Download SWL CE Bulletin Issue 18 Aug-Sept 2012

Primary Care Clinical Effectiveness Bulletin
Edition No. 18: August & September 2012
Welcome to your South West London digest of
best practice relevant to primary care. This
information is collated each month from
national and local sources, with hyperlinks to
the more detailed guidance within each
section – simply [control + click] within the
sections to follow the links to websites.
across the cluster. This months featured
criteria are from the current 2012/13 ECI list.
Insertion of Grommets (ventilation
tubes)
These criteria apply to children aged under 12
years only. The PCT will fund treatment with
grommets for children with persistent otitis
media with effusion (OME) where:
Contents (Ctrl+Click to go straight to section)
1. South West London Effective
Commissioning Initiative (SWLECI)

Persistent bilateral OME has been
documented over a period of 3 months with a
hearing level in the better ear of 25–30 dBHL
or worse averaged at 0.5, 1, 2 and 4 kHz (or
equivalent dBA where dBHL not available).
Insertion of grommets
2. Local Guidance
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simvastatin prescribing recommendations
following revised safety advice
Guidance on the use of rivaroxoban for
stroke prevention in AF
OR
3. NICE Clinical & Public Health
Guidelines
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Persistent bilateral OME with a hearing loss
less than 25–30 dBHL where the impact of
the hearing loss on a child’s developmental,
social or educational status is judged to be
significant
Osteoporosis fragility fracture
Lower limb peripheral arterial disease
Urinary incontinence in neurological
disease
Antibiotics for early-onset neonatal
infection
Headaches
Neutropenic sepsis
Smokeless tobacco cessation - South Asian
communities
In children with additional disabilities such as
Down’s Syndrome or cleft palate, involvement
of a multidisciplinary team with expertise in
assessing and treating OME in these children is
essential.
4. NICE Technology Appraisals and IPGs
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2. Local Guidance
Bevacizumab for breast cancer
Alteplase for stoke
Wandsworth
Clinical
Effectiveness
and
Medicines Management Group (CEMMaG) has
approved the following guidance:
 simvastatin prescribing recommendations
5. Other news

1. South West London Effective
Commissioning Initiative (ECI)
following revised safety advice
Guidance on the use of rivaroxoban for stroke
prevention in Atrial Fibrilation
Click on the Hyperlinks above to access this
guidance via the SW London Public Health and
the South London Cardiac and Stroke Network
websites respectively.
The SW London Effective Commissioning
Initiative (ECI), is driven by the need to
ensure that NHS funded treatments are
effective, evidence-based, provide value for
money, and that access to them is equitable
3. NICE Clinical Guidelines
Osteoporosis fragility fracture (CG146)
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Primary Care Clinical Effectiveness Bulletin
Edition No. 18: August & September 2012
Each year in the UK over 300,000 people are
seen in hospital because of fragility fractures.
Recommendations in the short clinical
guideline include:
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Estimate absolute risk when assessing risk
of fracture
Use either FRAX (without a bone mineral
density [BMD] measurement) or
QFracture, within their allowed age
ranges, to estimate 10-year predicted
absolute fracture
Interpret the estimated absolute risk of
fracture in people aged over 80 years with
caution
Do not routinely measure BMD to assess
fracture risk without prior assessment
using FRAX (without a BMD value) or
QFracture
Measure BMD to assess fracture risk in
people aged under 40 years who have a
major risk factor
further imaging (after duplex ultrasound)
before considering revascularisation.
Offer a supervised exercise programme to
all people with intermittent claudication.
Urinary incontinence in neurological
disease (CG148)
Detailed assessments should be offered to
people who have neurological conditions like
stroke, multiple sclerosis and head and spinal
cord injuries, and who experience incontinence
or other urinary problems. This should include
obtaining information about their urinary tract
and neurological symptoms, other health
problems (e.g. bowel or sexual problems), and
their use of medications and therapies.
Other factors should be assessed such as
mobility, hand function, cognitive function,
social support and lifestyle in order to inform
how their patient's urinary problem should
eventually be managed.
Assessments should take place at intervals
dictated by the person's individual
circumstances but should happen at least
every three years.
Lower limb peripheral arterial disease
(CG147)
Peripheral arterial disease is a common
condition, affecting 3% to 7% of people in the
general population and 20% of people over
the age of 60. Key priorities for
implementation identified in the guideline
include:
 Offer all people with peripheral arterial
disease information, advice, support and
treatment regarding the secondary
prevention of cardiovascular disease.
Advice could include smoking cessation,
diet and exercise, diabetes and high blood
pressure
 Assess people by asking about the
presence and severity of possible
symptoms of intermittent claudication and
critical limb ischaemia, examining the legs
and feet and femoral, popliteal and foot
pulses, measuring the ankle brachial
pressure index
 Offer contrast-enhanced magnetic
resonance angiography for people with
peripheral arterial disease who need
Antibiotics for early-onset neonatal
infection (CG149)
The guidance recommends that the NHS
needs to prioritise the treatment of sick babies
and use antibiotics appropriately to avoid the
development of bacterial resistance to
antibiotics.
Early-onset neonatal bacterial infection is the
cause of death for 1 in 4 babies who develop
it, even when they are given antibiotics. Such
infections may develop suddenly and rapidly,
with mortality particularly high in premature
babies and those with a low birth weight. They
may also lead to the development of cortical
lesions in the brain, and so subsequently
cause neuro-developmental delay.
Recommendations include:
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Using a framework based on risk factors
and clinical indicators to identify and treat
Primary Care Clinical Effectiveness Bulletin
Edition No. 18: August & September 2012
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babies with an increased likelihood of
having an early-onset neonatal infection.
Offering intrapartum antibiotic prophylaxis
in a timely manner to women whose
babies are at higher risk of infection.
Ensure babies with suspected infection
receive antibiotics within 1 hour of the
decision to treat.
Benzylpenicillin and gentamicin should be
used in combination as the first-choice
antibiotic regimen
Perform a blood culture before
administering the first dose.
years from around 300 in 2001 to around 700
in 2011. Neutropenic sepsis is also the second
most common reason for hospital admission
among children and young people with cancer,
with approximately 4000 episodes occurring
annually in the UK. Key priorities include:
 Treat suspected neutropenic sepsis as an
acute medical emergency and offer
antibiotic therapy immediately.
 Diagnose neutropenic sepsis in patients
having anti-cancer treatment whose
neutrophil count is equal to or lower than
0.5 x 109/litre and who have either:
a temperature higher than 38oC or
other signs or symptoms consistent
with clinically significant sepsis.
 Provide patients undergoing anti-cancer
treatment and carers with written and oral
information before starting and throughout
treatment on:
neutropenic sepsis
how and when to contact 24-hour
specialist oncology advice
how and when to seek emergency
care.
Headaches (CG150)
This guideline covers the diagnosis and
management of tension-type headache,
migraine (including migraine with aura and
menstrual-related migraine), cluster headache
and medication overuse headache in young
people (aged 12 years and older) and adults.
It advises consideration of the possibility of
“medication overuse” in patients taking
medicines for up to half of the days in a
month, over three months.

More than 10 million people in the UK
experience regular or frequent headaches,
making them one of the most common health
complaints. They account for around 1 in 25 of
GP consultations. It has been estimated that
up to 1 in 50 people experience headaches
caused by medication overuse and that
women are five times more likely to get them
than men. They occur when people take
painkillers or triptan drugs too often for
tension-type (“every day”) headaches or
migraine attacks. Doing this can reduce their
effectiveness and cause further pain.
A healthcare professional with competence
in managing complications of anti-cancer
treatment should assess the patient's risk
of septic complications within 24 hours of
presentation to secondary or tertiary care,
basing the risk assessment on
presentation features and using a
validated risk scoring system
Smokeless tobacco cessation - South
Asian communities (PH39)
The guidance covers support for people in
South Asian communities on stopping the use
of smokeless tobacco products, such as Paan,
Gutka, Shupari, and Betel Quid. Contrary to
perceptions that these types of products are
healthy or beneficial, they are in fact
associated with serious health problems such
as oral cancer, serious dental problems, heart
attack and stroke, and problems in pregnancy.
It's thought that using these products is one of
the main reasons why South Asian women are
nearly four times more likely to develop oral
Neutropenic sepsis (CG151)
This guideline covers the prevention,
identification and management of neutropenic
sepsis in patients having anticancer treatment.
It has been estimated that the total number of
deaths from neutropenic sepsis in England and
Wales has more than doubled over the last 10
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Primary Care Clinical Effectiveness Bulletin
Edition No. 18: August & September 2012
cancers than women from other ethnic groups
in England. Use is often highest among older
women of South Asian descent, but in some
parts of the UK, a high percentage of young
South Asians also. Recommendations include:
 In areas of identified need, commissioning
a range of services to help South Asian
people stop using smokeless tobacco,
ensuring services are coordinated and as
part of a comprehensive local tobacco
control strategy
 Ensuring that any materials on smokeless
tobacco cessation: refer to the products
using the names people use locally;
provide information about the risks
associated with smokeless tobacco and the
availability of services to help people quit;
and challenge the perceived benefits of
smokeless tobacco
 Ensuring that training for health, dental
health and allied professionals (e.g.
community pharmacists) covers: the
health risks associated with smokeless
tobacco and the local names used for
smokeless tobacco products and
recognition of the signs of smokeless
tobacco use.
 All health professionals should be trained
to provide brief advice and referral to
tobacco cessation services, including
recording the response to any attempts to
encourage or help people to stop using
smokeless tobacco in their patient notes
(as well as recording whether they
smoke).
1.2
Stroke (acute, ischaemic) - alteplase
(TA264)
Alteplase is recommended within its marketing
authorisation for treating acute ischaemic
stroke in adults if:
 treatment is started as early as
possible within 4.5 hours of onset of
stroke symptoms, and
 intracranial haemorrhage has been
excluded by appropriate imaging
techniques.
For other NICE publications please click
on titles below:
Interventional Procedure Guidance
Diagnostic Guidance
Medical Technologies Guidance
Quality Standards
5. Other News
End blacklisting of NICE-approved drugs
All NHS information which sets out which NICE
technology appraisals are included in their
local formularies from April 2013, the
Department of Health has announced
organisations should publish. Primary care
trust clusters and clinical commissioning
groups will be expected to take the lead on
this work and should ensure that the data on
local formularies are made available as part of
standard terms and conditions in NHS
contracts.
4. NICE TAs and IPGs
Bevacizumab in combination with
capecitabine for the first-line treatment
of metastatic breast cancer (TA263)
1.1
part of adjuvant treatment within the
past 12 months.
People currently receiving bevacizumab
in combination with capecitabine that is
not recommended according to 1.1
should have the option to continue
treatment until they and their clinician
consider it appropriate to stop.
Bevacizumab in combination with
capecitabine is not recommended within
its marketing authorisation for the firstline treatment of metastatic breast
cancer, that is, when treatment with
other chemotherapy options including
taxanes or anthracyclines is not
considered appropriate, or when taxanes
or anthracyclines have been used as
Rheumatoid arthritis in QOF 2013/14
menu
Rheumatoid arthritis could be added to the
Quality and Outcomes Framework (QOF) for
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Primary Care Clinical Effectiveness Bulletin
Edition No. 18: August & September 2012
the first time, as NICE unveils potential
indicators for 2013/14. NICE has
recommended four new indicators on
rheumatoid arthritis (RA) which cover practices
producing a register of all patients aged 16
years and over with RA, and patients with RA
being assessed for cardiovascular risk and
fracture risk.
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
’Eyes on Evidence’ (NHS Evidence)
This monthly newsletter covers major new
evidence as it emerges, with an explanation
about what it means for current practice.
First Commissioning Outcomes
Framework indicators revealed
New Evidence Updates on NICE guidance
Guidance is continually under review in the
light of new scientific evidence. Recent
evidence updates have included Generalised
anxiety disorders in adults.
Care for those recovering from stroke, tackling
diabetes, and improving maternal health are
among topics covered in the first set of
Commissioning Outcomes Framework (COF)
indicators published by NICE. A set of 44
indicators recommended by the COF Advisory
Committee and are now published. A selection
of final indicators will be considered by the
NHS Commissioning Board in autumn 2012 for
inclusion in the 2013/14 COF.
Practical support for general practice
NICE provide a collection of resources to
enable general practice professionals to
improve outcomes for their patients by
ensuring that their practice is up to date with
current recommendations from NICE on
clinical practice, public health, social care and
support for GP led commissioning.
NICE Pathways - the fast and easy way
to access NICE guidance and products
NICE Pathways brings together - for the first
time - all related NICE guidance and
associated products in a set of interactive
topic-based flowcharts. A total of 75 pathways
have been produced so far and can be
browsed A to Z or by topic.
Editorial team
Thank you to those who have fed back on the
usefulness of this bulletin and made
suggestions for improvement. All comments
are helpful to continually improve it. Contact
details for your borough leads are:
BNF Apps
Health and social care professionals in England
can now download for free The NICE British
National Formulary (BNF) and NICE British
National Formulary for Children (BNFC) apps
for smart phones and tablets
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, S&M Borough Team,
[email protected]
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