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Press releases Saturday 18 November 2006
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(1) OCCUPATIONAL THERAPY IMPROVES QUALITY OF LIFE FOR DEMENTIA PATIENTS AND THEIR CARERS
(2) NEW AGREEMENT QUESTIONS NHS RELATION WITH INDUSTRY
(4) CASE MANAGEMENT DOES NOT REDUCE HOSPITAL ADMISSIONS OR MORTALITY RATES
(1) OCCUPATIONAL THERAPY IMPROVES QUALITY OF LIFE FOR
DEMENTIA PATIENTS AND THEIR CARERS
Online First
(Community occupational therapy for patients with dementia and their
caregivers: a randomised controlled trial)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.39001.688843.BE
Occupational therapy can help to improve the ability of people with dementia patients to perform daily activities and can also reduce the pressure on their caregivers, says a BMJ study published today.
Dementia can have far reaching effects for patients and their caregivers and is a major driver of costs for both health and social care systems across the developed world. The most significant problems associated with dementia are the losses in independence, initiative and participation in social activities – factors which affect the quality of life for both patients and their caregivers and families.
Previous research had suggested that non-pharmalogical treatment could have the same or better effects that drug treatment for people with dementia.
Researchers from The Netherlands set out to measure the effect of occupational therapy on people with dementia and their main carer. A group of 135 patients with mild to moderate dementia and their caregivers were randomly split into two groups. The first group received 10 home-based sessions of occupational therapy - provided by an experienced occupational therapist - over a period of five weeks, whilst the second group received no occupational therapy. The groups were then assessed six weeks and 12 weeks after the therapy sessions.
At both six weeks and three months the patients who received occupational therapy functioned significantly better in daily life than those who did not – with 75% of those in the group showing an improvement in motor skills and 82% needing less assistance in day to day tasks. Primary caregivers who received occupational therapy also felt significantly more competent than those who did not.
The authors suggest that occupational therapy is likely to be more effective than drugs or other psychosocial interventions – as the levels of improvement in their trial outstrip the effects recorded in previous trials of drugs and other interventions.
They add that they ‘strongly advocate’ the inclusion of occupational therapy in dementia management programmes; ‘the clinical gains…obtained with occupational therapy for both patients and their caregivers underlines the importance of adequate diagnosis and pro-active management in dementia’ they conclude.
Contact:
Maud Graff, Scientific Researcher,
Research Group for Allied Health Care, Department of Allied Health Care Disciplines,
Occupational Therapy, University Medical Center Nijmegen, Netherlands
Email: m.graff@ergo.umcn.nl
(2) NEW AGREEMENT QUESTIONS NHS RELATION WITH INDUSTRY
Online First
(Editorial: A model clinical trials agreement)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.39030.418229.BE
The Department of Health’s new clinical trials agreement raises questions about the NHS’s relation with the drug industry, says an editorial published on bmj.com today.
Following the tragedy of the TGN1412 trial, the Department of Health announced last month that a model clinical trials agreement has been finalised. This provides a template that can be used by all NHS trusts for any clinical trial, without modification.
But before embracing this agreement with open arms, we should examine what it actually says and what the deeper implications might be, warns Professor Michael Goodyear of Dalhousie University, Canada.
The agreement is the product of a unique consortium of industry, government, and academia, but other organisations, such as the Central Office for Research Ethics Committees, are not mentioned, despite being central to many issues covered in the agreement.
The agreement also applies only to contract research (commercial, industry sponsored trials usually directed towards pharmaceutical product licensing). It does not apply to phase I testing with healthy volunteers (as in TGN1412), to studies initiated by investigators, to trials in which the sponsor merely provides funding, or to research in non-NHS institutions.
While collaboration is admirable, we must realise that the development of a business model for research is a primary motivation behind this initiative, says Goodyear. As the guidance document states, the NHS is being “harnessed” in what is essentially a competitive model.
A surprising and disturbing element of the agreement relates to the crucial principles of transparency and accountability in research. Rather than incorporating and upholding the new and widely supported standards for an open research culture, the agreement has embedded an older and more problematic industry standard.
And, given that this agreement appears at a time when public trust in the drug industry has never been lower, the likelihood of guilt by association is appreciable, he warns.
The removal of counterproductive roadblocks in research regulations is generally a good thing, but research is far more than just a business, he writes. No matter how important the research is, thoughtful analysis cannot be bypassed for the sake of convenience.
The government and academia would be well advised to maintain a respectable distance from sources of funding, he concludes. The NHS is not for sale.
Contact:
Michael Goodyear, Assistant Professor,
Division of Medical Oncology, Department of Medicine, Dalhousie University,
Halifax, Canada
Email: mgoodyear@dal.ca
(Personal View: Clinician
led management can fix the NHS)
http://bmj.com/cgi/content/full/333/7577/1077
Clinician led management can fix the NHS, argues a senior doctor in this week’s BMJ. He calls on the government to let clinicians and managers plan and run their services free from political control.
Senior medical professionals are often branded as opponents of reform, writes David Flook, Consultant General Surgeon at the Royal Oldham Hospital. But most medical personnel support changes, they just oppose “the cynical, superficial reforms through which politicians have exploited the NHS.”
For instance, he condemns the “fraudulent claims” by health ministers that initiatives such as the “two week wait rule” have contributed to the recent modest fall in cancer deaths, and argues that fast track referral prioritises the worried well at the expense of the target population.
And he questions how patients can make a meaningful “choice” of who treats them from the vast NHS array. Was not personal referral to consultants by a GP preferable to the current lottery?
Other examples of subtle misinformation abound, he writes. The reduction in accident and emergency waiting times achieved by one recent initiative is hailed as evidence of improved performance. But this overlooks the sometimes dangerous means by which this goal was achieved, such as the premature transfer of acutely ill patients to almost anywhere outside A&E.
For strategic planners, the evidence suggests that they recognise the problem but choose to cut corners in service provision and avoid any political upsets, he says. And the problem for NHS managers is that politicians have replaced doctors in priority setting. “Managers are now no more than foot soldiers implementing the latest vote-winning initiative and I have seen no evidence that management consultants do better at even greater costs,” he writes.
Even good managers can only make the NHS safe and fair, if freed from political control and willing to prioritise in accordance with guidance from the staff who treat the patients, he concludes.
Contact:
David Flook, Consultant General
Surgeon, The Royal Oldham Hospital, UK
Email: david.flook@pat.nhs.uk
(4) CASE MANAGEMENT DOES NOT REDUCE HOSPITAL ADMISSIONS OR MORTALITY RATES
Online First
(Impact of case management (Evercare) on frail elderly patients. Controlled
before and after analysis of quantitative outcome data)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.39020.413310.55
Online First
(Editorial: Case management for elderly people in the community)
http://bmj.bmjjournals.com/cgi/rapidpdf/bmj.39027.550324.47
The Evercare case management system for older patients – a key element of Government community care policy - fails to reduce emergency admissions, emergency bed days or mortality, a BMJ study reveals today.
The system, provided by UnitedHealth Europe was piloted in nine sites in England between 2003 and 2005, has since been rolled out across England as a one of the main elements of the Community Matron policy.
Case management aims to improve patient outcomes, and in particular to reduce unplanned hospital admission. In England the Evercare sites selected patients on the basis of patients’ age (65 years and over) and a past history of emergency admissions. Under the system Advanced Practice Nurses deliver a form of comprehensive geriatric assessment and draw up an individualised care plan which is agreed with the patient, GP and other staff. Patients are then monitored at a frequency best suited to their condition.
Researchers from Manchester carried out a qualitative and quantitative evaluation of the Evercare pilots and analysed the rates of emergency admission, emergency bed days and mortality in 62 Evercare practices. The results of the qualitative analysis suggested that case management added a frequency of contact, regular monitoring, psycho-social support and a range of referral options that had not previously been provided to frail, elderly people.
However, the Evercare system had no significant impact on rates of emergency admission, bed days or mortality. The authors note that their results are actually consistent with the limited patient level evaluation published by UnitedHealth Europe.
An accompanying editorial, notes that whilst reducing unplanned admissions to hospital has become ‘a cornerstone of the commissioning plans of all Primary Care Trust’s (PCTs)’ there is ‘sparse’ evidence to support case management.
The editorial also says that following an interim review of the Evercare system, published in 2005, ‘there was criticism about the failure to fund a proper control study design beforehand, the cost and use of public funds (over £4m) with much of that going on travel, consultancy fees and training, and further national investment in a systematic case management approach across England without convincing evidence’.
The researchers argue that whilst ‘lessons have been learned’ from these initial pilots, they predict the same outcome from the newly introduced Community Matron policy. ‘Community matrons are likely to prove popular with patients and increase access to care, but they are unlikely to reduce hospital admissions unless accompanied by more radical system redesign’, they conclude.
Contact:
Martin Roland, Director of the National
Primary Care and Development Centre, University of Manchester
Email: m.roland@manchester.ac.uk
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