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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 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] SW London Primary Care Clinical Effectiveness Bulletin 10th Edition Oct 11 FINAL Page 1 of 5 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 o 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 o 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: 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. SW London Primary Care Clinical Effectiveness Bulletin 10th Edition Oct 11 FINAL Page 2 of 5 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: 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. SW London Primary Care Clinical Effectiveness Bulletin 10th Edition Oct 11 FINAL Page 3 of 5 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. SW London Primary Care Clinical Effectiveness Bulletin 10th Edition Oct 11 FINAL Page 4 of 5 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: o 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. o 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. o 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. o 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. o 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] SW London Primary Care Clinical Effectiveness Bulletin 10th Edition Oct 11 FINAL Page 5 of 5