Wednesday 16 May 2012

Take a deep breath

To accompany last year's outcomes strategy for COPD and asthma, DH has produced a companion document that sets out best practice guidance for commissioners, particulraly in the transition period, ahead of the CCGs and the NHS Commissioning Board taking up the reins.  As Pulse points out, the guidance includes a case-finding approach to identifying undiagnosed patients.  A Swedish study of the use of a mini-spirometer in improving diagnosis of COPD finds it a highly effective device.  The companion document also reveals that DH is trialling the use of microspirometry in case finding in Yorkshire and Humber: the project is due to report in late 2012.

Tuesday 15 May 2012

Pack shot

DH has launched its consultation on food labelling, aimed at a creating single system of front of pack nutritional information display.   Currently, around 80% of food products sold in the UK do provide nutritional labelling, but there are many systems.  DH estimates that if the big 7 supermarkets all hamonised their nutritional labelling, this would affect about half of all the food sold in the UK.  Responses are due in by 5 August.  Join the queue!  A recent study of Australian consumers found rather poor understanding of energy labelling at least.  The May issueof Public Health Nutrition carries a few articles on the subject, , looking at strategies to increase food label use int he US, German consumer responses to traffic light labelling systems and an online test from New Zealand of consumer response to low sodium labelling.

Saturday 28 April 2012

Price rise

Minimum pricing for alcohol, a key element in the Government's new alcohol strategy, has been questioned by the Local Government Association, over concerns that this will "cause a surge in counterfeit wine and spirits", the BBC reports.  A study from British Columbia, Canada, where minimum pricing has been in force for many years, suggests that it is effective in reducing alcohol consumption.  Approaching the problem from another perspective, a new Public Health Responsibility Deal pledge aims to make lower strength drinks more widely available.  A paper from the University of Sheffield considers the health economic assessment of public health alcohol harm strategies.  Minimum pricing has found support amongst pub landlords in Wales, who have blamed supermarket sales for a fall in their trade.  A study in Alcohol and Alcoholism examines trends in home drinking in the UK. 

Friday 27 April 2012

Named and shamed

Several UK supermarkets were on the receiving end of the wrath of the Children's Food Campaign for undermining parents' efforts to encourage their children to eat healthily.  The report, Checkouts Checked Out, was highly critical of how much junk food is displayed at checkouts, both in supermarkets and non-food stores.  One of its recommendations is that removal of this kind of food from checkout areas should be included in the Public Health Responsibility Deal, the latest element of which (a calorie reduction initiative) was announced by DH recently. Public Health features an evaluation of the MEND (Mind, Exercise, Nutirition ... Do it!) healthy living programme as delivered in the West Midlands.  A systematic review of evidence about the association of childhood obesity with primary school built environments finds little to commend in the literature.  Community Practitioner offers an overview of the Food Dudes school-based healthy eating programme. 

Thursday 26 April 2012

Integration ahead

DH's recent evaluation of  the integrated care pilots has been found wanting in several quarters.  GP magazine put in a Freedom of Information Act request for clarity on DH's claim that this telecare route will offer £1.2 bn savings, but was turned down.  A lesss investigative approach from Nick Goodwin of the King's Fund echoes the less than enthusiastic response: "It is fair to say that the collective results of these pilots have been mixed."  He also observes that these pilots suffered from a common problem with integrated care, where the process of integration gets priority over the experience of care.  Another significant finding from the report was that emergency admissions increased over the period studied, while outpatient and elective admissions decreased.  The King's Fund is itself currently looking for case sites in its study of co-ordinated care for people with complex chronic illnesses.

Sunday 25 March 2012

On your bike

Preventive Medicine offers several articles on physical exercise interventions, including a UK study on the contribution of active travel to physical activity levels in schoolchildren, the effect of a school-based active commuting intervention and a population-based RCT of a pedometer combined with an intervention toolkit for people with low levels of fitness or physical activity. A systematic review in the American Journal of Preventive Medicine assesses the state of knowledge on adult sedentary behaviour.

Saturday 24 March 2012

Risky rice?

A study linking consumption of white rice with risk of type 2 diabetes has gained an amount of excitable press coverage. NHS Choices Behind the Headlines assesses the merit of this meta-analysis and systematic review and finds it adequate but not overly well represented in the media. Meanwhile, a study from the US Centers for Disease Control (CDC) finds that the HbA1c test is a cost effective pre-diabetes test where the threshold for diagnosis is set at 5.7%, rather lower than the current US level of 6.5%.

Friday 23 March 2012

The right measure

The new NHS framework for patient experience offers, suggests Jocelyn Cornwall of the King's Fund, a secure evidence base for measuring and improving this key aspect of healthcare. She also argues that measures of patient experience should be aligned with clinical level data on processes and outcomes and embedded in the new NICE quality standard. A discussion paper from NHS Confederation aims to stimulate debate on what it calls the uneasy consensus between patients, citizens and the NHS. While patient experience is not entirely about keeping people happy, some research on the shape of happiness over the lifecourse may be of interest: a survey by ONS shows that happiness is a U-shaped curve, highest amonst teens and people in their 70s.

Thursday 22 March 2012

A breath of fresh air

The American Journal of Preventive Medicine provides an umbrella review of public health interventions for asthma over the past twenty years, with self-management education being the most consistently effective strategy. Asthma UK reports on a project in Yorkshire and Humber that involved training for education professionals. A study in the BMJ looks at the cost effectiveness of mobile phone monitoring for asthma control as compared with the usual paper based approach. This UK primary care based trial, which involved adolescents and adults with poorly controlled asthma, found that using phones didn't work any better than the old school method in enabling asthma control and that it was more expensive.

Balancing act

A DH discussion paper on personal health budgets sets the scene for the programme, which will be rolled out from April 2014. Reflecting on the experience of the Netherlands, an article in the BMJ offers some wisdom based on having learned the hard way. At a recent conference, deputy head of NHS Commissioning Andrew Sanderson proffered the warning that personal health budgets did not provide "an open ended system of entitlement" and that there would need to be a robust way of managing demand. There's also a paper from the Association of Directors of Adult Social Services that looks at the position of young carers in the era of personalisation.

Wednesday 21 March 2012

Plain speaking

Plain packaging for tobacco products throughout the EU could be a reality, the EU health Commissioner has implied. At a meeting hosted by the European Parliament, the Commissioner suggested that there should be changes to the EU tobacco products directive to include electonic cigarettes as well as minimising the attractiveness of tobacco products. Recently announced plans to reduce tobacco consumption in France include plain packaging and higher prices. Australia, the first country to adopt plain packaging, is facing a variety of legal challenges to the new regime.

Tuesday 13 March 2012

Feet first

NHS Diabetes highlights the cost to patients and the NHS of poor quality diabetic foot care. The annual bill for foot ulcer treatment and amputation is about £650 million. Something like 7% of people with diabetes have had a foot ulcer, a condition that may lead to amputation. In several studies about a third of patients foot ulcers went on to have some form of amputation. Mortality from major amputation and also from foot ulcers is high. Again, effective preventive services, delivered by multidisciplinary teams (MDTs) are offered as the solution: the report provides evidence of how the introduction of MDTs can substantially reduce costs.

Friday 9 March 2012

What's the risk

Pulse reveals that there is pressure from DH for NICE to recommend lowering the threshold for diabetes testing for adults. Draft guidance on prevention of type 2 diabetes, published last year, proved unpopular when it recommended a case finding approach, whereby GPs would be expected to assess risk of patients and offer lifestyle advice and testing to high risk patients. At this stage, the threshold was set at HbA1c levels of 6.0- 6.4%; according to Pulse, the new proposals suggest a level below 6.0% for high risk patients. A modelling study has recently suggested that using this lower threshold would prevent more cases but with a "disproportionately higher workload". Much reported was the study on variation in incidence of lower limb amputation in England, which suggested that multidisciplinary teams could be a better way of dealing with the issue.

Wednesday 22 February 2012

Does it last?

Recent studies from the US, the UK and Finland have shown that there has been a substantial rise in total knee replacements (TKR) for younger people. The study from Finland, published in Arthritis and Rheumatism, shows that, along with an overall increase in the procedure, there was also a marked increase amongst those aged 50-59, while the journal's editorial suggests that more research into outcomes for younger patients is warranted. Another study from the US dismisses the idea that this growth is simply caused by rising obesity and an increase in population numbers. The practice of rationing TKR in the UK is judged not to be cost effective by a study in the BMJ. Researchers used data from the Knee Arthroplasty Trial to show that only offering surgery to patients with a high-to-moderate Oxford Knee Score was "probably unjustified". Body Mass Index, also occasionally used as a metric for rationing, was also found to have no significant effect on cost or outcome.

Monday 20 February 2012

Steady as she goes

Tai chi retains its status as exercise regime of choice for a range of health conditions. A recent trial of a tailored Tai chi programme to improve postural stability with people with Parkinson's disease found benefit amongst mild to moderate Parkinson's sufferers. Research in Sports Medicine offers another review of this form of exercise for falls prevention. Elsewhere, Tai chi is described as a "promising intervention" for reducing fracture risk amongst older osteopenic women. Exercise of any kind is recommended for people with chronic illness and depressive symptoms in a systematic review.

Sunday 19 February 2012

Ratings

A bad TripAdvisor review can strike fear into the hearts of owners of hotels or restaurants, but does this kind of feedback bear any relation to more formal quality assessments? A team from Imperial College matched feedback given via NHS Choices to a range of hospital quality measures and found there to be a reasonable level of agreement, especially as regards mortality and infection rates. DH announces that "the Government welcomes these findings". A study from the US looks at the relationship between patient satisfaction and healthcare use. A systematic review of the impact of patient and public involvement on NHS healthcare finds there's still room for improvement.

Saturday 18 February 2012

Halcyon daze

Healthy Ageing Across the Life Course, or HALCyon is an interdisciplinary study looking at the factors that contribute to healthy ageing. A survey of early findings from five of the eight workstreams appears in the journal Public Health. The Department of Work and Pensions has released its final report on the Active at 60 pilot into the scope for using smart technology for delivering services to older people. The Journal of Epidemiology and Community Health publishes an evaluation study of a "worksite vitality intervention" for older hospital workers.

Friday 17 February 2012

Handle with care

Community based screening for frailty in older people is attracting a degree of attention in the literature. A review of how frailty is recognised and managed in primary care is a timely addition. The Journal of the American Geriatrics Society publishes a panel review of screening older people for particular conditions, as represented in a raft of guidelines. They find that screening for insufficient physical activity, cardiovascular risk factors and smoking are appropriate in aiming to prevent functional decline. A systematic review of screening tools for use in primary health care identifies the Tilburg Frailty Indicator and the SHARE Frailty Index as the most appropriate. A prospective study in a community context looks at Tilburg alongside the Gronigen Frailty Indicator and the Sherbrooke Postal Questionnaire.

Thursday 16 February 2012

Clean break

Fragility fractures are often linked to osteoporosis. NICE has just opened consultation on draft guidance to assess the risk of fragility fractures in adults. Responses are due in by 8 March. There's a comparison of UK case-finding strategies for management of hip fractures in the latest issue of Osteoporosis International, looking at the Royal College of Physicians strategy and the newer National Osteoporosis Guideline Group approach. Some more detail is provided on the SCOOP trial of community based screening for osteoporosis. Finally, Value in Health offers a systematic review of cost-effectiveness in strategies for selecting and treating people at risk of osteoporosis and osteopenia.

Wednesday 15 February 2012

It's a mystery

Or, it's difficult to see how C diff spreads in hospital wards, as NHS Choices Behind the Headlines put it. The study from the John Radcliffe Hospital in Oxford considered ward-based transmission of Clostridium difficile, finding that contact with infected patients is not the main cause of new cases in hospital.

Tuesday 14 February 2012

Venn diagram

The overlap between long term conditions relating to physical health and mental health conditions is substantial. According to a report from the King's Fund and the Mental Health Foundation, over a third of people in England with a physical long term condition also have mental health problems; on the flipside, nearly half of people in England with a mental health problem also have a long term physical health condition. Either way, this amounts to something like 4.6 million people and between £8 billion and £13 billion per year in healthcare spending. The report argues that we could do better and that the main route to improvement is through integration. Doing nothing to address the emotional and mental health problems attendant on long term conditions risks the ability of people to manage their physical health. A study from the US looks at how to improve medical adherence amongst people in primary care with co-morbid long term physical and mental conditions (diabetes, coronary heart disease and depression). An analysis of results from the CO-MED trial focuses on depression treatment in patients with general medical conditions. A Cochrane systematic review of self monitoring of blood glucose for people with type 2 diabetes finds this has limited effect on glycaemic control in patients not using insulin. A study underway in Australia, Diabetes MILES, assesses the psychological aspects of living with diabetes: an early publication examines the methods and sample characteristics.

Friday 10 February 2012

Keep up

There's a raft of evaluations and monitoring reports for active travel programmes, including the I Bike project in Scotland, the Living Streets community walking programme and the Travel Actively projects. A study of urban, multi-ethnic school children considers the association of active travel to school with general physical activity levels. Do "use the stairs" notices work, asks a team from the New York City Department of Health and Mental Hygiene. This study examined the effectiveness of a prompt ("burn calories, not electricity") across a range of different sized buildings and found an immediate increase in stair climbing, which was also maintained after 9 months. An analysis of the Aerobics Center Longitudinal Study adds a little more to the sum of knowledge about the dynamic relationship between fitness, overweight and cardiovascular health. Exercise on prescription schemes are examined in a systematic review and meta-analysis and are found to be of uncertain value in increasing physical activity, fitness and other health outcomes. A cost effectiveness study also suggested that exercise referral schemes only delivered a "modest increase in lifetime costs and benefits."

Thursday 9 February 2012

Lies, damned lies ...

Widely reported in the press was a study by a team at Oxford University's Department of Public Health that revealed a significant improvement in heart attack mortality over the past 10 years. This was a huge study, using HES data, but although the headline numbers tell a clear story, the reasons behind them are less evident. The study shows both a reduction in heart attacks and a rise in survival from attacks; the fall in heart attacks may well be attributable to improvements in lifestyle, detection and management, but as usual further study is needed. Another day, another set of data: the fourth annual national heart failure audit reports relatively poor outcomes, with high mortality rates, particularly amongst patients not admitted to cardiology wards. In-hospital mortality rates for patients admitted to cardiology wards were less than half those for patients admitted to other wards (8% for cardiology ward patients, 15% for general wards and 17% for other wards). Less than half of all patients with acute heart failure were admitted to cardiology wards. Finally, for the cynics, a paper in BMC Public Health considers the question of how to measure and analyse this kind of data, taking US decline in coronary heart disease as a case study.

Tuesday 24 January 2012

No smoke ...

A study questioning the efficacy of nicotine replacement therapy (NRT) gained the attention of the press. The prospective cohort study carried out by the Harvard School of Public Health looked at relapse rates for quitters, finding that "persons who have quit smoking relapsed at equivalent rates, whether or not they used NRT to help them in their quit attempts". According to the study's authors, NRT is wrongly perceived to help with quitting, rather than simply withdrawal symptoms. A meta-analysis of varenicline for smoking cessation considered 10 trials, finding the treatment effective over 52 weeks, although with the caveat that psychiatric adverse effects merited caution as regards people with pre-existing mental illnesses.

Monday 23 January 2012

Croydon strikes again

Low clinical priority procedures (aka those that appear on the Croydon list) returned to the top of the pile briefly at the end of last year as the Right Care elective surgery project released its phase 1 report. The programme was prompted by an earlier Audit Commission study on reducing spending on low clinical priority procedures. The government took to heart the recommendation that national guidance be developed. However, critics (amongst which was the Federation of Surgical Specialty Associations - FSSA) have argued that the evidence base for this kind of decision-making is poor and that it doesn't sit at all well with the patient choice agenda. Hence the Right Care project, which involved the FSSA. Initial themes from the project include guarded support for national guidance, the suggestion that, since the current terms of art are unhelpful, "there should be a change in terminology to reflect a more holistic approach" and that blanket bans and resultant postcode lotteries should be avoided. A briefing from solicitors Mills and Reeve looks at the legal issues behind decisions about restricting access to low priority procedures.

Friday 20 January 2012

Endgame

Over a fifth of people in England and Wales are dying at home, a study published in Palliative Care reports. The time series analysis, which covered 2004-2010, showed a steady rise, from 18.3% in 2004 to 20.8% in 2010. This increase was also more marked amongst people with cancer and in the older population: it is the first rise in home deaths since 1974 amongst people over 85 years old. Guidance from NICE on commissioning end of life care focuses on designing "high quality evidence based services" supporting the national End of Life Care Strategy and the NICE quality standard. It also includes a benchmarking tool that promises a 10% reduction in hospital admissions that end in death and a possible £52million cost saving. The National End of Life Care Programme has produced guidance for professionals on developing bereavement services.

Wednesday 18 January 2012

Trying to be heard

A paper from the NHS Confederation and the Royal College of Paediatrics and Child Health considers options for involving children and young people in decisions about health and wellbeing services. Looking back at survey data since 2000, it seems that "the voice of under 16s is not included in most national surveys". A study based on experience at Sheffield Children's Foundation Trust assesses effective surveys to measure patient experience amongst children and young people. Meanwhile, Penny Woods from the Picker Institute explains in Pulse how this survey forms the basis for the Children's Patient Experience Questionnaire, from which the new Outcomes Framework indicator on young people's experience of care.

Tuesday 17 January 2012

Data monitor

NHS Information Centre has launched a very useful indicator portal, bringing together in one handy place all those pesky health and social care indicators. The 20th annual Health Survey for England was released last month. Special focus for this issue is respiratory health.

An aspirin a day?

Widely reported in the press was a large-scale review that questioned the use of aspirin for primary prevention in cardiovascular disease. The meta-analysis published in the Archives of Internal Medicine looked at data from 9 RCTs each involving over 1000 participants. Researchers found reductions in non-fatal heart attacks in each trial, but also the chance of suffering serious internal bleeding increased by about 30%. The study's authors conclude that while the benefit for people who already had a history of heart attack or stroke was not in doubt, "routine use of aspirin for primary prevention is not warranted and treatment decisions need to be considered on a case-by-case basis." An article in Pulse quoted several GPs who already advised against aspirin taken in this way and noted doctors should be aware that there was a tendency for patients to self-medicate.

Wednesday 11 January 2012

Futurology

The rallying cry to "make every contact count" has formed the headlines about the NHS Future Forum's latest offering. However, it's by no means the only thing the Forum has to say. The other areas attended to are integration, information and education and training. Regarding information (as leaked just before Christmas), there's a stress on effective data sharing and interoperability rather than a national system, along with more explicit support systems to facilitate the roll-out of full patient access to health records by 2015 and a back-to-basics proposal of universal use of the NHS number at the point of data capture (again!). The proposals about integration focus on the principle of "integration around the patient" and the role of electronic accessible care records and patient reported experience measures. Along with the Future Forum's report on education, there is also a paper out from DH on the subject.