Issue 99
Patients with most to gain are least
likely to get drug treatments for heart failure
We already know
that patients with heart failure don't always
get the drug treatments they need.
But a new study shows that
the sickest patients are the most
likely to miss out.
In a cohort
of 1418 hospital patients with heart
failure, researchers found
a paradoxical relation between risk
of death and treatment with
blockers, angiotensin converting
enzyme (ACE) inhibitors, and
angiotensin II receptor blockers.
All three classes of drug
are known to prolong survival in
patients with heart failure
and are recommended in management
guidelines from Canada and
the United States.
In this Canadian
study, discharge data from a national database
showed that 81% of low risk patients
and 60% of high risk patients
were given ACE inhibitors on
discharge from hospital; 86% and
65% were given either ACE inhibitors
or angiotensin II receptor
blockers; 40% and 24% were given
beta-blockers. The inverse trend
was significant for all three drug
classes.
The mismatch
between need and treatment persisted for at least 90 days, and was
not explained by patients' age or sex, the
presence of other serious diseases
such as cancer, or contraindications
to the drugs. All patients were
younger than 80 and had a left
ventricular ejection fraction of
less than 40%.
The authors say
that high risk patients have the most to gain
from drug treatment, which is the
cornerstone of management
for heart failure. More should be
done to find out why they
don't get it.
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GPs beat expectations for quality
Even the Daily
Express (Sep 1:2)—not instinctively sympathetic to the NHS—said
"most family doctors are providing their patients with a high
quality of care that beats expectations. "Healthcare systems around
the world are looking for ways to drive up quality. Sheila
Leatherman, an executive vice president with the US based United
Healthcare group and a member of President Clinton's Commission on
Health Care Quality, has described the UK's attempts to do that—not
just through the new GP contract but through the National Institute
for Health and Clinical Excellence, the national service frameworks,
the National Patient Safety Agency, and other measures—as the most
ambitious in the world.
A mechanism that
works, and one that shows without any doubt that GPs respond to
financial incentives to improve the quality of care, not just its
volume, will be generally welcomed, not least because the new
contract potentially provides a database on chronic disease that
will underpin research and allow services to be much better
targeted. From the point of view of NHS finance officers some news
was rather less good, at least in the short term. When the contract
was signed it was expected that GPs would, on average, achieve
around 75% of the maximum score. The better than expected
performance has cost primary care
trusts in England around £200m more than planned, and spending in
the rest of
the UK has been, relative to the
population, even higher.
But although the GPs'
scores are good, they are in practice
only the
earliest and first test of the new approach. The clinical
standards in areas such as asthma, diabetes, heart disease,
and
chronic obstructive pulmonary disease were selected because
it was
judged that in these areas the evidence was good that
better
care in the community would produce better health outcomes.
The data
are still being tested for that. Mike Farrar, chief
executive of the West Yorkshire Strategic Health Authority and
one of
the lead NHS negotiators for the original contract, said
that
early figures emerging in Birmingham and the Black Country
and in
Hertfordshire and Bedfordshire show that hospital attendances
among
patients in the target groups have fallen.
How far hospital
attendances fall and how widely the falls occur
will be
an important test of whether this new approach does
actually
deliver the goods: better care in the community, a
reduced
load on hospitals, improved outcomes, and higher satisfaction
for
patients.
The spectacularly
high scores do raise the question of whether
the
targets were pitched too low, in other words that the exercise
was too
easy. The answer almost certainly has to be yes. But that, as a
criticism, is itself too easy. It was always
going to
be hard to place the hurdle at just the right height
the
first time around. And the deal was always intended to be
an
iterative process: what is counted in and what is rewarded
will
change over time, and work is already under way to revise
it.
How effectively the
framework evolves—as well as showing
that
hitting the standards has indeed produced the expected
improvement in care—will, in the end, be the acid test
of this
initiative. Negotiating such moves will not be simple. If it is
achieved,
the new
contract will be rated as ground breaking, not just
in the
UK but internationally. If it is not, it will go down
in
history as a mighty one-off pay rise that delivered only
a
distinctly limited gain, rather than continuous improvement.
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Diagnostic value of systematic prostate
biopsy
This is a
reminder of the excellent series of systematic reviews produced by
the Centre for Reviews and Dissemination at York. This particular
report says that there are a number of prostate biopsy schemes and
strategies established in routine practice, which use systematic,
rather than lesion directed, biopsy patterns. The ways in which they
vary relate to their two main features:
The
systematic sextant biopsy protocol, a fixed pattern with six cores
from the mid-lobar peripheral zone, has been the standard procedure
used for many years. However, recent tudies with more extended
schemes have shown that the sextant protocol fails to detect between
10% and 30% of cancers. Consequently many new biopsy protocols have
been proposed.
The
addition of laterally directed cores from the lateral peripheral
zone to the mid-lobar peripheral zone increases the yield
significantly. Biopsy schemes with 18-22 cores from the 5-region
pattern showed the highest cancer yield of the
schemes. However, the cancer yield of 12 cores from the mid-lobar
peripheral zone plus lateral peripheral zone pattern and 10 cores
from the 5-region pattern was not significantly lower.
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