Post 13: January 6 2006
Links are given to online full text resources, all other materials can be obtained via the Fade Library, just mail your request to library.services@fade.nhs.uk
Latest Reports
Wood J, Hennell T, Jones A, Hooper J, Tocque K, Bellis MA (2006) Where Wealth means Health: Illustrating Inequality in the North West. Liverpool: North West Public Health Observatory.
The most comprehensive study of health inequalities in the North West of England yet to be undertaken. The report identifies how a range of the most common, debilitating and life threatening health and social conditions affect those in the poorest areas of the region far more frequently than those in the most affluent.
Evidence from Journals
Economics
Review: prompt endoscopy is not a cost effective strategy for initial management...
Talley
Evid Based Med.2005; 10: 185
Katon WJ, Schoenbaum M, Fan MY, Callahan CM, Williams J Jr, Hunkeler E, Harpole L, Zhou XH, Langston C, Unutzer J. (2005) Cost-effectiveness of improving primary care treatment of late-life depression. Arch Gen Psychiatry. 2005 Dec;62(12):1313-20.
CONTEXT: Depression is a leading cause of functional impairment in elderly individuals and is associated with high medical costs, but there are large gaps in quality of treatment in primary care.
OBJECTIVE: To determine the incremental cost-effectiveness of the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression.
DESIGN: Randomized controlled trial with recruitment from July 1999 to August 2001.
SETTING: Eighteen primary care clinics from 8 health care organizations in 5 states.
PARTICIPANTS: A total of 1801 patients 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%).
INTERVENTION: Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual primary care (n = 895). Intervention patients were provided access to a depression care manager supervised by a psychiatrist and primary care physician. Depression care managers offered education, support of antidepressant medications prescribed in primary care, and problem-solving treatment in primary care (a brief psychotherapy).
MAIN OUTCOME MEASURES: Total outpatient costs, depression-free days, and quality-adjusted life-years.
RESULTS: Relative to usual care, intervention patients experienced 107 (95% confidence interval [CI], 86 to 128) more depression-free days over 24 months. Total outpatient costs were USD $295 (95% CI, -$525 to $1115) higher during this period. The incremental outpatient cost per depression-free day was USD $2.76 (95% CI, -$4.95 to $10.47) and incremental outpatient costs per quality-adjusted life-year ranged from USD $2519 (95% CI, -$4517 to $9554) to USD $5037 (95% CI, -$9034 to $19 108). Results of a bootstrap analysis suggested a 25% probability that the IMPACT intervention was "dominant" (ie, lower costs and greater effectiveness).
CONCLUSIONS: The IMPACT intervention is a high-value investment for older adults; it is associated with high clinical benefits at a low increment in health care costs.
Coast J, Noble S, Noble A, Horrocks S, Asim O, Peters TJ, Salisbury C. (2005) Economic evaluation of a general practitioner with special interests led dermatology service in primary care. BMJ. 2005 Dec 17;331(7530):1444-9.
OBJECTIVE: To carry out an economic evaluation of a general practitioner with special interest service for non-urgent skin problems compared with hospital outpatient care.
DESIGN: Cost effectiveness analysis and cost consequences analysis alongside a randomised controlled trial.
SETTING: General practitioner with special interest dermatology service covering 29 general practices in Bristol.
PARTICIPANTS: Adults referred to a hospital dermatology clinic who were potentially suitable for management by a general practitioner with special interest.
INTERVENTIONS: Participants were randomised 2:1 to receive either care by general practitioner with special interest service or usual hospital outpatient care.
MAIN OUTCOME MEASURES: Costs to NHS, patients, and companions, and costs of lost production. Cost effectiveness, using the two primary outcomes of dermatology life quality index scores and improved patient perceived access, was assessed by incremental cost effectiveness ratios and cost effectiveness acceptability curves. Cost consequences are presented in relation to all costs and both primary and secondary outcomes from the trial.
RESULTS: Costs to the NHS for patients attending the general practitioner with special interest service were 208 pounds sterling (361 dollars; 308 euro) compared with 118 pounds sterling for hospital outpatient care. Based on analysis with imputation of missing data, costs to patients and companions were 48 pounds sterling and 51 pounds sterling, respectively; costs of lost production were 27 pounds sterling and 34 pounds sterling, respectively. The incremental cost effectiveness ratios for general practitioner with special interest care over outpatient care were 540 pounds sterling per one point gain in the dermatology life quality index and 66 pounds sterling per 10 point change in the access scale.
CONCLUSIONS: The general practitioner with special interest service for dermatology is more costly than hospital outpatient care, but this additional cost needs to be weighed against improved access and broadly similar health outcomes.
Briffa TG, Eckermann SD, Griffiths AD, Harris PJ, Heath MR, Freedman SB, Donaldson LT, Briffa NK, Keech AC. (2005)Cost-effectiveness of rehabilitation after an acute coronary event: a randomised controlled trial. Med J Aust. 2005 Nov 7;183(9):450-5.
Objective: To estimate the incremental effects on cost and quality of life of cardiac rehabilitation after an acute coronary syndrome.
Design: Open randomised controlled trial with 1 year’s follow-up. Analysis was on an intention-to-treat basis.
Setting: Two tertiary hospitals in Sydney.
Intervention: 18 sessions of comprehensive exercise-based outpatient cardiac rehabilitation or conventional care as provided by the treating doctor.
Participants: 113 patients aged 41–75 years who were self-caring and literate in English. Patients with uncompensated heart failure, uncontrolled arrhythmias, severe and symptomatic aortic stenosis or physical impairment were excluded.
Main outcome measures: Costs (hospitalisations, medication use, outpatient visits, investigations, and personal expenses); and measures of quality of life. Incremental cost per quality-adjusted life year (QALY) saved at 1 year (this estimate combines within-study utility effects with reported 1-year risk of survival and treatment effects of rehabilitation on mortality). Sensitivity analyses around a base case estimate included alternative assumptions of no treatment effect on survival, 3 years of treatment effect on survival and variations in utility.
Results: The estimated incremental cost per QALY saved for rehabilitation relative to standard care was $42 535 when modelling included the reported treatment effect on survival. This increased to $70 580 per QALY saved if treatment effect on survival was not included. The results were sensitive to variations in utility and ranged from $19 685 per QALY saved to rehabilitation not being cost-effective.
Conclusions: The effects on quality of life tend to reinforce treatment advantages on survival for patients having postdischarge rehabilitation after an acute coronary syndrome. The estimated base case incremental cost per QALY saved is consistent with those historically accepted by decision making authorities such as the Pharmaceutical Benefits Advisory Committee.
Diagnosis
Neurological examination identified 61% of patients with focal cerebral hemisphere...
Holloway
Evid Based Med.2005; 10: 183
Clinical Predication Guide
A web-based clinical prediction tool predicted 10 year survival in breast cancer
Williams
Evid Based Med.2005; 10: 186
An algorithm comprising 7 baseline variables predicted the 2 year work disability...
Evans and Hadler
Evid Based Med.2005; 10: 187
Therapeutics
Epidermal lidocaine safely reduced pain in children having venipuncture at the antecubital...
Hardin
Evid Based Med.2005; 10: 180
A multidimensional non-drug intervention reduced daytime sleep in nursing home residents...
Beghe Evid Based Med.2005; 10: 178
Amlodipine or lisinopril was not better than chlorthalidone for reducing CVD risk...
Rosenberg and Jain
Evid Based Med.2005; 10: 170
A varicella-zoster virus vaccine reduced the burden of illness of herpes zoster...
Fekete
Evid Based Med.2005; 10: 177
Pearlman DS, Berger WE, Kerwin E, Laforce C, Kundu S, Banerji D.(2005) Once-daily ciclesonide improves lung function and is well tolerated by patients with mild-to-moderate persistent asthma. J Allergy Clin Immunol. 2005 Dec;116(6):1206-12.
BACKGROUND: Inhaled corticosteroids are recommended as first-line therapy for persistent asthma.
OBJECTIVE: We sought to assess the efficacy and safety of ciclesonide once daily in patients with mild-to-moderate persistent asthma.
METHODS: An integrated analysis of 2 identical, multicenter, double-blind, randomized, parallel-group, placebo-controlled trials was conducted. Patients (n = 1015; aged > or =12 years) with mild-to-moderate asthma (FEV1 of 60% to 85% of predicted value) were randomized to ciclesonide 80 microg (CIC80), 160 microg (CIC160), or 320 microg (CIC320), once daily (exactuator doses) in the morning or placebo for 12 weeks.
RESULTS: All ciclesonide groups showed significant improvements from baseline to week 12 in FEV1 compared with the placebo group (CIC80, 0.12 L [P = .0007]; CIC160, 0.13 L [P = .0004]; and CIC320, 0.14 L [P < .0001]). Likewise, FEV1 percent predicted, morning and evening peak expiratory flow, 24-hour asthma symptom score, daily albuterol use, and nighttime awakenings were significantly improved in all ciclesonide groups compared with the placebo group. Overall ciclesonide safety profile and rates of oropharyngeal adverse events for all groups were low and similar to those of the placebo group. Fewer ciclesonide-treated patients exhibited asthma-aggravated adverse events, and fewer ciclesonide-treated patients discontinued the study for any reason or because of a lack of efficacy compared with those in the placebo group. No suppression of hypothalamic-pituitary-adrenal-axis function (as assessed by means of 24-hour urinary cortisol levels corrected for creatinine and peak serum cortisol levels after stimulation with low-dose [1 microg] cosyntropin) was observed with any dose of ciclesonide.
CONCLUSIONS: In this integrated analysis, ciclesonide once daily administered in the morning is effective and well tolerated.
Dale, K.M., Coleman, C.I., Henyan, N.N., Kluger, J and White, C.M. (2005)Statins and Cancer Risk: A Meta-analysis. JAMA. 2006;295:74-80. (Requires password avaialable from Fade for full text)
Context: Statins are cholesterol-lowering drugs that have been proven in randomized controlled trials to prevent cardiac events. Recent retrospective analyses have suggested that statins also prevent cancer.
Objectives: To investigate the effect of statin therapy on cancer incidence and cancer death and to analyze the effect of statins on specific cancers and the effect of statin lipophilicity or derivation.
Data Sources: A systematic literature search of MEDLINE, EMBASE, CINAHL, Web of Science, CANCERLIT, and the Cochrane Systematic Review Database through July 2005 was conducted using specific search terms. A review of cardiology and cancer abstracts and manual review of references was also performed.
Study Selection: Twenty-seven of the 8943 articles (n = 86 936 participants) initially identified met the inclusion criteria, reporting 26 randomized controlled trials of statins, with a mean duration of follow-up of at least 1 year, enrolling a minimum of 100 patients, and reporting data on either cancer incidence (n = 20 studies) or cancer death (n = 22 studies).
Data Extraction: All data were independently extracted by 3 investigators using a standardized data abstraction tool. Weighted averages were reported as odds ratios (ORs) with 95% confidence intervals (CIs) using a random-effects model (DerSimonian and Laird methods). Statistical heterogeneity scores were assessed with the Q statistic.
Data Synthesis: In meta-analyses including 6662 incident cancers and 2407 cancer deaths, statins did not reduce the incidence of cancer (OR, 1.02; 95% CI, 0.97-1.07) or cancer deaths (OR, 1.01; 95% CI, 0.93-1.09). No reductions were noted for any individual cancer type. This null effect on cancer incidence persisted when only hydrophilic, lipophilic, naturally derived, or synthetically derived statins were evaluated.
Conclusions: Statins have a neutral effect on cancer and cancer death risk in randomized controlled trials. We found that no type of cancer was affected by statin use and no subtype of statin affected the risk of cancer.
Olson JE, Vachon CM, Vierkant RA, Sweeney C, Limburg PJ, Cerhan JR, Sellers TA. (2005) Prepregnancy exposure to cigarette smoking and subsequent risk of postmenopausal breast cancer. Mayo Clin Proc. 2005 Nov;80(11):1423-8.
OBJECTIVE: To examine the association of cigarette smoking before first pregnancy with risk of postmenopausal breast cancer in a large population-based cohort.
PATIENTS AND METHODS: The Iowa Women's Health Study is a prospective cohort study of 55- to 69-year-old women at baseline in 1986. In January 1986, a questionnaire was mailed to 99,826 postmenopausal women to Identify risk factors for cancer and other chronic diseases; 41,836 women responded (42.7% response rate). The primary analyses examined the associations among smoking, parity, age at first birth, and postmenopausal breast cancer.
RESULTS: Of the 37,105 women in the cohort at risk, 7095 (19%) and 4186 (11%) initiated smoking before and after first pregnancy, respectively, and 2017 breast cancers were identified before December 31, 1999. Compared with parous women who never smoked, women who began smoking after their first full-term pregnancy were not at increased risk of postmenopausal breast cancer (multivariate-adjusted risk ratio, 1.03; 95% confidence interval, 0.88-1.21). However, women who began smoking before their first pregnancy had a slightly elevated risk of breast cancer (risk ratio, 1.21; 95% confidence Interval, 1.07-1.37). Results were not attenuated by adjustment for age at first pregnancy or number of live births.
CONCLUSION: These data suggest that cigarette smoking is associated with a slightly greater risk of postmenopausal breast cancer for women who started smoking before their first full-term pregnancy.
Trials
Latest Questions to the Primary Care Question Answering Service
CAUSES, RISKS AND PREVENTION
Apart from health care workers who else should be vaccinated against hepatitis b as an occupational risk?
What is the incidence of post-operative complications of male religious circumcisions done under local anaesthesia in the community, by non -surgeons. I know that hospital rates are between 2-10 percent.
In treating a 4 month old child with eczema on the face, how long can I continue to use topical steroids, what potency and what risks from prolonged use
Is it possible to transport the flu vaccine in a coolbox (couple of hours) without compromising the cold chain?
Are hydrocolloid dressings useful to combat over granulation in wounds or do they in fact encourage the problem?
Is there a list of drugs where alcohol should be avoided. I can only think of the metronidazole/antabuse family. Patients often worry that they cannot drink when they are on antibiotics and someone showed me the data sheet for lisinopril saying alcohol should be avoided. What is the real list.
What is the evidence for using any one particular bisphosphonate over another in the prevention of osteoporosis - including the new monthly bisphosphonate?
After depoprovera, some patients bleed PV on and off OR continuously. We try giving another depoprovera early. What else can we use to stop it. Is oestradiol 1mg OD any use? One wants to avoid giving a COC pill.
Is there any evidence for the claim often asserted by patients "unable" to loose weight that a person has a 'natural' weight about which their bodies metabolism alters to maintain it?
COC What are the side effects of oestrogen? Of progestogen? The literature is confusing. Some side effects are mentioned under both oestrogen and progestogen.
What is risk to foetus of a women taking subutex (buprenorphine)?
ASSESSMENT AND DIAGNOSIS
When should we check an ESR and what do raised results mean?
Is there any advantage of routinely asking for CRP instead of ESR? I was taught that the main advantage of CRP is monitoring disease activity such as rheumatoid? Which test costs more?
If you take an axillary temperature should you add 1degree to the reading
What's the value of the RNase-L test in the diagnosis of ME/CFS?
DEPRESSION/SELF-HARM
Is there any evidence that asking patients with depression about intention to self harm reduces the risk of subsequent episodes of self harm?
CANCER
Compared to the population of non HIV positive adults with Hodgkins, what is the relative prognosis for Hodgkins disease in HIV positive adults? Does it depend upon CD4 count?
Is there any evidence for the use of metronidazole gel in the treatment of fungating breast cancer? Also can it be used in conjunction with actisorb silver to reduce bacterial load?
A patient has been prescribed Zoladex and Tamoxifen for stage 1 Breast cancer ER+ with clear margins and no lymph node or metatsies, is it necessary to take both treatments.
TREATMENT AND DISEASE MANAGEMENT
In female patients complaining of loss of libido is there any evidence that hormone therapy (oestrogen or progestogen or androgen) is beneficial?
Patient on combined oc pill, how often should the BP be checked, 6 monthly or 3 monthly or yearly ?
CARDIOVASCULAR DISEASES
Is there evidence to start Simvastatin in a borderline hypertensive patient (with normal lipids and very low CHD risk) and who has been diagnosed with disc drusen?
Is previous history of Haemorrhagic CVA an absolute contraindication to Warfarin use in a patient whose Atrial Fibrillation otherwise fits the criteria for warfarinisation?
In primary prevention chd, if a pt does not stop smoking, is there any benefit in actively treating the pts raised cholesterol?
MENTAL HEALTH
In patients with Myalgic encephalitis would adding Modafinil, a CNS stimulant, lead to clinical benefit in terms of reduced daytime sleepiness? Are there any guidelines on whom should prescribe this-primary or secondary care?
EYE HEALTH
What resources are available for electronic diagnostic coding in Ophthalmology?
HEALTH MANAGEMENT
I am trying to find information on the NICE report and bupa wellness poll about refusing treatment to people/patients who are smokers, alcoholics or obese - any ideas where to find it?
Hitting the Headlines - Evidence Behind the Press Stories
Oral contraceptive pill and sex drive
Taking the oral contraceptive pill may lead to a long-term or even permanent decrease in sex drive, reported five newspapers (3 January 2006). The reports are based on a study from the USA of women attending a sexual dysfunction clinic. Full details of the research are not yet available.
Five newspapers (1-5) reported that women who take the oral contraceptive pill may be at increased risk of a long-term reduction in sexual desire because of the pill's suppressive effect on the sex hormone testosterone.
The reports are based on a research article scheduled for publication in the Journal of Sexual Medicine. The researchers studied women attending a clinic for sexual problems. The newspapers reported that levels of sex hormone binding globulin (SHBG), a protein that suppresses the circulation of testosterone in the body, were markedly higher in women currently taking the pill compared with those who had never used it. Two newspapers (2, 5) reported that SHBG levels remained high six months after discontinuing use of the pill.
The full report of the study is not yet available and therefore it is not possible to comment on either the quality of the research or the accuracy of the newspaper reports.
Systematic reviews
Information staff at CRD searched for systematic reviews relevant to this topic. Systematic reviews are valuable sources of evidence as they locate, appraise and synthesize all available evidence on a particular topic.
There were no related systematic reviews identified on the Cochrane Database of Systematic Reviews (CDSR) or on the Database of Abstracts of Reviews of Effects (DARE).
References and resources
1. Pill linked to reduction in women's sexual desire. The Independent, 3 January 2006, p8.
2. Women warned: the Pill can ruin sex drive. Daily Express, 3 January 2006, p8.
3. Taking oral Pill may kill your sex drive for ever. Daily Mirror, 3 January 2006, p21.
4. Taking the pill can affect sex drive, study finds. The Guardian, 3 January 2006, p8.
5. Women say pill is no thrill. The Star, 3 January 2006, p2.
Consumer information
Previous Hitting the Headlines summaries on this topic
The contraceptive pill and sex drive. Hitting the Headlines archive, 26 May 2005.
What's New from the National Library for Health
Smarter prescribing for walking-around antibiotics
Whatever it sounds like, ‘ambulatory care’ might not be quite the same as ‘walking around’, but a new Cochrane review of ways to improve prescribing certainly is about the smarter use of antibiotics.
Link to Review.
0 Comments:
Post a Comment
<< Home