Releases Saturday 25 August 2001
No 7310 Volume 323

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(1)  FEW WOMEN IN THE UK GET SAFEST TEST
FOR DOWN'S SYNDROME

(2)  DEMENTIA CARE IN RESIDENTIAL HOMES
NEEDS RADICAL IMPROVEMENT

(3)  HEALTH PROMOTION PAYMENTS DON'T
CHANGE GP BEHAVIOUR

(4)  INFORMATION FOR HEART VALVE PATIENTS
MUST IMPROVE

(5)  LOW DOSE TREATMENT FOR PARASITIC
INFECTION IS EFFECTIVE BUT STILL
UNAFFORDABLE

(1)  FEW WOMEN IN THE UK GET SAFEST TEST
FOR DOWN'S SYNDROME

(Screening for Down's syndrome: effects, safety, and
cost effectiveness of first and second trimester
strategies)
http://bmj.com/cgi/content/full/323/7310/423

Most pregnant women in the UK do not receive the
most effective and safest screening tests for Down's
syndrome, yet switching to a better test would not
necessarily cost any more, finds a study in this week's
BMJ.

Gilbert and colleagues compared the effects, safety, and
cost effectiveness of no screening with nine screening
strategies currently available for Down's syndrome in
the UK. Most women are offered the double serum test
in the second trimester of their pregnancy.

They found that moving from the double serum test to
the first trimester combined test or quadruple test would
not cost any more and would detect more fetuses
affected by Down's syndrome. Moving from the double
test to the integrated test (the most effective and safest
test currently available) would result in fewer affected
babies, but would incur additional costs.

The choice of screening strategy should be between the
integrated test, first trimester combined test, quadruple
test, or measurement of nuchal translucency, say the
authors. All other strategies, including the most
commonly used test, are more costly and less effective
than these four options. These findings clearly have
important implications for antenatal practice, they
conclude.

Contact:

Stuart Logan, Senior Lecturer in Epidemiology, Institute
of Child Health, London, UK
 

(2)  DEMENTIA CARE IN RESIDENTIAL HOMES
NEEDS RADICAL IMPROVEMENT

(Quality of care in private sector and NHS facilities for
people with dementia: cross sectional survey)
http://bmj.com/cgi/content/full/323/7310/426

(Editorial: The challenge of looking after people with
dementia)
http://bmj.com/cgi/content/full/323/7310/410

Standards of care given to people with dementia in
residential and nursing homes in the UK needs radical
improvement, concludes a study in this week's BMJ.

The quality of care received by over 200 people with
dementia, living in 10 private sector and seven NHS
care facilities, was rated using a recognised method
known as dementia care mapping.

The dementia care index rated all seven NHS facilities
and five of the private sector facilities as needing radical
improvement. The remaining five private sector facilities
were rated as needing much improvement. No home
showed even a fair standard of care.

Over the six hour daytime period of observation,
residents spent almost 50% of their time either asleep,
socially withdrawn or not actively engaged in any form
of basic or constructive activity. Only 50 minutes (14%)
were spent communicating with staff or other residents,
and less than 12 minutes (3%) were spent engaged in
everyday constructive activities other than watching
television.

These findings clearly show that current care provision
for these vulnerable patients is inadequate and urgent
action is required, say the authors. The proposed
national standards for care in residential and nursing
homes for elderly people describe interaction and daily
activity as one of 11 key domains, and it is these
aspects of care that require particular attention, they
conclude.

Contact:

Robert Howard, Reader in Old Age Psychiatry,
Maudsley Hospital, London, UK
 

(3)  HEALTH PROMOTION PAYMENTS DON'T
CHANGE GP BEHAVIOUR

(Qualitative study of pilot payment aimed at increasing
general practitioners' antismoking advice to smokers)
http://bmj.com/cgi/content/full/323/7310/432

(Intervention study to evaluate pilot health promotion
payment aimed at increasing general practitioners'
antismoking advice to smokers)
http://bmj.com/cgi/content/full/323/7310/435

Paying general practitioners to identify smokers who
have recently stopped does not change their behaviour
and is unlikely to improve smoking cessation rates,
according to research in this week's BMJ. GPs in the
study were also strongly against wider introduction of
payments for health promotion activities.

Thirteen general practices in Leicester agreed to pilot a
new health promotion payment, aimed at increasing
advice on stopping smoking. Practices were paid £15
for identifying a patient who had stopped smoking for at
least three months. Interviews were then conducted
with at least one general practitioner and practice nurse
from each participating practice.

The new pilot health promotion payment did not change
behaviour towards advising patients on stopping
smoking. Payment did not overcome general
practitioners' resistance to raising the issue of smoking
when they felt that it could cause confrontation with
patients. Many were strongly against wider introduction
of payments but were more positive about payments
that rewarded "extra" effort ? for example, setting up
smoking cessation clinics.

These findings show the value of assessing new financial
incentives to general practitioners, say the authors.
Future payments for health promotion should be
carefully piloted and evaluated to determine whether
they alter clinical practice, they conclude.

Contact:

Tim Coleman, Senior Lecturer, Leicester General
Hospital, Leicester, UK
Email:  tjc3{at}le.ac.uk
 

(4)  INFORMATION FOR HEART VALVE PATIENTS
MUST IMPROVE

(Cohort survey of heart valve replacement patients:
does the valve card scheme have room for
improvement?)
http://bmj.com/cgi/content/full/323/7310/429

Patients who have had heart valves replaced should
receive an implant card after their operation. This is to
ensure that any future complications associated with
particular valves can be quickly identified and treated.
But a study in this week's BMJ finds that present
implant card schemes are falling well below acceptable
standards.

Over 1,900 patients who underwent heart valve
replacement in 1998 responded to a questionnaire
about the date of their operation, if they had received an
implant card, and the interval between operation and
card receipt.

Nearly half of the patients had not received an implant
card 12 months after their operation. Furthermore,
patients who had not received the implant card six
months postoperatively were unlikely ever to do so,
add the authors.

This situation could easily be improved by authorising
the heart valve registry to send the implant card to the
patient, say the authors. This would remove the
manufacturer and clinician from the process, would be
cost effective, could be financed through a small charge
per valve implanted, and would contribute to patients
surveillance, they conclude.

Contact:

Maria-Benedicta Edwards, United Kingdon Heart
Valve Registry, Hammersmith Hospital, London, UK
Email:  m.b.edwards{at}ic.ac.uk
 

(5)  LOW DOSE TREATMENT FOR PARASITIC
INFECTION IS EFFECTIVE BUT STILL
UNAFFORDABLE

(Treatment of Indian visceral leishmaniasis with single or
daily infusions of low dose liposomal amphotericin B:
small randomised trial)
http://bmj.com/cgi/content/full/323/7310/419

(Commentary: cost and resistance remain issues)
http://bmj.com/cgi/content/full/323/7310/419

Half the world's cases of a serious parasitic infection
(visceral leishmaniasis) occur in India, but effective
drugs remain prohibitively expensive. Yet researchers in
this week's BMJ find that a short course, low dose
treatment is effective and could make the drug more
affordable.

Ninety-one patients in Bihar, India, with symptoms of
the disease received a low dose drug either as a single
infusion or as once daily infusions for five consecutive
days. Patients were examined daily until 14 days after
the last infusion and monitored for six months after
treatment.

The treatment cured 92% of patients at a cost of $519
per patient. This is more affordable than current
treatment but still too high, say the authors. If proved
effective in larger trials, drug companies will have to cut
prices for the potential benefits to be realised, they
conclude.

This is good but tantalising news for patients, many of
whom are landless peasants, writes Diana Lockwood in
an accompanying commentary. This treatment remains
an extremely expensive drug that no patient or health
service in the developing world is ever going to be able
to buy, and there are no patient activists to pressurise
the manufacturer into providing the drug at an
affordable price, she concludes.

Contacts:

[Paper]: Professor Shyam Sundar, Kala-Azar Medical
Research Centre, Banaras Hindu University, India
Email:  shyams_vns{at}satyam.net.in

[Commentary]: Diana Lockwood, Consultant
Physician, Hospital for Tropical Diseases, London, UK
Email:  Diana.Lockwood{at}lshtm.ac.uk

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