Introduction of the two week wait rule for breast cancer

This study was set up to investigate the long term impact of the two week wait rule for breast cancer on referral patterns, cancer diagnoses, and waiting times.

It was a prospective cohort study in a  specialist breast clinic in a teaching hospital in Bristol.  It looked at all patients referred to breast clinic from primary care between 1999 and 2005.

They looked at the number, route, and outcome of referrals from primary care and waiting times for urgent and routine appointments.

They found that the annual number of referrals increased by 9% over the seven years from 3499 in 1999 to 3821 in 2005. Routine referrals decreased by 24% (from 1748 to 1331), but two week wait referrals increased by 42% (from 1751 to 2490) during this time.

The percentage of patients diagnosed with cancer in the two week wait group decreased from 12.8% in 1999 to 7.7% in 2005, while the number of cancers detected in the "routine" group increased from 2.5%  to 5.3% over the same period.

About 27% of people with cancer are currently referred in the non-urgent group. Waiting times for routine referrals have increased with time.

The authors conclude that the two week wait rule for breast cancer is failing patients. The number of cancers detected in the two week wait  population is decreasing, and an unacceptable proportion is now being referred via the routine route. If breast cancer services are to be improved, the two week wait rule should be reviewed urgently.

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Acupuncture as an adjunct to physiotherapy for osteoarthritis of the knee: randomised controlled trial

This study was set up to investigate the benefit of adding acupuncture to a course of advice and exercise delivered by physiotherapists for pain reduction in patients with osteoarthritis of the knee.

It was a multicentre, randomised controlled trial in 37 physiotherapy centres accepting primary care patients referred from general practitioners in the Midlands, United Kingdom.

352 adults aged 50 or more with a clinical diagnosis of knee osteoarthritis took part.

One third of the patients were given advice and exercise, another third advice and exercise plus true acupuncture, and the last third advice and exercise plus non-penetrating acupuncture.

The primary outcome was change in scores on the Western Ontario and McMaster Universities osteoarthritis index pain subscale at six months. Secondary outcomes included function, pain intensity, and unpleasantness of pain at two weeks, six weeks, six months, and 12 months.

The study showed that the mean baseline pain score was 9.2. At six months mean reductions in pain were 2.28 for advice and exercise, 2.32 for advice and exercise plus true acupuncture, and 2.53 for advice and exercise plus non-penetrating acupuncture.

Mean differences in scores between advice and exercise alone and each acupuncture group were 0.08 for advice and exercise plus true acupuncture and 0.25 for advice and exercise plus non-penetrating acupuncture.

Similar non-significant differences were seen at other follow-up points. Compared with advice and exercise alone there were small, statistically significant improvements in pain intensity and unpleasantness at two and six weeks for true acupuncture and at all follow-up points for non-penetrating acupuncture.

The authors concluded that the addition of acupuncture to a course of advice and exercise for osteoarthritis of the knee delivered by physiotherapists provided no additional improvement in pain scores. Small benefits in pain intensity and unpleasantness were observed in both acupuncture groups, making it unlikely that this was due to acupuncture needling effects.

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Assertive community treatment in psychiatry

Assertive community treatment is a specific model of intensive community mental health care and a key component of the national service framework for mental health in England. Over 220 new teams using this model have been implemented since 1999.

Assertive community treatment originated in the United States, evolving from a pioneering approach to delivery of treatment for people with mental health problems in the community. The treatment has been extensively researched. Good evidence exists for its efficacy outside the United Kingdom, but results in England have been disappointing.

Possible reasons for this include differences in adherence to assertive community treatment and differences between the US and the UK in the comparison group of standard community mental health care. However, even in the UK, clients seen as being "difficult to engage" (those with whom community mental health services have found it difficult to arrange meetings) find assertive community treatment more acceptable than standard community care in terms of satisfaction with services and the amount of contact they have with them.

A systematic review of randomised controlled trials compared the impact on the use of inpatient services of various forms of intensive case management (including assertive community treatment) compared with standard community mental health care.

It found that the way in which the team organises its approach to the work and whether it is implemented in an area with high use of inpatient services accounts for the differences in findings regarding inpatient service use.

The assessment of the organisation of the team was based on whether the team was the primary therapy for its clients; was based off the hospital campus; met daily; shared responsibility for caseloads; was available 24 hours; had a team leader who was also a case manager; and offered services without a time limit.

The authors state that these features reflected the extent that case managers worked as a team rather than as independent practitioners. They suggest that similarities in the organisation of the team between community mental health teams and assertive community treatment teams could explain the lack of efficacy in the UK.

With an increasing focus across all health specialties to provide services in the community, it seems premature to dismantle assertive community treatment teams now that we really know how they should work.

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