Issue 12.
Drugs
‘less suitable for prescribing’
Concerns about the cost of new
drugs in the NHS make it increasingly important that we use those that are most effective.
Social Audit stated last month that in 1997 30m
prescriptions were written by GPs in England for drug products identified in the British
National Formulary as "less suitable for prescribing". The cost to the NHS in
England was over £100m.
Analgesics (pain killers) and other CNS drugs made
up about two-thirds of the total. For details see the social audit web page on:
http://www.socialaudit.org.uk/5016-BNF.htm. Figure 1 shows a summary. The individual
drugs costing the NHS most were Co-proxomol, costing £14,097 and Tylex - £10,237 in the
year.
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The treatment of
cancer in old age
A recent Age and Ageing
editorial has made the point that the incidence of most tumours rises steeply with age.
This does not correlate with the number of older people receiving therapy. Despite a 23%
decrease in the cancer death rate of those aged 65 years or younger, the death rate in
those aged over 65 has increased by 17%.
Older patients (>71 years of age) are less likely
to have both rectal examination and faecal occult blood testing. In the case of rectal
examination, this reduction has been shown to be stepwise with each decade. Physicians are
still reluctant to perform a rectal examination, despite it being a well tolerated
procedure, even in very elderly patients.
In a study of 140,000 residents in Denmark,
screening for colorectal cancer with faecal occult blood testing was found to be
acceptable, with >90% accepting repeated screenings. There was a reduced mortality seen
in the screened group. The proportion of positive tests after 10 years of follow-up was
highest in individuals over 79 years. This study is on-going to assess compliance for
repeated screenings and the effect of increasing age on detection of tumours.
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Prevention of DVT
Bandolier (#16) reported on systematic review and
meta-analysis of Graduated Compression Stockings and DVT. This showed that the
prophylactic use of stockings in moderate risk surgery resulted in a reduction in risk of
DVTs by 68% and had a NNT of 9 (7-13) compared to no treatment. The low molecular weight
heparins pose a somewhat different problem - but this month we examine some work on these
for comparison.
When randomised controlled trials (RCTs) which compared LMWH
directly with standard heparins in total hip replacement were sought – six were found
involving over 1400 patients.aged 40 years or more.
The numbers needed to treat to prevent one episode
of total DVT using LMWH compared with standard heparin was 17 (10-57) and to prevent one
episode of proximal DVT was 14 (10-24).
Proximal DVT increased hospital stay by 5 days. The
cost analysis showed that this would add about $1,400 to the total cost. The relative cost
of LMWH to standard heparin was an important factor in the cost analysis. If the relative
cost of LMWH was less than 3.7 times that of the standard heparin, the cost analysis
favoured LMWH.
Only when the cost of LMWH was 10 times that of
standard heparin was there a significant balance of cost in favour of standard heparin. In
the UK, LMWH costs about 10 times more than standard heparin.
The cost analysis did not include the cost of
managing recurrent DVT and the post thrombotic syndrome, two potentially important
long-term complications of DVT. Inclusion of these factors in a cost analysis would favour
the use of LMWH.
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Inappropriate
lab tests
Bandolier reported last month on 34 studies looking at the
appropriateness of use of lab tests.
The main results of the study are shown in figure 2. In studies with
implicit criteria, the 34 mentioned above 56% of all tests were thought to be
inappropriate!
About £1.6 billion is spent each year on lab tests. The UK has one of
the best, and cheapest, laboratory services but a high proportion of tests appear to be
inappropriate suggesting that a huge amount of money can be saved at no expense to patient
well-being.
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Complaints Ignored
A National Consumer Council report says that many NHS patients still do
not how to complain about health services, and when they do their complaints are often
ignored.
The report had much of praise for the NHS but pointed to concerns about
mixed hospital wards, infrequent dental check-ups and the suggestion that the NHS is
failing poorer people.
On complaints, the NCC warns that 76% of people who complained about
their GP and 65% of those who complained about hospital services said they received no
response.
An effective system for resolving complaints, and one under which
comments on service provision are welcome, should lead to an NHS in which it is alright to
complain and where staff can learn from users how to provide a more responsive service,
the NCC survey report ‘Consumer Concerns 1998’ advises.
It also notes that patients are concerned about the time they have to
spend waiting in clinics or surgeries before being seen, and about the difficulty of
making appointments.
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The
Quince is one year old!
This is the twelfth edition of The Quince. The aim has been to
stimulate discussion, pass on a little useful advice and be entertaining. It is for our
readers to judge how far we have acheived this.
Quality and clinical effectiveness have moved up the NHS agenda
considerably in the last 12 months which is to be welcomed. A concern is that the narrow
margin in clinical effectiveness work between education and admonition is increasingly
being tested. This can make people wary of the whole agenda.
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