram suggestive of ischaemia plus one of the characteristics defined in section
1.2. Before ticagrelor is continued beyond the initial treatment, the diagnosis of unstable
angina should first be confirmed, ideally by a cardiologist.
Diagnostic Technologies Guidance - relevant to secondary acute care
DTG1 - EOS 2D/3D imaging system
The EOS 2D/3D imaging system is an emerging technology with potentially important clinical
benefits. Current evidence shows there are some patient benefits for people with spinal
deformities in terms of radiation dose reduction and increased throughput. However, those
benefits alone are insufficient to justify the cost of the system. No clinical evidence was available
to quantify the extent of patient benefits from the EOS system's imaging features including 3D
reconstruction, weight-bearing whole-body imaging, and simultaneous posteroanterior (PA) and
lateral imaging. Therefore, the EOS 2D/3D imaging system is not currently recommended for
routine use in the NHS.
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. The October 2011 issue contains several
interesting articles including ‘highlighting the global rise in diabetes’ ‘medical conditions linked to
challenging behaviour’, and ‘Chemotherapy duration for advanced breast cancer’.
NICE Pathways is an online tool that provides quick and easy access, topic by topic, to the range
of guidance from NICE. New pathways recently added that are relevant to primary care include
autism, HIV testing and prevention, immunisation, preventing STIs, preventing type 2 diabetes
and self harm.
Measuring NICE Implementation
NICE’s tips on ways of measuring any necessary changes outlined in NICE guidance.
Ways to influencing the work of NICE
There are a number of ways you can get involved. Details of all NICE consultations can be
accessed here.
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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 from CG119 - Diabetic foot problems inpatient management is:
Rec 1.2.29: Do not use prolonged antibiotic therapy for mild soft tissue infections.
NICE News
The following is a list of recent news items (not exhaustive) from the NICE website:
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Calls to curb unnecessary antibiotic prescribing
Doctors and nurses are being urged to tackle the rise in antibiotic resistance by helping to cut
back on unnecessary use of the drugs.
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Seek early diagnosis of COPD to slow its progress
Charities are urging people to seek an early diagnosis of chronic obstructive pulmonary disease
to slow down progress of the condition.
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Improvement in cancer diagnosis times, following NICE guidance
Bowel, oesophageal and pancreatic cancers have seen the greatest improvement in the time it
takes from when a patient first visits their GP with symptoms to when they are diagnosed with
the disease, research suggests.
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Call for GPs to investigate headache problems
GPs should be given direct access to CT scans to investigate patients who present with
headache for any serious underlying problems, say researchers.
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NICE QOF indicators taken up
GPs will be able to provide better care for smokers and patients with atrial fibrillation,
peripheral arterial disease and osteoporosis, following changes to the quality and outcomes
framework (QOF) for 2012/13.
Editorial team
As always your feedback on the usefulness of this bulletin would be much appreciated.
Dr. Usman Khan, Richmond Borough Team, [email protected]
Tracy Steadman, Croydon Borough Team, [email protected]
Alastair Johnston, Wandsworth Borough Team, [email protected]
Livia Royle, Kingston Borough Team, [email protected]
Jacqueline Lindo, Sutton & Merton Borough Team, [email protected]
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