• Allogeneic pancreatic islet cell transplantation for type 1 diabetes mellitus
• Intraoperative red blood cell salvage during radical prostatectomy or radical cystectomy
• Interstitial photodynamic therapy for malignant parotid tumours
• Perioperative hypothermia (inadvertent)
• Ulcerative colitis - infliximab
• Abatacept for the treatment of rheumatoid arthritis

• Antenatal care
• Diabetes in pregnancy
• Prophylaxis for Infective Endocarditis
• Maternal and child nutrition
• Mental wellbeing of children in primary education
• Sleep apnoea hypopnea syndrome (obstructive) - continuous positive airway pressure
• Asthma (in adults) - corticosteroids
• Intraoperative nerve monitoring during thyroid surgery
• Suburethral sling insertion for stress urinary incontinence in men

Today’s post based on the excellent material from the NLH Search 2.0 SHA Representatives group.

When to use them?

Whenever you need ready done quality synthesised reviews of the best available evidence.

The Content

• Bandolier - advice about particular treatments for health professionals and consumers based on primary and secondary research.
• Cochrane Library Database of Systematic Reviews - systematic reviews and protocols for future reviews.
• Database of Abstracts of Reviews of Effects - abstracts of systematic reviews published in places other than the Cochrane Library Database of Systematic Reviews.
• NHS Economic Evaluation Database - structured economic evaluations of health care interventions.
• Health Technology Assessment Database - focussing on prevention and rehabilitation, vaccines, pharmaceuticals and devices, medical and surgical procedures and the systems within which health is protected and maintained.

Searching Evidence Based Reviews

Check the Evidence Based Reviews check box in the search box at the top of the NLH page.

This will allow you to conduct a simple search across all of the evidence based review databases and materials.

As yesterday’s post suggested there are key linking phrases available to allow you to define the relationship between concepts in your search. As a reminder we’ve detailed them again below.

• AND - to make sure the words used appear in the results - this will limit your search results.
• OR - to create an either/or link to expand your search
• NOT - to exclude a word from a search (this will limit your search).
• EXACT PHRASE - by putting your search in “speech marks” you will search for the phrase as you type it. This technique also works with Google and other search engines and is a Fade top tip to find relevant material on the internet.

Searching indivdual or Multiple Evidence Based Reviews Whilst Ignoring Others

If you click on the Evidence Based Reviews Link (as illustrated below)

You will be taken to a specific Evidence Based Reviews Search where you can use the check boxes to select the resources as illustrated below. The usual range of linking terms are available to design your search to bring back optimum results (as detailed above).

Advanced searches can also be run using the same set of parameters as described yesterday.

Saving Search Results

To save results requires you to be logged into Athens (which you can get from the NHS here, providing you work for the NHS). Check the check boxes of the items you want to save and then click the button. Alternatively just click on Save Search Result for individual items.

To retrieve items you’ve saved when you’ve logged in with your Athens password jsut click on the Saved Search Results link in the MY SEARCH section of the page.

This is also where you can find Saved Search Histories, Saved Search Criteria and your Search Profiles.

E-Mailing Search Results

You can e-mail individual search results by clicking on the More Details link. This will then bring up an e-mail form (shown below) which you can mail to yourself or a colleague you think will be interested in the item. It has space for you to add your own message.

The Government’s Response to the Health Select Committee’s First Report of Session 2007-08 on the National Institute for Health and Clinical Excellence sets out the Government’s response to the Health Select Committee’s report on the National Institute for Health and Clinical Excellence (NICE). It welcomes and endorses the Committee’s expression of support for and confidence in NICE. Separate reports by the World Health Organisation on NICE’s technology appraisal and clinical guidelines programmes have commended the way in which it discharges its vital responsibilities.

Safe Births: Everybody’s business: An independent inquiry into the safety of maternity services in England from the Kings’s Fund makes the following recommendations:

• Teams themselves should:
  • agree safety-focused objectives
  • identify clear roles and responsibilities
  • utilise clear communication standards and protocols
• Safety should be placed at the heart of shared objectives for maternity services in quality joint working The Royal College of Midwives (RCM) and Royal College of Obstetricians and
• Regular reviews of demand and staffing should be conducted with an emphasis on deliveringthe right skill mix todeliver safe services
• Trust boards and managers should regularly receive information employment levels, skill mix and deployment achieved across all shift.
• Simple and effective tools to help maternity managers to manage employment and deployment, to map demand, capacity and patient flow and to provide timely feedback on levels achieved across all shifts and locations should be developed using work used in other specialties.
• A designated maternity unit manager should keep information on all training completed and planned.  Managers and Boards should reveive regular reports on training.
• RCOG, the Nursing and Midwifery Council (NMC) and the Postgraduate Medical Education and Training Board (PMETB) should spread expertise on skills training and emergency drills to all maternity units by adapting elements of existing simulation based training models and turning them into high-quality training tools that can be
  used locally at minimal cost and disruption
• Safety awareness training must be mainstream professional education at all levels.
• A single set of evidence-based guidelines that are backed by professional organisations, National Institute for Health and Clinical Excellence (NICE) and other organisations shoulddeveloped.
• Guidelines must be supplemented by short one page summaries and usable, consistent protocols.
• All disciplines should be encouraged to familiarise themselves with using guidelines in a local setting and should be trained to use the relevant protocols.  Their use should be regularly audited.
• Annual evidence digests and a national briefing system, tools like Map of Medicine should reinforce use of guidelines.
• A small set of reliable, safety-critical information measures should be collected.
• Simple systems for capturing local information on safety should be designed, implemented and maintained locally.
• Boards must prioritise safety, communicate that to staff and patients and make data on safety publicly available.
• Board members should be trained to strengthen advocacy for maternity safety.
• Governance structures must be in place to assure safety, this should strengthen safety committees and systems for collecting and reporting safety information.
• Regular executive walk-rounds, analysis of claims data, incident reports and other safety indicators, and by reviewing safety incidents in detail should be undertaken.
• Safety must be recognised as a business imperative.
• Standards for the safety of maternity services should be set and monitored only by the Healthcare Commission (in future the Care Quality Commission), with approarpiate advice received by professional bodies.
• Existing standards hould be distilled into a smaller number that are critical to safety, and can beconnected to data that can be collected by teams.
• Strategic health authorities and others providing regional leadership for maternity services should be primed to offer specific support to trusts undergoing reconfiguration.
• DH shouldensure financial incentives are aligned to promote the safest care and to galvanise boards into prioritising safety commissioning and patient choice should act as drivers for improvement.

Latest guidance from NICE.

• Prostate cancer
• Osteoarthritis
• Ventilation tubes (grommets) in children with OME
• Irritable bowel syndrome
• Liposuction for chronic lymphoedema
• Laparoscopic mobilisation of the greater omentum for use in breast reconstruction
• Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal metastases
• Psychosis (first onset) - neuroimaging
• Follicular non-hodgkins lymphoma (recurrent or refractory stage III or IV) - rituximab
• Community engagement
• Smoking cessation

In the Know  (Executive Summary) from the Audit Commision aims to encourage people to think about the information they use whenever they make decisions. It has examples, drawn from many different sources, of how information has been used in improving public services. It notes:

When decision makers use information well, local public services improve.

• The quality and cost of our local public services depend upon the decisions that many people make: users make choices; professionals exercise judgement; managers prioritise; and politicians allocate resources.
• Using information well in decision making leads to better local public services. Examples vary from reducing the number of young people not in education, employment or training to increasing the number of ambulances reaching incidents quickly; improvements include reducing fly-posting by 90 per cent, and increasing library membership by 58 per cent.
• Two-thirds of 3 and 4 star councils use information well, but only a tenth of 1 and 2 star councils do.

Information needs to be relevant for the decision at hand.

• Different decisions require different information, and judging what information is relevant for a decision is not easy.
• Performance indicators alone will not be adequate for important decisions.
• Aggregating information (for example over geography or time), using a range of information from different sources, and sharing information, will generate a fuller picture.

Good quality data are the foundation of good quality information.

• Data should be captured once and used numerous times.
• Data should be sufficiently accurate for the intended purpose. Highly accurate data are often neither cost-effective nor possible for many decisions.
• Decision makers need to judge how quickly and frequently they need information. Some information may need to be updated and available immediately, in real-time, but for many political, financial and strategic issues, understanding trends over time is more important than immediacy.

The way information is presented is important for accurate interpretation.

• Relevant, good quality, information will not help decision makers if they cannot understand it.
• How information is presented, and what story it helps to tell, can affect the decisions based upon it.
• The way information is presented, therefore, needs to be tailored for both the audience and the decision at hand.

Using information well requires decision makers and analysts to have particular skills.

• Decision makers need to be able to identify the information they need and to interpret it accurately.
• Those providing information need strong analytical and presentation skills.
• Evidence suggests that these skills are in short supply.

People need to think carefully about the information they use whenever they make decisions.

• Those who make important decisions about local public services should demand better and clearer information.
• Public bodies need to evaluate whether their information is fit for purpose and used to best effect.
• Relevance, quality and presentation, summarised as RQP, are the key characteristics for useful information.

Updated from Prodigy to new CKS Format:

• Anaemia - iron deficiency
• Immunizations - childhood
• Leg ulcer - venous
• Opioid dependence
• Palliative cancer care - constipation

Clinical summaries of the Topic Reviews issued in February 2008 please follow the links below:

• Clinical summary: Iron deficiency anaemia – assessment
• Clinical summary: Iron deficiency anaemia - management
• Clinical summary: Immunizations childhood programme
• Clinical summary: Immunizations childhood – children up to 1 year of age
• Clinical summary: Immunizations childhood – children 1-2 years of age
• Clinical summary: Immunizations childhood – children 2-10 years of age
• Clinical summary: Immunizations childhood – children over 10 years of age
• Clinical summary: Immunizations childhood – additional immunizations
• Clinical summaries: Leg ulcer venous – uncomplicated venous leg ulcer
• Clinical summaries: Leg ulcer venous – infected venous leg ulcer
• Clinical summaries: Leg ulcer venous – healed venous leg ulcer
• Clinical summaries: Leg ulcer venous – persistent venous leg ulcer
• Clinical summaries: Opioid dependence – new presentation
• Clinical summaries: Opioid dependence – Considering substitution therapy
• Clinical summaries: Opioid dependence –Starting and stabilizing on maintenance therapy
• Clinical summaries: Opioid dependence – Continuing maintenance therapy
• Clinical summaries: Opioid dependence – Detoxification – from maintenance therapy
• Clinical summaries: Opioid dependence – Detoxification – not on maintenance therapy
• Clinical summary: Opioid dependence – Missed or vomited doses
• Clinical summary: Opioid dependence – Acute withdrawal syndrome
• Clinical summary: Opioid dependence – Collapse due to opioid overdose
• Clinical summary: Opioid dependence – Travelling abroad
• Clinical summary: Opioid dependence – Unknown patient
• Clinical summary: Palliative cancer care – constipation

To access this video you will be required to give some details about yourself to HealthExecTV.

David Stout, Director of PCT Network at the NHS Confederation, shares his vision for World Class Commissioning and its potential to transform health services and drive improvements in health outcomes.

He advises on how Trusts can step-up their current approaches in World Class ways - for example, planning for the longer term needs of the population through more effective public engagement and techniques such as risk stratification.

In particular, Mr Stout defines the role of the NHS Confederation and how they are supporting PCTs in their transition.

To access this video you will be required to give some details about yourself to HealthExecTV.

The World Class Commissioning initiative provides a major opportunity for Trusts to transform care services and develop new ways of maximising the value of limited healthcare budgets.

While Trusts wait for the WCC Assurance Framework, there are many ways to start planning the transition to World Class Commissioning. Evidence-based analysis of population requirements, how money has been spent and how other organisations are approaching commissioning is a key starting point.

In this interview, Andrew Beale, Executive Director of Matrix Knowledge Group consultancy, discusses how evidence-based analysis can help Trusts to better understand their current position, population healthcare patterns and to maximise the benefit of their investments within the available resources.

Consultations from NICE seeking views on a clinical practice guideline developments for:

• Familial hypercholesterolaemia: consultation
• Lipid modification: Consultation on section 4.3 - Cardiovascular risk assessment

and requesting views on the use of erlotinib to treat small-cell cancer.

• Lung cancer (non-small cell) - erlotinib (appraisal consultation)

From the Center for Evidence Based Physiotherapy based at the School of Physiotherapy at the University of Sydney, as a database it provides the model for yesterdays OT Seeker.  The aim of PEDro is to make the bibliographic details and abstracts of randomised controlled trials, systematic reviews and evidence-based clinical practice guidelines in physiotherapy readily available.

OT Seeker is a database of systematic reviews and randomised controlled trials relevant to occupational therapy and was developed by OTs at the University of Queensland and University of Western Sydney.

Guidance offering evidence-based recommendations on how to improve the physical environment to encourage physical activity. It demonstrates the importance of such improvements and the need to evaluate how they impact on the public’s health

• PH008 Physical activity and environment: Quick reference guide
• PH008 Physical activity and environment: Guidance
• 2008/004 New NICE public health guidance on creating environments to encourage physical activity
• PH008 Physical activity and environment: Costing report

• Interventions in medicines reconcilliation at the point of admission
• Physical activity and environment
• Psoriasis - infliximab
• Ultrasound guided catheterisation of the epidural space
• Arteriovenous extracorporeal membrane carbon dioxide removal
• Mesothelioma - Pemetrexed

Creating a stir in the news today is House of Commons Committee of Public Accounts (2008) Department of Health: Prescribing costs in primary care: Second Report of Session 2007–08: Report, together with formal minutes, oral and written evidence. London: TSO it concludes and recommends:

1. The NHS could save more than £200 million a year, without affecting patient
   care, by GPs prescribing lower cost but equally effective medicines.
   • Generic drugs should be prescribed
2. The proportion of prescriptions written by chemical name rather than by brand
   name, known as generic prescribing, rose from 51% in April 1994 to 83% in
   September 2006.
   • Where it is clinically appropriate, GPs should prescribe those available in generic form.
3. The proportion of lower cost prescriptions for some common conditions varies
   greatly between Primary Care Trusts (PCTs), for example between 28% and 86%
   for statins.
   • Strategic Health Authorities should work with the National Prescribing
     Centre to spread best practice in prescribing and help those PCTs that have difficulty implementing switching programmes to learn from PCTs that have successfully one so.
4. Comparing GP practices and PCTs on indicators of efficient prescribing is an
   effective way of influencing prescribing behaviour.
   • The Department, with the NHS Institute for Innovation and Improvement, should develop more ‘Better Care, Better Value’ prescribing indicators to measure the proportion of generics dispensed and the level of potential savings where more cost effective prescribing would generate significant savings.
   • Strategic Health Authorities should use these indicators to hold PCTs to account for prescribing costs.
5. Despite large variations between PCTs in prescribing efficiency, nearly all GP
   practices achieve maximum points on the ‘medicines management’ indicators in
   the Quality and Outcomes Framework.
   • The Department should strengthen the medicines management
     indicators when the Quality and Outcomes Framework is next renegotiated, and set more ambitious prescribing improvement targets for practices in order to be warded the medicine management points. The Framework should also reward GPs or prescribing drugs that are available in generic form when clinically appropriate.
6. One in five GPs responding to the NAO’s survey said pharmaceutical companies
   had more influence on prescribing decisions than official advisers.
   • The Department should specify the minimal level above which gifts, hospitality, etc provided to prescribers by pharmaceutical companies should be disclosed to the PCT.
   • PCTs should publish an annual register of this information.
7. Hospital consultants’ prescribing choices are bound by agreed ‘formularies’ of
   cost effective drugs, but GPs are generally not subject to formularies.
   • The Department should encourage PCTs to pilot joint primary/secondary care formularies.
   • Strategic Health Authorities should work with the National Prescribing Centre to promote agreement and consistency of formularies across primary and secondary care, and across PCTs.
8. 88% of prescription items are dispensed free, and the remainder for a standard
   charge not directly linked to actual cost.
   • The Department should do more to make atients aware of the costs of drugs, and hence the importance of not wasting them, for example by displaying on dispensed drugs information such as the cost of the specific items dispensed or an indication of the typical cost of items to the NHS.
9. Unused and wasted drugs cost the NHS at least £100 million a year.
   • The Department should commission research to establish the
     extent to which medicines are not used, and establish the reasons why patients do not take their drugs.
10. Generic versions of drugs can vary considerably in appearance, colour and
    packaging.
    • The Department should explore with the industry the scope to achieve greater consistency of appearance, labelling and/or packaging of the more common drugs supplied to the NHS.

A key document that should be read in conjunction with this is Prescribing in primary care: Understanding what shapes Scoggins, A, Tiessen, J., Ling T and Rabinovich L (2006) GPs’ prescribing choices and how might these be changed. London: RAND. This survey conducted on behalf of the National Audit Office and has been drawn on heavily by the Public Accounts Committee.

The House of Commons Health Committee. National Institute for Health and Clinical Excellence: First Report of Session 2007–08, Volume I: Report, together with formal minutes

The report identifies the following problems

• Topic selection. Only a few selected medical technologies are chosen as suitable for assessment as technology appraisals. There is also far too little emphasis on disinvestment. Here we found NICE’s responses to our questions disingenuous. While few older treatments may do no good at all, many will not be cost-effective;

• The wider benefits of treatment to society, for example to carers, are not included in NICE’s economic evaluations;

• NICE often does not have all the information it needs to make a full assessment. It does not have access to all the information the Medicines and Healthcare products Regulatory Agency (MHRA) uses and clinical trials are usually designed without NICE’s work on cost-effectiveness in mind;

• Experts are not sufficiently well used; and

• Publication of guidance is slow; licensed medicines are often not prescribed while PCTs and clinicians wait for NICE to make a decision.

Key recommendations are:

• The need for a system whereby all medicines are assessed at launch. A shorter, less in-depth evaluation should be made between the time of licensing authorisation and marketing, so that clinicians can prescribe useful and cost-effective drugs as soon as they are launched.  A lower cost-per-quality adjusted life year (QALY) threshold should be employed during this early assessment to ensure that only the products that are most cost- and clinically effective are available straightaway.

• NICE should have access to the same material used by the licensing body, clinical trials should be registered and there should be closer working between NICE and the pharmaceutical industry.

• Evaluation of older, possibly cost ineffective therapies should take place too

• Legislation shoul be changed to accommodate the need to ensure that assessments of products take account of the wider benefits to society

• The threshold used by NICE in its full assessments be reviewed; further research comparing thresholds used by PCTs and those used by NICE should be undertaken. An independent body should determine the threshold used when making judgements of the value of technologies to the NHS.

• Elements of clinical guidelines should be made mandatory. A suitable example would be risk assessment for all patients at risk of developing venous thromboembolism.

• Better mechanisms are needed to ensure that the NHS pays a fair and affordable price for medicines. We recommend that NICE should be involved in any new system and that any change to its remit should be adequately resourced.

• Risk-sharing schemes, such as the recently approved case of bortezomib (Velcade) and the older example of beta interferon and glatiramer acetate, should be used with caution. They hould not be used as a catch-all in cases of uncertainty over a drug’s benefit. Uncertainty could be better addressed by the careful design and performance of a publicly funded randomised controlled clinical trial. Better use should be made of NICE’s ‘only in research’ recommendation in this regard.

The rport identifies issues with uptake of guidance by PCTs to ensure this happens NICE should offer:

• More help for PCTs to implement guidance
• Better assessment of the level of uptake
• PCTs should play a larger role in the development of guidance
• Better use of experts in the development of guidance

The report though concludes that conclude that NICE does a vital job in difficult circumstances. The development of more and more health technologies and procedures, alongside rising patient expectations and the ageing population, is going to make it even more difficult in the future. Healthcare budgets in England, as in other countries, are limited. Patients cannot expect to receive  every possible treatment. Demand outstrips resources and priorities have to be determined.  Rationing is essential, and NICE has a key role to play.

The Database of Uncertainties about the Effects of Treatments (DUETs) has been established in the UK as a resource to help prioritise research by identifying uncertainties that cannot currently be answered by referring to reliable up-to-date systematic reviews of existing research evidence.

DUETs draws on three main sources to identify uncertainties about the effects of treatments:

• patients’, carers’ and clinicians’ questions about the effects of treatments
• research recommendations in reports of systematic reviews and clinical guidelines
• ongoing research, both systematic reviews in preparation and new ‘primary’ studies

Top tip: On the home page, for an idea of the content, click on BROWSE on the left hand side, you will see a list of Topic areas covered.

Posted with a tip of the still missing Ushanka to Sue over at the Lancashire Care Library and Information Service blog.

New from the Trip Database comes the Critical Care Trip Search which searches the following journals alongside core Trip resources.

Critical Care Medicine
Pediatric Critical Care Medicine
Intensive Care Medicine
American Journal of Respiratory and Critical Care Medicine
Intensive Care Medicine
Critical Care Nurse
Dimensions of Critical Care Nursing
American Journal of Critical Care
Australian Critical Care
Anesthesiology
Anesthesia and Analgesia
British Journal of Anaesthesia
Anaesthesia

Advanced warning the Fade Nativity is on the way…