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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 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 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 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) Page 1 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: 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: Page 2 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 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 Page 3 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 Page 4 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] Page 5