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Press releases Saturday 15 September 2007

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(1) Experts propose cholesterol tests at 15 months of age
(2) GP targets on heart disease should be simpler and based more on treatment and prevention
(3) No need for children with lazy eye to wear patches all day
(4) Disease-specific aid distorts countries' efforts to deal with their problems
(5) Concerns over direct to consumer drug advertising in Europe

(1) Experts propose cholesterol tests at 15 months of age
(Child-parent screening for familial hypercholesterolaemia: screening strategy based on meta-analysis)
BMJ Online First

Children could have their cholesterol levels tested at about 15 months of age to prevent heart disease later in life, say doctors in a study published on bmj.com today.

High cholesterol which runs in families is known as familial hypercholesterolaemia. It affects about two in every 1000 people and causes very high levels of low density lipoprotein (LDL) or ‘bad cholesterol' in the blood. It carries a high risk of death from coronary heart disease.

Treatment to lower cholesterol reduces the risk substantially, but there is uncertainty over what screening strategy is likely to be effective.

So researchers at Barts and the London Queen Mary's School of Medicine and Dentistry analysed published studies on total and LDL cholesterol in people with and without familial hypercholesterolaemia to determine the efficacy of screening and the best age to do this.

They identified 13 studies involving 1,907 cases and 16,221 controls.

They found that screening was most effective if done in early childhood (1-9 years). Screening at this age detected 88% of affected individuals, while screening newborns and young adults was much less effective.

Based on these results, the authors suggest that children could be screened when they visit their general practice for routine vaccinations at about 15 months of age.

Once an affected child is identified, their parents would then also be screened, since, given the inheritance of this disorder, for every affected child there would be one affected parent. Treatment to lower cholesterol could then be initiated immediately in the affected parent and delayed in the child until adulthood.

A potential strength of screening at the time of childhood immunisation, they explain, is that it would take place at a time when parents are receptive to the possibility of preventing disease in their child and therefore may be receptive to a family based strategy to prevent the consequences of the same disease within the family as a whole.

The proposed strategy elegantly screens for familial hypercholesterolaemia in two generations simultaneously with the potential of preventing premature coronary heart disease in nearly everyone with the disorder.

Contact:
David Wald, Consultant Cardiologist and Senior Lecturer, Wolfson Institute of Preventive Medicine, Barts and The London Queen Mary's School of Medicine and Dentistry, University of London, UK
Email: d.s.wald@qmul.ac.uk 

(2) GP targets on heart disease should be simpler and based more on treatment and prevention
(Tackling therapeutic inertia: role of treatment data in quality indicators)
http://www.bmj.com/cgi/content/short/335/7619/542
http://www.bmj.com/cgi/content/short/335/7619/523

GP performance related payments for tackling heart disease are too complex. They should be simplified and based more on disease treatment and prevention and less on risk factor measurement, experts advise in this week's BMJ.

General practice in the United Kingdom has the largest healthcare pay for performance programme in the world - the quality and outcomes framework (QOF). Practices earn points for the services they provide and these points attract financial resources into the practice.

Professor Bruce Guthrie and colleagues discuss the effectiveness of the system in relation to the management of cardiovascular disease and show how practices can earn many points and extra payments without necessarily reducing its risk.

For example, a practice could receive nine points (each worth about £125) for generating a list of patients with high blood pressure. An extra 30 points would be earned if 90% or more of such patients have a record of risk factors (blood pressure and smoking history) in their notes, and 56 more points would be earned if 70% or more of such patients have a record of blood pressure lowered to below specific target values.

Overall, 15% of payments, worth an estimated £200m across the approximate 11,000 general practices in the UK, arise from measuring cardiovascular risk factors (such as blood pressure and cholesterol) and recording whether they are below specified values.

They reason that it's time to incorporate treatment information into quality indicators, since it is the treatment of risk factors that reduces risk, not their measurement.

Meeting current targets for cardiovascular disease does not guarantee good management, they warn. Treatment information would clearly identify opportunities for intervention and improved patient care.

These views are supported by Consultant Cardiologist, David Wald, in an accompanying editorial. He believes that the treatment and prevention of cardiovascular disease is becoming a series of isolated tasks predicated on financial rather than clinical value, and argues that many of the QOF measurements relating to cardiovascular disease achieve little.

The QOF has been useful in drawing attention to the importance of the treatment and prevention of cardiovascular disease, but not how best to do so, he says.

He suggests simplifying the system so that payments are directly linked to treatment and prevention rather than the process, while protecting the independent professional status of doctors in the UK.

Contacts:
Bruce Guthrie, Professor of Primary Care Medicine, Community Health Sciences, University of Dundee, Scotland  
Email: b.guthrie@chs.dundee.ac.uk 

Editorial: David Wald, Consultant Cardiologist and Senior Lecturer, Wolfson Institute of Preventive Medicine, Barts and the London Queen Mary's School of Medicine and Dentistry, University of London, UK  
Email: d.s.wald@qmul.ac.uk 

(3) No need for children with lazy eye to wear patches all day
(Objectively monitored patching regimens for treatment of amblyopia: randomised trial)
BMJ Online First

Children with amblyopia (commonly known as lazy eye) need only wear an eye patch for three to four hours a day for 12 weeks to improve vision, say researchers in a study published on bmj.com today.

Patching for all waking hours for up to several years, which is often recommended, is almost certainly excessive, they argue.

Amblyopia results from a disturbance to the vision pathways between the eyes and the brain, which is often associated with blurred vision or crossed eyes (strabismus).

Studies have shown that occlusion therapy (patching) can improve vision, but results suggest that "maximal" doses (12 hours a day) are no more beneficial than "substantial" doses (six hours a day). Despite this, many doctors still prescribe large doses, above six hours a day.

So researchers at City University in London and McGill University in Montreal funded by Fight for Sight, London, set out to determine the amount of occlusion treatment required in children with amblyopia to achieve the best outcome.

The study involved 97 children aged 3-8 years with a confirmed diagnosis of amblyopia. All children had a full ophthalmic assessment and were instructed to wear glasses all the time for 18 weeks. On completion of this phase, 80 children who still met the study's definition of amblyopia were then told to wear a patch for either six or 12 hours a day.

Two electrodes were attached to the under surface of each patch to monitor the amount of occlusion each child actually received. Visual function was recorded every two weeks.

There was no significant difference in visual acuity between the two groups. However, the mean dose rates (hours a day with a patch) actually achieved were also not significantly different (4.2 in the six hour group and 6.2 in the 12 hour group).

Visual improvement was similar for those children who received 3-6 hours a day or 6-12 hours a day, but significantly worse for children who received less than three hours a day.

Children under 4 years of age required significantly less occlusion (under three hours a day) than older children to correct their vision.

This analysis suggests that achieving an initial dose rate of three to four hours a day should be a clinical priority, say the authors. The response depends on age, however, so for children under 4 years this could be reduced. Patching beyond 12 weeks did not confer additional benefit.

Eye patching can cause considerable distress for both the child and family, they add, so doctors should try to minimise the amounts necessary for the best expected outcome.

Contacts:
Dinah Lartey, Press Office, City University, London, UK 
Email: dinah.lartey.1@city.ac.uk 
or
Cathy Hill or Michelle Acton, Fight for Sight, London, UK  
Email: press@fightforsight.org.uk 

(4) Disease-specific aid distorts countries' efforts to deal with their problems
(Personal View: The dangers of disease specific aid programmes)
http://www.bmj.com/cgi/content/short/335/7619/565

Billions of dollars are being spent on disease-specific aid programmes in developing countries. But in this week's BMJ, Roger England, Chairman of Health Systems Workshop, argues that these programmes distort countries' efforts to deal with their problems.

His views follow the launch of a new International Health Partnership that Prime Minister Gordon Brown hopes will accelerate progress towards achieving the United Nations' millennium development goals for health.

Will the partnership make a difference, he asks?

Although international aid to developing countries for health has doubled to $14bn (£7bn; €10bn) since 2000, much of the increase is tied to individual diseases and is delivered outside of recipient countries' planning and budgeting systems, causing big problems for the recipients, he writes.

Money for combating HIV and AIDS is the worst. It distorts countries' efforts to deal with their problems, because most of this new aid is delivered "off budget,"resulting in separate plans, operations, and monitoring - all in parallel with government systems.

What is missing, he says, is strengthened national healthcare systems that can deliver the range of services that countries need, according to their own priorities, not those of international lobby groups.

No one is funding this adequately, and no international body is equipped to provide the technical support countries need. The obvious candidate, the World Health Organization, suffers from serious constitutional and institutional flaws and is chronically under funded.

So what can Mr Brown's new International Health Partnership do to redress this?

He suggests several actions, including stopping funding for global programmes that do not put their money through recipient countries' planning and budgeting processes and providing real support to countries that are seriously reforming their systems.

Finally, he believes the partnership can lead a complete rethink of the millennium development goals, not because we are not going to meet them, but because they are more trouble than they are worth - and always were.

We will not achieve better health care for the world's poor without better national health systems to fund and deliver it, he says, and we will not achieve that without a better international system for aid. Disease specific programmes do a disservice to this ambition, and the International Health Partnership must not only recognise this but be bold enough to act.

Contacts:
Roger England, Chairman, Health Systems Workshop, Grenada, West Indies  
Email: roger.england@healthsystemsworkshop.org 

(5) Concerns over direct to consumer drug advertising in Europe
(Editorial: Direct to consumer advertising of drugs in Europe)
http://www.bmj.com/cgi/content/short/335/7619/526

Researchers in this week's BMJ raise concerns over suggestions that drug makers could supply information on medicines to patients, as part of a proposal to modify the current ban on direct to consumer advertising in Europe.

Direct to consumer advertising (the promotion of prescription drugs to the public) is currently used only in the United States and New Zealand. Yet a recent report from the Institute of Medicine confirmed that direct to consumer advertising increases the early use of new drugs and called for a two year moratorium of such advertising for newly approved drugs.

A proposal to modify the current ban on direct to consumer advertising is due to be considered by the European parliament in the next few months.

But an interim report released at the end of April 2007 concludes that reliable information on medicines is not sufficient for patients' needs and calls for a partnership between drug manufacturers and regulatory bodies to plug this information gap.

The authors argue that such a partnership would be confusing. They also point out that several examples of good information sources are now available in Europe. The difficulty for the public is finding them and distinguishing between promotional material and unbiased evidence based information.

So where do we go from here, they ask? They propose two areas of real partnership with the drug industry that would reinforce public trusts in the system.

The first would entail giving full access to data on the effectiveness and safety of drugs to enhance transparency.

The second would be to move the European Medicines Evaluation Agency from the Enterprise and Industry Directorate General to the Health and Consumer Protection Directorate General to avoid the current conflict between supporting the competitiveness of the drug industry and the interests of patients.

The most sensible way to protect public health, they conclude, would be to identify sources of unbiased and systematically reviewed information and maintain the current European legislation on drug promotion, while reinforcing the role of the European Medicines Evaluation Agency.

Contacts:
Nicola Magrini, Clinical Pharmacologist, NHS Centre for the Evaluation of the Effectiveness of Health Care, Modena Local Health Authority, Modena, Italy  
Email: n.magrini@ausl.mo.it 

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