Press releases Monday 29 November to Friday 3 December 2010

Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's website (http://www.bmj.com).

• (1) Referral for specialist care varies by age, sex and social deprivation
• (2) Joined-up care for people with low back pain saves money
• (3) Premature delivery and birth defects are major causes of death in newborn babies from deprived backgrounds
• (4) Frequently used antiepileptic drug linked to spina bifida in infants

(1)Referral for specialist care varies by age, sex and social deprivation

(Research: Explaining variation in referral from primary to secondary care: cohort study )
http://www.bmj.com/cgi/doi/10.1136/bmj.c6267
(Editorial: Referral from primary care)
http://www.bmj.com/cgi/doi/10.1136/bmj.c6175

In the UK, the likelihood of being referred for specialist care varies according to age, sex and socio-economic circumstances, finds a study published on bmj.com today.

The research, which looked at referral rates for three common conditions, shows that older patients are less likely to be referred than younger patients, women are less likely to be referred for hip pain, and referrals fall with increasing deprivation for patients with hip pain and younger patients with indigestion (dyspepsia).

It is well known that inequalities in health care use exist within the NHS, but it is unclear whether inequalities occur once patients are within the secondary care sector or at the point of entry to specialist care.

So a team of London-based researchers from UCL and the King's Fund analysed referral data for nearly 130,000 patients from 326 general practices across the UK from 2001 to 2007 with postmenopausal bleeding, hip pain or dyspepsia.

Information on age, gender and socio-economic circumstances was recorded. Other factors which could influence a doctor's decision to refer, such as smoking, body mass index, alcohol intake, and existing conditions (co-morbidity) were also taken into account.

For all three conditions, older patients were less likely to be referred than younger patients. This age gradient was particularly noticeable for postmenopausal bleeding.

Women were less likely than men to be referred for hip pain. Rates of referral also fell with increasing deprivation for patients with hip pain and for those aged under 55 with dyspepsia.

Inequalities in referral were more likely to occur in the absence of both explicit guidance and potentially life threatening conditions.

The researchers suggest several explanations for their findings, including the possibility that GPs serving more deprived communities being in general less likely to refer, or patient preference.

These referral inequalities could lead to delays in treatment and poorer outcomes, warn the authors. They call for more research "to understand the complex determinants of inequalities in referral from primary care."

An accompanying editorial warns that, although research using databases is attractive, it "cannot provide information to help understand patterns that arise from human interactions." Moyez Jiwa, Professor of Health Innovation in Perth, Australia, says: "Research is needed on the interaction between doctors and patients in the primary care consultation, which ultimately determines who is referred and who is not."

Contacts:
Research: Rosalind Raine, Professor of Health Care Evaluation, UCL Dept of Epidemiology and Public Health, 1-19 Torrington Place, London WC1E 6BT

Editorial: Moyez Jiwa, Professor of Health Innovation, Curtin Health Innovation Research Institute, Perth, Australia
Email: m.jiwa@curtin.edu.au

(2) Joined-up care for people with low back pain saves money
(Research: Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomized controlled trial)
http://www.bmj.com/cgi/doi/10.1136/bmj.c6414

An integrated approach to care for people on long term sick leave because of chronic low back pain has substantially lower costs than usual care, finds a study published on bmj.com today.

Researchers in the Netherlands found that an integrated care approach has significant benefits for patients, society and employers.

Chronic low back pain is one of the most common health problems in industrialised countries and places a huge economic burden on individuals, health care systems, and society as a whole. Most (93%) of this burden is related to costs of productivity losses.

The researchers identified 134 patients aged 18 to 65 years who were on sick leave from work because of chronic low back pain. Sixty-six patients received an integrated care programme, while 68 patients received usual care according to Dutch guidelines.

Integrated care consisted of workplace assessments, treatment with graded exercise, and reassurance that despite pain, moving can be safe while increasing activity levels (for full details of the intervention see http://www.bmj.com/content/340/bmj.c1035/suppl/DC1). The main aims of the programme were to achieve lasting return to work and improved quality of life, and these results were published in the BMJ in March 2010.

The patients were surveyed at regular intervals over 12 months to assess their use of health care resources and absenteeism from work.

Usual care patients consulted health care professionals more often than patients who received integrated care, and they used more informal care and had longer stays in hospital. Sustainable return to work and quality of life gained were also significantly more favourable in the integrated care group compared with usual care.

After 12 months, total costs in the integrated care group (£13,165) were significantly lower than in the usual care group (£18,475). Integrated care was therefore more cost effective than usual care. Cost-benefit analyses showed that every £1 invested in integrated care will return an estimated £26. For society, the net benefit of integrated care compared with usual care was £5,744.

Limited health care budgets are making economic evaluations increasingly important, say the authors. The integrated care programme has large potential to significantly reduce societal costs and improve quality of life and function. They conclude: "The success and failures of implementing the integrated care programme need to be investigated to determine the boundary conditions for nationwide application."

Contact:
Johannes Anema, Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, Netherlands
Email: h.anema@vumc.nl

(3) Premature delivery and birth defects are major causes of death in newborn babies from deprived backgrounds
(Research: Nature of socioeconomic inequalities in neonatal mortality: population based study)
http://www.bmj.com/cgi/doi/10.1136/mj.c6654

Deaths in newborn babies (neonatal deaths) are over twice as high in the most deprived areas compared to the least deprived and around 80% of these additional deaths are a result of premature birth and congenital anomalies (birth defects) according to research published on bmj.com today.

The authors, led by Dr Lucy Smith from the University of Leicester, argue that the current strategy in England to tackle socioeconomic inequalities does not adequately address these two major causes of death.

They also say that understanding the link between deprivation and premature birth should be a major research priority.

The UK Government has made attempts to deal with socioeconomic inequalities in infant mortality and has a target to reduce the relative gap between the affluent and the deprived populations in England and Wales by 10% by 2010.

However, recent evidence suggests that this target is unlikely to be achieved and the deprivation gap appears to be widening.

So the research team investigated all neonatal deaths in England from 1 January 1997 to 31 December 2007. Each death was assigned a deprivation score, based on the mother's residence.

During this period 18,524 newborn babies died and the most common causes were premature birth and congenital anomalies.

In 1997-1999 neonatal mortality rates were over twice as high in the most deprived areas of England compared with the least deprived, and the relative gap widened over time to a peak in 2003-2005, before slightly narrowing in 2006-2007.

"Neonatal deaths would be 39% lower if all areas had the same neonatal mortality rates as the least deprived areas," say the authors.

However, they stress that, while the relative deprivation gap in neonatal mortality has generally widened over time, in absolute terms, the number of neonatal deaths in deprived areas has fallen. So, to some extent, they say, government initiatives have been successful.

They also point out that measures to reduce the deprivation gap have focused on increasing breast feeding rates and reducing obesity, smoking, and teenage pregnancy. Although these are all laudable aims, the authors warn that "unless interventions target specifically the risk of very premature birth and potentially lethal congenital abnormalities the effect on the deprivation gap is likely to be minor."

Instead, they call for a greater understanding of the link between deprivation and preterm birth to identify interventions to reduce preterm birth.

While this study has been based on data for England, the authors conclude that similar patterns probably exist in other developed countries, and that this kind of analysis could be useful on a global level.

Contact:
Lucy Smith, Research Fellow, Department of Health Sciences, University of Leicester, UK
Email: lks1@leicester.ac.uk

(4) Frequently used antiepileptic drug linked to spina bifida in infants
(Research: Intrauterine exposure to carbamazepine and specific congenital malformations: systematic review and case control study)
http://www.bmj.com/cgi/doi/10.1136/mj.c6581
(Editorial: Carbamazepine in pregnancy)
http://www.bmj.com/cgi/doi/10.1136/mj.c6582

Women who suffer from epilepsy and take a common drug (carbamazepine) to treat the illness have a higher chance of having an infant with spina bifida compared with women not taking antiepileptic drugs, finds a study published on BMJ.com today. Some women choose to terminate their pregnancy because their baby has this condition.

The researchers, led by Professor Lolkje de Jong-van den Berg from the University of Groningen in the Netherlands, carried out a review of all published studies to identify specific major malformations linked with carbamazepine use in the first three months of pregnancy.

Of the five identified indications in the literature, spina bifida was the only specific major congenital malformation significantly associated with exposure to carbamazepine monotherapy (spina bifida was 2.6 times more likely in infants of women who had taken carbamazepine compared with no antiepileptic drug, but the risk was smaller for carbamazepine than for valproic acid).

The authors did not conclude that carbamazepine is associated with other major malformations and say it is less risky than another frequently used antiepileptic drug, valproic acid.

They also stress that "although most antiepileptic drugs taken during pregnancy significantly increase the risk for one or more specific congenital malformations, the occurrence of these malformations is nevertheless rare . . . most exposed pregnancies result in a baby without malformation." For carbamazepine taken in the first three months of pregnancy the overall risk of a major malformation was 3.3%.

Carbamazepine is one of the most commonly used anti-epilepsy drugs in Europe among women of reproductive age, says the paper.

The material was derived from EUROCAT - a database containing information from 19 registers of pregnancy outcomes with major congenital malformations in Europe from 1995 to 2005. The data relates to almost four million European births, of which over 98,000 involved a major malformation.

The authors say that their earlier study on valproic acid (published in the New England Journal of Medicine in 2010) concludes that women on valproic acid are six times more likely to have a pregnancy outcome with spina bifida and seven times more likely to have an outcome with hypospadias (a condition where a boy's urinary opening develops in the wrong part of the penis or in the scrotum) compared with women using other antiepileptic drug use. The research team therefore agrees with the recent recommendation from the American Academy of Neurology that women should avoid valproic acid in pregnancy if possible.

The authors conclude that although the overall risk of birth defects is low for women taking antiepileptic drugs, "the best option regarding antiepileptic drug treatment can be chosen only on an individual basis by the woman and neurologist before pregnancy, weighing the benefits of epilepsy control against the risk of teratogenicity."

In an accompanying editorial, Irena Nulman, Associate Professor of Paediatrics at the University of Toronto, says: "Of all the anticonvulsant drugs, "carbamazepine is associated with the lowest rate of morphological defects ... and should therefore be considered the drug of choice in pregnancy." She points out that, for many pregnant women, dicontinuing antiseizure drugs is not an option and that women should plan their pregnancy, receive evidence based prenatal counselling, and be given the safest antiepileptic drug.

Contact:
Lolkje de Jong-van den Berg, Division of Pharmacy, University of Groningen, Netherlands
Email: l.t.w.de.jong-van.den.berg@rug.nl

Emma Dickinson
Tel: +44 (0)20 7383 6529
Email: edickinson@bma.org.uk

Press Office telephone : 020 7383 6254 (Weekdays : 0900hrs - 1800hrs)
British Medical Association
BMA House, Tavistock Square, London WC1H 9JP

and from:

the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)
http://intranet.bmj.com/departments/dept-bmj/bmj-team-resources/web-team-resources/General_blogging_principles.doc