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Press releases Saturday 24 August 2007

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(1) UK has worst outcome for stroke patients in western Europe
(2) Is NICE's cost effectiveness threshold too high?
(3) Senior doctor "disappointed" over charity's legal challenge against NICE
(4) HPV vaccination needs careful long term planning

(1) UK has worst outcome for stroke patients in western Europe
(Improving the outcome of stroke)
http://www.bmj.com/cgi/full/335/7616/359

The UK urgently needs to reorganise stroke services to improve outcomes for patients, argues a senior doctor in this week's BMJ.

Studies have found that the UK has the worst outcome in western Europe. In one study the differences in the proportion of patients dead or dependent between the UK and eight other European countries were between 150 and 300 events per 1000 patients.

What underlies this variation and why is outcome so poor in the UK, asks Professor Hugh Markus at St George's University of London?

Differences in the process of care are likely to be important, he writes. In many European countries stroke care is an integral part of neurology. In contrast, in the UK it has, until recently, been a "Cinderella" subject, often falling between neurology and general and geriatric medicine.

It is tempting to conclude that this lack of interest has led to underinvestment and a resulting poor outcome, he says. Yet the cost of care of stroke patients seems to be as high, if not higher, in the UK than in European countries with better outcomes.

He suggests several organisational and structural problems, such as poor focus on acute stroke care.

This has become even more important now that there are specific treatments for acute stroke, such as thrombolysis (giving anti-clotting drugs to patients within three hours of a stroke), he says. Effective thrombolysis services exist in many countries in Europe, North America, and Australia, where in some centres as many as 20-30% of eligible patients receiving thrombolytic therapy. Currently less than 1% receive such therapy in the UK.

These deficiencies have already been recognised in England in a 2005 National Audit Office report, he writes. The report concluded that if care was better organised, every year £20m could be saved, 550 deaths could be avoided, and 1700 patients would recover fully who would not otherwise do so. In response, England's Department of Health National Stroke Strategy is due to publish its recommendations in autumn 2007.

A major challenge is to change the perception of stroke among both health professionals and the public, so that stroke is viewed as a condition that requires emergency action. The UK also has a severe shortage of specialists trained in acute stroke care and access to imaging technology, says Markus.

For example, in many European countries, brain scans are performed on admission in the accident and emergency department, while in the UK many units struggle to provide it within 24 hours, despite research showing that scanning patients immediately is the most cost effective strategy.

Improved early diagnosis with imaging, together with improved monitoring and treatment of physiological parameters, will improve outcome independent of administration of thrombolysis, he concludes. If we can set such acute systems in place they will also facilitate implementation of other new treatments.

Contact:
Hugh Markus, Centre for Clinical Neuroscience, St George's University of London, UK
Email: hmarkus@sgul.ac.uk 

(2) Is NICE's cost effectiveness threshold too high?
(NICE's cost effectiveness threshold)
http://www.bmj.com/cgi/full/335/7616/358

Is NICE's cost effectiveness threshold too generous, ask experts in this week's BMJ?

The National Institute for Health and Clinical Excellence (NICE) is an independent body that decides which drugs should be available on the NHS in England and Wales. Since its inception in 1999, NICE has adopted a cost effectiveness threshold range of £20,000 to £30,000 per quality adjusted life year (QALY) gained. A QALY is a combined measure of quantity and quality of life.

But the uncomfortable truth is that NICE's threshold has no basis in either theory or evidence, argue John Appleby, Chief Economist at the King's Fund, and colleagues Nancy Devlin and David Parkin at City University in London.

Cost effectiveness is emerging as a key factor in an ongoing House of Commons Select Committee inquiry into NICE, which has received evidence that the threshold may be too generous, they explain. If this suggestion is correct, the implications are profound.

It means that NICE has recommended too many new technologies. It also means that when primary care trusts implement NICE's guidance, resources may be diverted from other healthcare services that are better value for money.

By setting the hurdle too low, NICE might reduce the efficiency of the NHS, they warn.

So, what should the threshold be? Evidence suggests a mismatch between NICE's threshold range and that apparent elsewhere in the NHS. For example, the average primary care trusts spends £12,000 to gain an extra QALY in circulatory disease and £19,000 in cancer. In contrast, an analysis of NICE's decisions suggests that its threshold is in practice even more generous than NICE admits, being closer to £45,000.

The authors recommend that the NHS be given independence from the Department of Health on the specific matter of setting a cost effectiveness threshold, in the same way that the Bank of England has operational independence from the treasury so that it can set UK interest rates to contain inflation.

NICE conjuring up a threshold and others not using one at all creates neither efficiency nor fairness in the NHS, they conclude.

Contacts:
Louise Scodie, Press Officer, City University London, UK
Email: louise.scodie.1@city.ac.uk 

Daniel Reynolds, Head of Press and Public Affairs, King's Fund, London, UK
Email: d.reynolds@kingsfund.org.uk 

(3) Senior doctor "disappointed" over charity's legal challenge against NICE
(The Alzheimer's Society, drug firms, and public trust)
http://www.bmj.com/cgi/full/335/7616/400

In this week's BMJ, a senior doctor describes his disappointment with the Alzheimer's Society's recent alliance with drug makers in bringing the first legal challenge to judgements reached by the National Institute for Health and Clinical Excellence (NICE), the body that recommends which drugs are available on the NHS in England and Wales.

On 10 August, the High Court ruled against the alliance and upheld NICE's decision to limit treatments for Alzheimer's disease.

NICE is an independent body established to tackle the difficult - some would say near impossible - but essential task of trying to judge how the resources of the NHS can be used effectively and equitably, writes Professor Iain Chalmers.

This process is bound to result in "winners" and "losers," but those like the Alzheimer's Society that now regard themselves as losers must make it clearer whether they support the principles upon which NICE was established, he says.

He finds it disturbing that, in response to the legal judgement, the society's chief executive questioned whether NICE had lost public confidence.

But how might the Alzheimer's Society's close alliance with drug manufacturers erode its own authority as a charity subsidised by the public - which thus also needs to retain the public's confidence, he asks?

There are steps he believes the society could take to restore his respect for and confidence in it.

First, he says, it should declare clearly on its website the sources and amounts of support it receives for its work. Second, having challenged NICE's judgements, the society should make clear what alternative distribution of limited resources it regards as more appropriate, and why.

Thirdly, he says, it should campaign for treatments for dementia to be evaluated using outcomes that are meaningful to patients and carers, and challenge the licensing and use in the NHS of any new drugs that fail to conform to these expectations.

Finally, it should insist that all data from clinical trials are published and that anonymised data for individual patients are made available, so that researchers can try to identify which patients are most likely to be helped by treatments and which patients are unlikely to benefit or may be harmed.

"These steps would be more effective and enduring ways for the Alzheimer's Society to serve the interests of people with dementia and their carers than forming alliances with organisations with vested commercial interests to take a public body to court," he concludes.

Contact:
Iain Chalmers, Coordinator, James Lind Initiative, Oxford, UK
Email: ichalmers@jameslindlibrary.org 

(4) HPV vaccination needs careful long term planning
(Challenges of implementing human papillomavirus (HPV) vaccination policy)
http://www.bmj.com/cgi/full/335/7616/375
(Commentary: Health inequality could increase in poor countries if universal HPV vaccination is not adopted)
http://www.bmj.com/cgi/full/335/7616/378

A successful HPV vaccination program requires more than just a series of injections, says a public health expert in this week's BMJ.

Careful planning, adequate education, and long term monitoring will be needed, argues Angela Raffle, a consultant in public health at Bristol Primary Care Trust.

Human papillomavirus (HPV) is a common sexually transmitted infection seen most often in young women and adolescents. There are more than 100 types of HPV, some cause only genital warts, but others cause cancers including cervical cancer.

Screening currently reduces deaths from cervical cancer by around 80% but a new jab can offer full protection against HPV strains linked to about 70% of cervical cancers. The UK government is now considering whether girls aged 11 or 12 should be vaccinated, before they become sexually active and can catch HPV.

Raffle believes that the only certain way of determining the long term impact of vaccination will be to follow vaccinated women for several decades, while an accompanying commentary warns that health inequality could increase in poorcountries if universal HPV vaccination is not adopted.

These views are reiterated in an accompanying editorial by Bernard Lo, a Professor of Medicine at the University of California San Francisco.

He discusses the issue of making HPV vaccine mandatory, but argues that a successful vaccination programme requires more than simply increasing uptake. A broader perspective is needed, he says, to tackle the controversial matters of adolescent sexuality, parental control, and protection of children.

Furthermore, physicians need to persuade people who have concerns about the HPV vaccine to trust in and cooperate with other measures to promote adolescent health, he concludes.

Contact:
Bernard Lo, Professor of Medicine, University of California San Francisco, CA, USA
Email: bernie@medicine.ucsf.edu 

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