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Press releases Saturday 2 February 2005
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(1) GOVERNMENT APPROACH TO CUTTING HOSPITAL STAYS MAY BE MISLEADING
(2) GUIDELINES RESTRICTING ENDOSCOPY REFERRALS PUT PATIENTS AT RISK
(3) LEAST PROTECTION OFFERED TO THOSE MOST AT RISK OF SUDDEN CARDIAC DEATH
(4) DOCTORS NEED TO PREPARE FOR BLOOD SHORTAGES NOW
(5) BEST TREATMENT
FOR MILD OR MODERATE DEPRESSION UNCLEAR
(1) GOVERNMENT APPROACH TO CUTTING HOSPITAL STAYS MAY BE MISLEADING
(Follow up of people aged
65 with a history of emergency admissions: analysis of routine admission
data)
http://bmj.com/cgi/content/full/330/7486/289
(Editorial: Identifying people
at high risk of emergency hospital admission)
http://bmj.com/cgi/content/full/330/7486/266
Government plans to use community matrons to help keep older people out of hospital may be based on misleading data, warn researchers in this week’s BMJ.
The new plans aim to cut hospital stays by tracking admission rates among older patients and then using specially trained nurses to care for them at home. But Martin Roland and colleagues show that this approach could be seriously misleading because admissions would probably decline anyway, without intervention.
To test their theory, they tracked emergency admissions in people aged 65 or more who had had at least two emergency visits to hospital in one year. This is the main criterion for admission to the Evercare programme* (which the authors are also evaluating) and one of the criteria being used to identify patients for enrolment in the NHS community matron scheme.
This ‘high risk’ group was monitored from 1997-8 to 2002-3 and compared with the general population of the same age.
They found a sharp decrease in total admissions and bed days over the five year period. The 65 to 74 age group had an admission rate 20 times greater than the general population of the same age in 1997-8, but this ratio fell to 5.2 in 1998-9 and by 2002-3 it was 1.7.
The entire group, comprising 2.9% of the total population of England aged over 65 in mid 1997, accounted for 38% of emergency admissions in 1997-8 but only 3.2% in 2002-3.
The authors say that further research to refine the definition of ‘high risk’ groups for interventions to reduce admissions is needed, and they warn that the effectiveness of admission avoidance schemes cannot be judged by tracking admission rates without careful comparison with a control group.
“When evaluating case management by community matrons, methods and outcome measures will need to be chosen with care to ensure that the true effect of this initiative on emergency admissions is measured,” adds Professor Jill Morrison in an accompanying editorial.
She believes that the wider impact of the plan to transfer 3000 experienced district nurses or other health professionals from their current roles to undertake this new role should also be considered because this might leave gaps in the delivery of other community based services.
Contacts:
Paper: Martin Roland, Director,
National Primary Care Research and Development Centre, University of Manchester,
UK
Email: m.roland@man.ac.uk
Editorial: Jill Morrison, Professor
of General Practice, Division of Community Based Sciences, University of
Glasgow, UK
Email: jmm4y@clinmed.gla.ac.uk
*Evercare is a model of care for
frail elderly people that combines nurse-led care and case-management as
a way of reducing the number of unplanned emergency admissions. It is administered
by the American firm United Health Group.
(2) GUIDELINES RESTRICTING ENDOSCOPY REFERRALS PUT PATIENTS AT RISK
(Letter: Upper gastrointestinal
surgeons comment on NICE dyspepsia guidelines)
http://bmj.com/cgi/content/full/330/7486/308
New guidelines restricting GPs from referring patients for endoscopy - a hospital procedure to check for cancer of the gullet or stomach - put patients at risk, says a letter in this week’s BMJ.
The guidelines, from the National Institute for Clinical Excellence, say that GPs should only refer patients suffering severe indigestion (dyspepsia) if they are showing “alarm symptoms”.
Instead, say the guidelines, patients without alarm symptoms are to be treated with antisecretory drugs or other measures.
But senior gastrointestinal specialists say that if patients are only referred once alarm symptoms are present, cancer may already be at an advanced stage - and too late for surgery.
Professor Michael Griffin, head of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, says that the guidelines are poorly researched and unsubstantiated. Though they mention poor outcomes for gastrointestinal (stomach and gullet) cancer sufferers in the UK, for instance, the guidelines ignore better results for patients in Japan and other Western countries - where a higher proportion of early gastric cancers are diagnosed.
The guidelines also undervalue endoscopy for diagnosing other serious and painful problems - such as inflammation of the gullet, or ulcers.
Until the evidence on endoscopy is properly assessed, GPs should continue to refer patients with continued severe indigestion for endoscopy, argue the authors.
Contacts:
Michael Griffin, President, Association
of Upper Gastrointestinal Surgeons of Great Britain and Ireland, London,
UK Via: Fiona Wilson,
Email: michael.griffin@nuth.nhs.uk
or
William Allum, National Clinical
Lead, Gastrointestinal Cancer Services Improvement Partnership, Royal Marsden
Hospital, London, UK Via: Debbie Newman,
Email: william.allum@rmh.nhs.uk
(3) LEAST PROTECTION OFFERED TO THOSE MOST AT RISK OF SUDDEN CARDIAC DEATH
Online First
(Inequity of use of implantable cardioverter defibrillators in England:
retrospective analysis)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38337.635648.82
Those most at risk of dying from sudden cardiac death in England are offered the least protection from available preventative measures, say researchers on bmj.com this week.
Implantable cardioverter defibrillators (ICDs), a type of pacemaker inserted into the heart, can prevent sudden cardiac deaths. Yet in those regions with the highest death rates from heart disease, rates of ICD use are conversely the lowest.
100,000 people die each year from sudden cardiac death in the UK. Most of these deaths occur when the heart’s rhythm suddenly goes out of sync, causing the heart to stop. But an ‘inverse care law’ is effectively in operation in England, say the report’s authors, with areas with those most at risk given the least amount of effective treatment.
The West Midlands, North West and South West were worst off, with the highest proportion of heart disease sufferers but the lowest ICD implantation rates across England.
The study looked at ICD use over five years from 1998 to 2002. Though implantation rose approximately 250% over that time, England still lags behind other European countries and the US.
Researchers also surveyed three quarters of ICD implantation centres in England to find out why eligible patients are being denied the treatment. They found three main explanations - overall funding issues, a lack of staff to perform the procedures, and that eligible patients are not being identified or referred.
All of the centres also expected to see increasing demands for ICDs in the future. Better planning and greater resourcing of ICD centres are needed to address the inequality in healthcare highlighted in this study, the authors conclude.
Contact:
Julie Parkes, MRC Clinical Training
Fellow, Health Care Research Unit, University of Southampton, UK
Email: jules@soton.ac.uk
(4) DOCTORS NEED TO PREPARE FOR BLOOD SHORTAGES NOW
(Editorial: Changes in blood
supplies, regulations, and transfusion practice)
http://bmj.com/cgi/content/full/330/7486/268
Doctors need to prepare for shortages in the supply of blood for transfusion, warns an expert in this week’s BMJ.
Dr Adrian Copplestone outlines how changes that might reduce the supply of blood are afoot and are going to affect all clinicians who use blood and blood products.
Restrictions following a second possible case of variant Creutzfeldt-Jakob disease (vCJD) transmitted by transfusion have reduced the number of donors, writes the author. This comes on top of a general trend of falling number of donors.
The Department of Health has also recently circulated a plan in case blood supplies run low. It suggests that hospitals need to reduce the stock of blood they hold and use blood more effectively. For instance, elective operations with more than a 20% chance of requiring blood are the first to be cancelled.
Reducing transfusion errors is also an important step, although this a major undertaking in large hospitals, he adds.
New regulations surrounding transfusion practice are on the way and will need to be incorporated in UK law by February 2005, says the author. “We need to act now to decrease our dependence or we will be faced with deciding which patient is going to get the remaining bag of blood in the fridge,” he concludes.
Contact:
Adrian Copplestone, Consultant Haematologist,
Derriford Hospital, Plymouth, UK
Email: adrian.copplestone@phnt.swest.nhs.uk
(5) BEST TREATMENT FOR MILD OR MODERATE DEPRESSION UNCLEAR
(Editorial: NICE guidelines
for the management of depression)
http://bmj.com/cgi/content/full/330/7486/267
Guidelines for the management of mild or moderate depression are unclear because firm evidence is lacking, claim doctors in this week's BMJ.
The National Institute for Clinical Excellence (NICE) provides clear guidance on the treatment of moderate to severe depression, but what is less clear is the appropriate treatment for mild to moderate depression, write Gene Feder and colleagues.
They say that the study on which the guidelines are based identifies evidence supporting problem solving therapies and counselling, but evidence on other interventions is weak or absent.
Although these shortcomings are acknowledged, the guidelines offer limited advice on how to determine whether or not a particular patient may benefit from treatment, they add.
They suggest that we need a better understanding of the interaction that occurs when individuals seek medical help for an emotional problem. "This medicalisation of unhappiness would benefit from sociological as well as clinical research," they conclude.
Contact:
Gene Feder, Professor of Primary
Care Research and Development, Barts and the London, Queen Mary's School
of Medicine and Dentistry, London, UK
Email: g.s.feder@qmul.ac.uk
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