Quit smoking advice at work, from NICE

The National Institute for Health and Clinical Excellence (NICE) has issued advice on the support that smokers should be offered in their workplace to help them quit smoking. The new advice comes as workplaces in England prepare to go smoke-free from 1 July, creating an additional opportunity to help improve health by supporting those smokers who want to give up.

Smoking costs the NHS an estimated £1.5 billion each year, and costs industry an estimated £5 billion in lost productivity, absenteeism and fire damage. The new laws banning smoking in workplaces are expected to motivate smokers who want to quit, to finally give up.

The new advice is aimed mainly at employers, but also at employees and those responsible for ensuring workplaces go smoke-free and for providing stop-smoking support.

The NICE guidance recommends the most effective ways to encourage and support employees to stop smoking.  These include providing information on local stop smoking services, and allowing smokers to attend stop smoking clinics during working hours without loss of pay.

Providing stop smoking support in the workplace will not only help employees who smoke to quit, but will also help employers and employees stay the right side of the new laws. As a healthier, smoke-free workforce means increased productivity, providing stop smoking support makes good business sense for employers.

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NICE guideline for Parkinson's disease

Parkinson's disease is one of the commonest chronic neurological conditions, affecting up to 1.6/1,000 of the general population. Prevalence rises sharply with age with up to 2% of the population aged 80 years and over affected.

The National Institute of Clinical Excellence (NICE) guideline for Parkinson's disease (PD) was published in June 2006 and covers a wide spectrum of clinical management including diagnosis, pharmacological and non-pharmacological therapies and palliative care. Of particular interest is the focus on service delivery and the emphasis on multi-disciplinary care.

A key recommendation is that PD patients should be referred quickly and untreated to a specialist for diagnosis and ongoing follow-up. This is based on the recognition that the diagnosis of PD remains clinical and can be challenging, with substantial error rates reported in both post-mortem and community-based series.

In practice, it is often difficult to differentiate true Parkinsonism from other tremor disorders, and the guideline recommends that I-FP-CIT single photon emission computed tomography should be made available to specialists with expertise in its use and interpretation. Because of the psychological stress of diagnostic delay it is suggested that all patients with suspected PD are seen within 6 weeks of referral (2 weeks for complex cases).

Another key recommendation is that people with PD should have regular access to specialist nursing care, occupational therapy, physiotherapy and speech and language therapy. The guideline recognises that more evidence of effectiveness is required in these areas, but the experience of the clinicians on the guideline development group (in common with most specialists managing PD) led to their support for therapy interventions, nonetheless.

Widespread implementation of the above recommendations on service delivery will be challenging. Whilst the availability of specialist PD services has increased substantially over the past decade, there are still large areas of the country without ready access. Nearly 20% of patients are currently never referred for specialist opinion.

Waiting for the first assessment was raised as one of the most significant issues. The Parkinson's Disease Society (PDS) has welcomed the 6-week limit but has pointed out that current practice is well short of this target. PDS research showed that only 4% of people referred to a neurologist had an appointment within 6 weeks and over 50% waited over 12 weeks.

Waiting times for Geriatric medicine were rather better, but 44% of people referred waited for over 6 weeks, and 13% waited over 12 weeks.

The PDS also warns that, although there are currently 220 PD Nurse Specialists (PDNS) employed across the United Kingdom, there will need to be significantly more in order that all people with PD have access to this key practitioner. All of the recommendations for audit in the guideline are concerned with the quality of  service delivery reflecting the fact that this is seen as the key priority for implementation.

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Telephone interventions for management of heart failure

Several randomised trials have established that disease management programmes offering, for example, home visits, heart failure clinics, and telephone interventions result in better adherence to treatment and reduced admissions to hospital for heart failure than standard care. Current evidence is unclear, however, on the impact of such programmes on mortality, all cause admissions, quality of life, and cost reduction.

The BMJ recently presented a meta-analysis that includes 14 trials of telephone interventions in heart failure; it shows an overall 21% reduction in admissions for heart failure (but not in total admissions) and a 20% reduction in total mortality. The authors also report a benefit of these interventions on quality of life and cost reduction. The two types of intervention—structured telephone support and  telemonitoring—were similarly effective.

The authors reported a reduction in mortality, but this effect was seen in only one structured telephone study. Conversely, in the largest trial done so far, mortality was not reduced, although admissions for heart failure were significantly reduced.

Evaluations of complex interventions with multiple and simultaneous strategies should aim to answer questions about how the interventions work and which of their components are essential. Available evidence suggests that disease management interventions in heart  failure should incorporate education on self care and adherence to diet and medicines; monitoring and surveillance to detect early signs of decompensation; people trained in heart failure management to provide the interventions; and facilitated access to specialised care for any clinical deterioration.

Overall, the evidence supports telephone interventions in the management of heart failure. But, there have been no head-to-head comparisons of different disease management strategies, any intervention that includes education, monitoring, facilitated access, and trained personnel may be effective, no matter how it is delivered.

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