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Press releases Saturday 12 November 2005
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(1) Risks of taking sedatives for insomnia in older people may be greater than the benefits
(2) Research to improve trauma patient care neglected
(3) Government plans for NHS more aggressive than Tories ever were
(4) Complete smoking ban leads to marked rise in smoking cessation efforts
(5) Poorest countries well behind global health goals agreed years ago
BMJ Online First
(1) Risks of taking sedatives for insomnia in older people may be greater than the benefits
(Sedative hypnotics in older people: meta-analysis of risks and benefits)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.38623.768588.47
For older people, the risks outweigh the benefits of taking sleeping pills and other sedatives, say researchers in this week±s BMJ.
Insomnia can often affect the quality of life for older people and between 5% and 33% of older people in the UK are prescribed sleeping pills such as benzodiazepine.
But in an analysis of 24 studies carried out between 1966 and 2003, researchers found that the adverse results for older people taking sedatives ± such as dizziness, loss of balance, falls, and disorientation ± were statistically significant enough to make them think non-drug treatments could be a better approach to tackling insomnia.
The 24 studies included 2,417 participants in total and looked at the effects of sedative hypnotics (sedatives), including over the counter medications such as antihistamines, and prescription only drugs like benzodiazepine. Research only included cases where people who were 60 and above had been taking them for five consecutive nights, compared to people taking placebos.
Effects such as dizziness or loss of balance ± psychomotor-type side-effects ± were reported in 13 studies (1,016 participants). Seven of the 59 psychomotor effects that were reported in these studies were serious events ± six falls and one car crash.
But the researchers also found there were many potential benefits for people taking sedatives such as improved quality of sleep (more sound uninterrupted sleep), ease of getting to sleep and total sleep time.
On balance however, they argue that although treatment with sedative hypnotics improves aspects of sleep, the risk of adverse effects rises with such treatment. There are also indicators that older patients are more than twice as likely to experience an adverse event as they are to gain a better quality of sleep from such sedatives. But they stress that this comparison is only a rough indicator because more studies contributed information on harmful events than on sleep benefits.
Improvements in sleep with sedative use are statistically significant, but the size of the effect is small, say the authors. ±In people over 60, the benefits of these drugs may not justify the increased risk,± they conclude.
Contact:
Usoa Busto, Head of Clinical Neuroscience, Centre for Addiction and Mental Health, Toronto, Canada. e-mail:
usoa_busto@camh.net
(2) Research to improve trauma patient care neglected
(Trauma care research and the war on uncertainty)
http://bmj.com/cgi/content/full/331/7525/1094
The ability to improve outcomes and treatment for trauma patients is seriously hampered by a ±dearth of clinical trials±, according to an editorial in this week±s BMJ.
More than 10,000 people die every day, world-wide, and 300,000 people are severely injured daily ± mostly from road traffic crashes and violence.
Trauma doctors, writing in this week±s BMJ, argue that there is an urgent need to improve the evidence base for trauma care, something that remains a major challenge to health professionals.
Compared with diseases, there are far fewer clinical trials into trauma, they argue, and those in existence are small which means their findings do not contribute much to certain improvements.
The first large scale clinical trials in trauma care carried out by the UK±s Medical Research Council found that a treatment that had been used for more than 30 years did more harm than good.
The main problem, the doctors argue, is that: ±Funding for trauma research is less than for almost any other cause of human suffering.±
Another obstacle is that clinical trials take place in an emergency situation with unconscious patients who are unable to give informed consent. Few countries have legislation in place to handle these situations.
Until there are more international trials into trauma care, these patients are being unfairly denied the benefits of medical research.
Contact:
Ian Roberts, Professor of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK e-mail:
ian.roberts@lshtm.ac.uk
(3) Government plans for NHS more aggressive than Tories ever were
The NHS Revolution: Health care in the market place
http://bmj.com/cgi/content/full/331/7525/1141
The Government±s use of private health care in the NHS is a much more open and aggressive version of the ±internal market± tried by the Conservatives in the 1990s, says an article in this week±s BMJ - the first of a series examining NHS reforms.
Initiatives like ±payment by results±, foundation hospitals, and the ±deliberate injection± of independent sector treatment centres (ISTCs) and other private sector services all create a sophisticated ±supplier market± in UK health care, says the author.
The escalating use of the private sector stems from the NHS Plan in 2000, when the Government pledged to reduce waiting times, but realised that the NHS was too short of doctors and facilities.
The NHS already paid for extra capacity from private healthcare on an ad hoc basis, usually to meet year-end targets. But at prices sometimes 40% higher than the average NHS cost for each operation, Health Secretary Alan Milburn was keen to find a more cost-effective system, says the author.
Independent sector treatment centres, derived from fast-track surgery units in the US and staffed from overseas to avoid draining the NHS, were his answer.
The reforms have proved unpopular with the wider Labour party, but successive health ministers have pursued the policies, says the author. Within a few years, for instance, ISTCs will perform 500,000 operations - providing the private sector with more than ±1bn worth of business annually.
The most important of the reforms is ±payment by results±, says the author, which underpins all others since it fixes a rate for treatment based on average NHS costs. Critics say that ISTCs are not good value for money, as they are paid at the national tariff per case but mainly perform simpler - and below average cost - procedures. The NHS is left with more difficult and costly cases, but only paid the average rate.
Private sector providers have to date also been given guaranteed volumes of patients from NHS managers, while NHS treatment centres are not allowed to ±compete± for patients. One result is that NHS units have been running half empty say critics - and thus losing money, adds the author.
Current reforms in the NHS represent nothing short of ±the biggest revolution±since its foundation in 1948,± says the author. Many fear they will result in the destabilising, and eventual closure of hospitals, he concludes.
Contact:
Nick Timmins, Public Policy Editor, The Financial Times, London, UK email:
nick.timmins@ft.com
(4) Complete smoking ban leads to marked rise in smoking cessation efforts
(Total smoking ban is accepted in New Zealand)
http://bmj.com/cgi/content/full/331/7525/1145
The public has made significantly more enquiries to a national Quitline for smokers, and demand for nicotine replacement treatment
vouchers has increased, following a total ban on smoking in indoor public places in New Zealand, according to a letter in
this week±s BMJ.
Nick Wilson, a senior lecturer in public health in New Zealand, writes that the complete ban in his country since December 2004 has been well accepted by the public, and smoking cessation services became busier when the ban was introduced.
Speaking of the UK±s approach on this issue, he writes: ±Having only a partial ban on smoking in public places is seriously inadequate in terms of protecting the public health from second-hand smoke.±
Contact:
Nick Wilson, Senior Lecturer in Public Health, Wellington School of Medicine, Otago University, Wellington, New Zealand email:
nwilson@actrix.gen.nz
(5) Poorest countries well behind global health goals agreed years ago
(Cluster of papers - Achieving the Millennium Development Goals for Health)
http://bmj.bmjjournals.com/onlinefirst_date.dtl
Despite a world strategy for health agreed five years ago, most of the poorest countries on earth are lagging far behind achieving it, say a series of papers published on BMJ.com today (11/11/05).
If these countries are to make meaningful progress on the strategy aims - the Millennium Development Goals - most will have to raise funds or be forced to reallocate monies from other programmes, argue the authors, all experts from the World Health Organisation.
The Millennium Development Goals were agreed between 189 of the world±s major western nations and much of the developing world. Those specifically on health were designed to take action on five key fronts: reducing mother and infant deaths, tackling child poverty, preventing the spread of HIV/AIDS, and controlling malaria and tuberculosis.
Current approaches must change if the goals are to be achieved more quickly. In curbing the spread of HIV/AIDS, treatment with first-line antiretrovirals has now become at least as cost effective as some of the well known preventive interventions, such as voluntary counselling and testing, say the authors. Educating sex workers, mass media messages, and treating people for other sexually transmitted infections, should also be the focus of new campaigns.
Mothers and newborns must have both basic and emergency medical services as a priority, and all children should get measles immunisation and micronutrients as a matter of course, say the authors.
The fight against malaria demands a much larger injection of resources than currently available, and substantial investment is also needed to meet targets on reducing tuberculosis, they argue.
The papers, which examine the cost-effectiveness of health policies in Africa and South-East Asia, preview a two-day Paris summit next week (14-15 November 2005) to look at why the Millennium Development Goals have not been met.
Both Africa and South-East Asia have such a huge degree of need, and so many underused interventions, that it is difficult to redeploy resources currently being spent on achieving the goals. But policy should shift to escalating the most cost-effective activities, say the authors.
±These results represent the best evidence currently available. We hope that this series contributes to not only improving population health with the available resources, but to raising more funds for health as well,± they conclude.
Contact:
Judith Mandelbaum-Schmid, Communications Officer, World Health Organization, Geneva, Switzerland email:
schmidj@who.int
Plus -
Editorial: Are cost effective interventions enough to achieve the Millennium Development Goals?
http://bmj.com/cgi/content/full/331/7525/1093
An accompanying editorial says that, in addition to better implementation of cost-effective health interventions, three key challenges must be addressed if the Millennium Development Goals are to be met.
Finance issues must be resolved, say the authors. Many developing countries are way behind target on allocating 15% of public funds to healthcare. And only the Scandanavian countries have met the donor nations± goal to give 0.7% of gross national product to official development assistance.
If improvements are to be sustainable they must be backed by local stability and growth, as well as adequate local resources, say the authors. Thailand for instance has redeployed 30% of its national budget since 1985 to social (including health) development - and away from national security and public debt.
Fairer international trade policies are also important. High farming subsidies in developed nations have meant much lower economic growth in less developed countries, particularly among poor farmers.
The second challenge is rethinking how financial aid is allocated. Too much global aid is earmarked for certain programmes, which can distort an individual country±s healthcare priorities. As a result health workers are shifted from badly funded but important programmes to support better paid global initiatives.
International migration of health workers exacerbates matters, say the authors. Nine of the 20 countries with the highest emigration rates are in sub-Saharan Africa - where the Millennium Development Goals are least likely to be reached.
The third challenge is to get accurate information on what is being achieved, so that policy makers can monitor progress towards the goals.
If the Millennium Development Goals are not to end up just another unfinished programme, these three areas, together with cost-effective measures, must be addressed.
Contact:
Suwit Wibulpolprasert, Senior Advisor on Health Economics, Ministry of Public Health, Nonthaburi, Thailand email:
suwit@health.moph.go.th
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