IMPACTE Groups - NHS Networks · 2 Glasziou, P. (2010) The impact of IMPACTE Groups: ... Created by Anne Gray ([email protected] ) and Ann Skinner

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IMPACTE Groups

Improving Medical Practice by Assessing CurrenT Evidence

Summaries of Group Discussions

in

MK Primary Care

2010

Quality:MK project1: IMPACTE workstream2

Compiled by: Date

Primary Care / eLearning Librarian, MKH Library Services January 2013

1 Saffin, K. (2010) Quality:MK Engaging with quality in primary care: A qualitative evaluation study commissioned by Milton

Keynes Primary Care Trust. Final report. Oxford, SPH. 2 Glasziou, P. (2010) The impact of IMPACTE Groups: Use of EBM journal clubs in general practice.

mailto:[email protected]

Quality:MK

IMPACTE group Date Topic

Broughton 30/06/2010 Managing abnormal LFTs

Broughton 25/08/2010 Management of UTI - symptom severity, duration and use of

antibiotics

Broughton 20/10/2010 GORD (gastric reflux / dyspepsia) and H pylori managemen

Broughton 20/10/2010 Hypertension in pregnancy

Broughton 20/10/2010 Transient loss of consciousness - blackouts

Broughton 20/10/2010 Heart failure

Broughton 24/11/2010 QRISK2 CVD risk assessment tool

CMK 26/03/2010 In patients with treated hypertension or recent TIA, what is

the relationship between various prognostic factors and risk of

CMK 04/06/2010 Vitamin D deficiency protocol

CMK 27/08/2010 Diagnosis of diabetes

CMK 27/08/2010 Audit report: Concomitant prescribing of triptans & SSRIs

CMK 27/08/2010 Audit report: Vitamin D deficiency

CMK 24/09/2010 GP consultations and self care for minor illness

CMK 29/10/2010 Pain referrals: clinical review - CMK Medical Centre audit

results

MK Village 28/05/2010 Review of NICE guidance on childhood UTI

MK Village 25/06/2010 Review of 2009 contraception guidelines

Parkside 02/02/2010 Management of dyspepsia; when to refer to endoscopy, when

to test for h pylori

Parkside 08/03/2010 What is the best way of managing UTI?

Parkside 30/03/2010 Psychotherapeutic tools to help adolescents in primary care

Parkside 04/05/2010 What are the risks & benefits of using quinine for muscle

cramps?

IMPACTE meetings 2010

IMPACTE 2010 MKH Library Services 2013-01-22

Quality:MK

IMPACTE group Date Topic

IMPACTE meetings 2010

Parkside 11/05/2010 Review of current guidance on the management of chest pain

Parkside 11/05/2010 Are we complying with best practice in the way we fit coils?

Parkside 18/05/2010 What is the current guidance for reducing the risk of venous

thromboembolism (VTE)?

Parkside 25/05/2010 What is the clinical significance of recent research on the

relationship between visit-to-visit variability of blood pressure

Parkside 15/06/2010 Review current NICE guidance on the management of LUTS in

men against current practice

Parkside 13/07/2010 Are we prescibing high levels of benzodiazepines and what

levels are harmful?

Parkside 13/07/2010 What is the latest guidance on bacterial meningitis?

Parkside 03/08/2010 Is it safe to manage alcohol detoxification in the community?

Parkside 09/11/2010 NICE guidelines on hypertension in pregnancy

Stony Stratford 16/06/2010 What is the evidence for the benefits & harms of long term

use of SSRIs and newer anti-depressants in adults with major

Stony Stratford 04/11/2010 Do ARBs affect cancer occurrence?

Wolverton 08/07/2010 Management of UTI

IMPACTE Central 09/02/2010 What has happened before a female patient comes to see their GP with suspected UTI?

IMPACTE Central 09/03/2010 Should we prescribe low dose aspirin to prevent CHD in patients with type 2 diabetes?

IMPACTE Central 13/04/2010 Is there an association between an educational program in mindful communication and primary care physician's burnout, empathy and attitude?

IMPACTE Central 01/06/2010 How accurate are diagnostic tests for identifying celiac disease

in adults presenting with abdominal symptoms in primary care

IMPACTE Central 13/07/2010 Doctors as patients

IMPACTE Central 12/10/2010 Does use of oral bisphosphonates increase the risk of cancer of oesophagus, stomach, and colorectum?

IMPACTE Central 09/11/2010 Effect of calcium supplements on risk of MI and cardiovascular

events

IMPACTE 2010 MKH Library Services 2013-01-22

Quality:MK

Quality:MK a whole system approach to quality improvement driven by primary care, patient engagement and evidence

health:mk IMPACTE summary v1.3 December 2009. Created by Anne Gray ([email protected] ) and Ann Skinner ([email protected] ) You may use this in its present form or adapt it for your own use but we request that you acknowledge Quality:MK and the original authors

IMPACTE Group summary

Practice/Group: CMK Medical Centre Date: 26 March 2010 Question/Topic :

In patients with treated hypertension or recent TIA, what is the relationship between various prognostic factors and risk of stroke?

Evidence used: i.e. References

Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension (Rothwell, P M et al) The Lancet, Volume 375, Issue 9718, Pages 895 - 905, 13 March 2010

Type of evidence

1RCT, 2Systematic Review 3Qualitative Research 4Guideline Prognosis; review Prompts on how to appraise the different types of evidence, and space for comments are given on the back of this sheet.

What the evidence is about Population/Setting

Patients with a recent TIA; patients with treated hypertension. 4 studies were used – 1) UK-TIA randomised trial 1979-1985 [J Neurol Neurosurg Psychiatry 1991; 54: 1044-

54]; 1200mg vs 300mg aspirin vs placebo in 2435 patients with a recent TIA or ischaemic stroke; analysis of 2006 patients presenting with TIA only – 1438 men, mean age 60.3yrs, median time since TIA 23 days.

+ 3 other TIA and stroke cohorts 2) European Stroke Prevention Study (ESPS-1 [Lancet 1987; 330: 1351-54]; 2500

patients randomly assigned to dipyridamole plus 325mg aspirin vs placebo; analysis of placebo group only ? patients

3) Dutch TIA trial [N Engl J Med 1991; 325: 1261-66]; 3150 patients randomly assigned to 30mg aspirin vs 283mg aspirin; sub-group of 1473 patients randomly assigned to 50mg atenolol vs placebo

4) ASCOT-BPLA randomised control trial [Lancet 2005; 366: 895-906]; included 2011 patients with previous TIA or stroke; patients with hypertension, aged 40-79 yrs with 3 or more other vascular risk factors but no coronary heart disease randomly assigned to 2 antihypertensive regimes – amlodipine with perindopril as needed vs atenolol with bendroflumethiazide and potassium as needed

Intervention:

Comparison: (optional)

Outcome: Risk of stroke or other vascular event in relation to prognostic factors Prognostic factors: visit-to-visit variability in blood pressure, maximum systolic blood pressure, untreated episodic hypertension and residual variability

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? “More work is needed to identify measures that would combine the prognostic information associated with visit-to-visit variability in blood pressure with ease of use in routine clinical practice … “ (Rothwell p.904) No causal link between variability in blood pressure (or maximum SBP) and stroke – more research is needed using large-scale pooled analysis of multiple cohorts. See also ‘Rothwell, P.M. Effects of antihypertensive-drug class on interindividual varation in blood pressure and risk of stroke: a systematic review and meta-analysis. The Lancet, Volume 375, Issue 9718, Pages 906 - 915, 13 March 2010’

IMPACTE summary v1.3 December 2009. Created by Anne Gray ([email protected] ) and Ann Skinner ([email protected] ) You may use this in its present form or adapt it for your own use but we request that you acknowledge Quality:MK and the original authors

Higher systolic reading is a predictor of stroke. Anti-hypertensive drug class-specific effects on risk of stroke; calcium-channel blockers seem to reduce risk to a greater extent? But, for now, need to continue to follow current guidelines. Discussion points How practically do you measure variability in blood pressure? Home monitoring vs clinic readings Instrumentation - mercury sphygmomanometer vs electronic readings. White coat syndrome. Choice of anti-hypertensive drug class. How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

.Drafted by: Linda Potter Date: 06/04/10 verified by: Cheryl Manna Date: 06/04/10 Appraisal of different types of evidence

1RCT

Recruitment Were the subjects representative of the target population?

Allocation? Was the treatment allocation concealed before randomisation, were the groups comparable at the start?

Maintenance Follow up over 80%?

Measurements Were the outcomes measured with: Blinded subjects and assessors and/or Objective outcomes?

UK-TIA – 66% (1324) of patients reached visit 7 Blood pressure measurements in the 4 studies UK-TIA – sitting after rest, mercury sphygmomanometer, measured once at every 4mth follow-up visit (? yrs); variables were calculated from visits 1-7 (0-24mths) and from 1-10 (0-36mths) ESPS-1 – sitting after rest, mercury sphygmomanometer, mean of left and right arm, measured at follow-up visits every 3mths for 2 years Dutch TIA - sitting after rest, mercury sphygmomanometer, measured at follow-up visits every 4mths for a mean of 2 . 6 years ASCOT-BPLA – sitting after 5 min rest, validated semi-automated oscillometric device, measured at every visit (baseline 6 wks, 3 mths, 6mths and every 6mths thereafter). Participants at 4 centres had yrly 24-h ABPM with readings every 30 min. Mean time-weighted daytime (0900 – 2100h), night time (0100-0600h) and 24-h SBP and DBP were calculated.

Statistical Results: eg Risk Reduction (RR), Number Needed to Treat (NNT), Number Needed to Harm (NNH), Confidence Intervals (CI), P values

2Systematic review


Question Does the research ask a clearly focussed question (PICO) and is it relevant?

Found all studies Did the search find all of the best evidence? (search strategy/publication bias

Appraisal/quality Have the studies been critically appraised

Synthesise Have the results been synthesised with appropriate summary tables and plots?

3Qualitative Research

Sampling strategy: Data collection methods : Data analysis methods: Relationship between the researcher and participant

:

4Guidelines Nationally recognised Guidelines e.g. NICE, SIGN, BTS are assumed to be based on high quality evidence and do not need to be appraised.

Quality:MK




Practice/Group: CMK Medical Centre Date: 4 June 2010 Question/Topic :

Vitamin D deficiency protocol


Presentation by Dr Anne Jenkins, Consultant Rheumatology

Type of evidence

1RCT, 2Systematic Review 3Qualitative Research 4Guideline Prompts on how to appraise the different types of evidence, and space for comments are given on the back of this sheet.


Intervention:


Outcome:

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? Levels of deficiency / sufficiency in nmol/l Severe <25; Deficiency 25-50; Insufficiency 50-75; Replete 75-200; Toxicity >400 Issues in sourcing Vit D preparations – colecalciferol, ergocalciferol

Discussion points Risk factors for Vit D deficiency Assessing the patient Whether to assay & how many times Treatments during pregnancy & breastfeeding Sourcing unlicensed Vit D preparations How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

Investigate sourcing Vit D preparations

SN

Search for more information on (a) the practicalities of treating Vit D deficiency in children and (b) Bristol & Birmingham protocols

LP

.Drafted by: L Potter Date:23/6/10 verified by: C Manna Date: 24/06/10


Appraisal of different types of evidence

1RCT






2Systematic review







:


Quality:MK




Practice/Group: IMPACTE Central Date: 9 February 2010 Question/Topic :

What has happened before a female patient comes to see their GP with suspected UTI?


A journey from self care to GP care: a qualitative interview study of women presenting with symptoms of UTI Br Journal General Practice 2009; v59: 490-5

Type of evidence

1RCT, 2Systematic Review 3Qualitative Research X 4Guideline


Female patients in General Practices across 4 counties in Southern England Already enrolled on a GP UTI management trial

Intervention: Interviews of patients to determine what patients did about their UTI symptoms before they consulted their GP


Outcome:

Is the evidence relevant to our practice? Is this a good source of evidence? Yes this evidence is relevant in general practice especially for trainees. Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? This is not new evidence but it shows how different people manage their diseases and how different clinicians manage patients. The numbers were small but still there are lessons to learn to support understanding of the patient journey before a GP consultation 4 common triggers for seeking help were identified 1. Failure to alleviate symptoms through lay remedies ie self care 2. Patient perception of symptom type ,duration, or escalation. Eg some patients thought their symptoms were out of the ordinary or escalation of symptoms. 3. Impending normal functioning and fulfilment of social roles. E.g some couldn’t go to work or couldn’t look after their children. 4. Concerns that it might be a serious illness or become serious. E.g fear of cancer. Discussion points Triggers identified came as no surprise Small numbers make it difficult to extrapolate findings Highlights new ideas about which questions to ask when taking histories on patients with

symptoms of UTI and new approaches to formulating management plan Difficult to repeat in MK setting.


Some missing data e.g how many people were recruited in the parent UTI management study How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

To ask more questions about actions the patients took to alleviate symptoms prior to the consultation.

Individual

To formulate management plan based on the ideas brought up by the paper provided they are in line with current NICE guidelines.

Individual

.Drafted by: Gloria Mosha, ST3 Date: 16 Feb 2010 verified by:Anne Gray Date: 16 Feb 2010 3Qualitative Research


33 patients approached, 21 interviewed, 20 interviews used in analysis. Not randomly assigned across UTI management trial arms Total number of people in the UTI management study not given Semi structured interviews – no indication of number of interviewers (one or many?) Recorded Interviews of 1 hour duration held in patients home, Interview tapes were transcribed for analysis. Data was analysed thematically, using principles of analytic induction. Relationship between the researcher and the participant was not given in the paper.

Quality:MK




Practice/Group: IMPACTE Central Date: 9 March 2010 Question/Topic :


Type of evidence



Intervention:


Outcome:

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? Discussion points How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

.Drafted by: Date: verified by: Date:



1RCT






2Systematic review







:


Quality:MK




Practice/Group: IMPACTE Central Date: 13 April 2010 Question/Topic :

Association of an educational programme in mindful communication with burnout empathy and attitudes among primary care physicians. The objective was to determine whether an educational programme in mindfulness communication and self awareness is associated with improvement in primary care physicians’ well-being, psychological distress, burnout and capacity for relating to patients. To look at the relationship b/w educational programme in mindfulness communication and self awareness which is associated with improvement in well-being, psychological distress and burn out.


Krasner, M.S. et al (2009) Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians JAMA. 2009;302(12):1284-1293

Type of evidence

1RCT, 2Systematic Review 3Qualitative Research 4Guideline Qualitative research - Before and after study design Prompts on how to appraise the different types of evidence, and space for comments are given on the back of this sheet.


Before and after study of 70 primary care physicians (average 15yrs in practice) in Rochester New York on CME course on mindfulness. An 8 week intensive phase was followed by 10mth maintenance phase.

Intervention: Continuing medical education course; 8wk intensive phase (2.5hrs /wk and 7hr retreat) followed by a maintenance phase of 10 monthly 2.5hrs sessions.


Outcome: Main outcome measures were mindfulness, burnout, empathy psychosocial orientation personality and mood measured at 2, 12 and 15 months Mindfulness burnout personality mood empathy and psychosocial orientation measured at baseline 2, 12, 15 months

Is the evidence relevant to our practice? Is this a good source of evidence? Yes but not a good source of information Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? Over the course of programme and follow-up participants demonstrated improvements in mindfulness

Discussion points Definition of mindfulness : quality of being fully present and ability to pay full attention Use of CME course to test the hypothesis Characteristics of participants i.e. primary care physicians There is an overall improvement Before and after study designs limit inference about intervention effects Limitations of the study i.e. not a randomised control trial Participants were self-selected


No long term follow up was offered Conducted in a single location thus limiting the generalizability How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

A proposed approach to addressing loss of meaning and lack of control in work/ practice life is developing greater mindfulness

.Drafted by: S. Anjum Date:29/05/10 verified by: L Potter Date: 01/06/2010



1RCT






2Systematic review







:



Supplementary Notes

13/04/2010 Association of an Educational Program in Mindful Communication With Burnout, Empathy, and Attitudes Among Primary Care Physicians JAMA. 2009;302(12):1284-1293

RECRUITMENT All primary care physicians in Greater Rochester, New York invited to participate; mailings, follow-up tel calls (METHODS)

871

Eligible for consideration as study participants (METHODS) 642 70 enrolled (RESULTS) 70 % of eligible population who consented and were included 11% MAINTENANCE Followed-up at 12 mths and 15 months Losses to follow-up at 12 months (survey 4) (RESULTS &

METHODS) 14 20%

Losses to follow-up at 15 months (survey 5) (RESULTS & METHODS)

19 27%

Losses to follow-up should be <20% MEASUREMENT Baer (2-factor) Mindfulness scale Table 4 Correlations are used to test if 2 variables are associated with each

other. Measuring the correlation will give an indication of how strong an association there is between 2 variables; in this study whether the measure of mindfulness [Baer mindfulness scale] was associated with measures of burnout, empathy, beliefs and mood states.

Generally a correlation coefficient will fall within the range of -1 to 1 Where there is perfect association, the values for the correlation are 1 (positive association) or -1 (negative association) When no association is present the correlation will be equal to 0

No clear consensus as to what is a high or low correlation but the following values have been proposed as indicators for interpretation:

Correlation Negative Positive Small -0.29 to -0.10 0.10 to 0.29 Medium -0.49 to -0.30 0.30 to 0.49 Large -1.00 to -0.50 0.50 to 1.00 CI - usually reported as 95% CI, which is the range of values within

which we can be 95% sure that the true value for the whole population lies.

CI for a difference between 2 means: If the interval includes [crosses] 0 (zero) then it is statistically insignificant

Quality:MK




Practice/Group: IMPACTE Central Date: 13 July 2010 Question/Topic :

What happens when doctors are ill?


What happens when doctors are patients? Qualitative study of GPs Fox, F., Harris, M., Taylor, G., Rodham, K., Sutton, J., Robinson, B., Scott, J British Journal of General Practice, 2009;59:811-818

Type of evidence



17 GPs (10 male, 7 female) from 2 PCTs in the west of England; median age 46

Intervention:


Outcome: What are GPs experiences of being a patient with significant illness (pyschiatric, physical, acute and chronic) and how does this affect their own subsequent practice?

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? There is more research going on. Discussion points GPs can become ill as well. Guidelines to be in place as to what steps to take when GPs are ill, as it is different from being a hospital doctor who becomes ill. Experiences of consultations with GP or other health professional as patient. How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

Look after your own and your colleagues health. Talk to someone early, when feeling poorly to avoid burn out.

.Drafted by: S. Bhatti Date: 15/7/10 transcribed by: L. Potter Date: 06/08/10

X

X



1RCT






2Systematic review







Phenomenological research Semi-structured interview guided by a schedule and all carried out by lead researcher; interviews audio-taped, transcribed verbatim and anonymised Lead researcher engaged in 'reflexive bracketing' Data analysis process described. Results discussed


Potter Linda

Callout

NICE CG54 (Aug 2007) Urinary tract infection in children

Potter Linda

Callout

UKMEC 2009 UK Medical Eligibility Criteria for Contraceptive Use www.ffprhc.org.uk/admin/uploads/UKMEC2009.pdf

Quality:MK




Practice/Group: Parkside Date: 2 February 2010 Question/Topic

Management of dyspepsia When to refer to endoscopy When to test for H. pylori


NICE Guideline CG17 (2004) Dyspepsia: Managing dyspepsia in adults in primary care. http://guidance.nice.org.uk/CG17 Map of Medicine – Dyspepsia pathway http://england.mapofmedicine.com

Type of evidence

1RCT, 2Systematic Review 3Qualitative Research 4Guideline X Prompts on how to appraise the different types of evidence, and space for comments are given on the back of this sheet.


Intervention:


Outcome:

Is the evidence relevant to our practice? X Is this a good source of evidence? X Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? Some uncertainties about when to test patients for helicobacter pylori and whether or not to arrange FBC on patients over 55 yrs. Evidence / guidelines are complicated and difficult to remember for everyday use.

Discussion points How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

Develop flow chart

NS 02/03/10

Share with other clinicians in practice

NS 02/03/10

.Drafted by: Nicola Smith Date: transcribed by:Linda Potter Date:3 Feb 2010



1RCT






2Systematic review







:


Quality:MK




Practice/Group: Parkside Date: 8 March 2010 Question/Topic :

What is the best way of managing UTI?


Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial BMJ 2010;340:c199, doi: 10.1136/bmj.c199 (Published 5 February 2010)

Type of evidence

1RCT, X 2Systematic Review 3Qualitative Research 4Guideline Prompts on how to appraise the different types of evidence, and space for comments are given on the back of this sheet.


309 non-pregnant women in primary care aged 18-70 presenting with suspected urinary tract infection.

Intervention: 5 groups treated differently; empirical antibiotics; empirical delayed (by 48 hours) antibiotics; or targeted antibiotics based on a symptom score (two or more of urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result (nitrite or both leucocytes and blood), or a positive result on midstream urine analysis


Outcome: Severity of symptoms (days 2-4) and duration and use of antibiotics

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? Best management plan is unclear. Discussion about value of sending mid stream urine (MSU) specimens to lab + delayed antibiotics. Plan - for uncomplicated UTIs – dipstick urine prescribe 3 day course of nitrofurantoin (based on local microbiology advice) Discussion points How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

Audit MSUs before and after discussion

Jemma Mid April

.Transcribed by: Linda Potter Date: verified by: Date:



1RCT





Yes Sealed in numbered envelopes Yes (research assistant was independent of the trial team and blinded to study group)


2Systematic review







:


Quality:MK




Practice/Group: Parkside Date: 30 March 2010 Question/Topic :

Psychotherapeutic tools to help adolescents in primary care


Expert opinion - Dr Mina Fazel, child psychiatrist and clinical lecturer in the Department of Psychiatry, University of Oxford. “Psychotherapeutic tools to help adolescents in primary care” - Psychiatry Study Day 2010 for GPs attended by GP

Type of evidence



Intervention:


Outcome:

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? Strategies for helping adolescents with mental health problems

Sleep hygiene Problem solving Behavioural activation

How to help parents with a challenging child

Meet parents & help them to help the child together Solution focus – “miracle question” Information about local services Discussion points How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

Buy books to patient library

RM 30/04/10

Use of power point info for patient information sheets

NS 30/04/10

.Drafted by: Nicola Smith Date: Transcribed by: Linda Potter Date: 19 April 2010

X X



1RCT






2Systematic review







:


Quality:MK




Practice/Group: Parkside Date: 4 May 2010 Question/Topic :

What are the risks & benefits of using quinine for muscle cramps?


Katzberg HD, Khan AH, So YT (2010) Assessment: symptomatic treatment for muscle cramps (an evidence-based review): report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology. 2010 Feb 23;74(8):691-6. Review.

Type of evidence



24 prospective controlled trials

Intervention:


Outcome:

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? Quinine effective for muscle cramps but risk of serious side effects is 2-4%. Use non-pharmacological methods first (Patient UK leg cramp leaflet) incl. slimline tonic; consider inv U+E, TFT, Ca++, LFT (?? magnesium) If quinine prescribed – use for 3 months then stop & see.

Discussion points How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

Search for patients on quinine for more than 3 months

NS

.Drafted by: N. Smith Date: transcribed by: L Potter Date: 11 May 2010

X

yes yes



1RCT






2Systematic review





Yes + Yes



:


Quality:MK





Are we complying with best practice in the way we fit coils?


Faculty of Sexual and Reproductive Healthcare (FSRH) Guidance: Intrauterine contraception (Nov 2007) http://www.fsrh.org/admin/uploads/CEUGuidanceIntrauterineContraceptionNov07.pdf

Type of evidence



Intervention:


Outcome:

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation?

Discussion points Current practice consistent with best practice. Check pulse + BP prior to insertion. Change template How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

Look out for new guidance (due out 2010)

MM

Change template

LH done

.Drafted by: N. Smith Date: transcribed by: L. Potter Date: 21/05/2010

X

X X



1RCT






2Systematic review







:


Quality:MK





Review of current guidance on the management of chest pain


NICE CG94 (March 2010) Unstable angina and NSTEMI NICE CG95 (March 2010) Chest pain of recent onset

Type of evidence



UK NICE Guidance

Intervention:


Outcome:

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? Diagnosis of stable angina is clinical (+1- CT) – consult risk chart Exercise ECGs have no place in diagnosing angina Query – Should clopidogrel be given with aspirin for patients presenting with ACS? O2 not to be given routinely Discussion points How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

Discuss with cardiologist

Completed

Pulse oximeter for emergency use (+ paediatric probe)

.Drafted by: N Smith Date: transcribed by: L Potter Date: 21 May 2010

X

X X



1RCT






2Systematic review







:


Quality:MK





What is the current guidance for reducing the risk of venous thromboembolism (VTE)?


NICE CG92 (Jan 2010) – Venous thromboembolism – reducing the risk.

Type of evidence



Intervention:


Outcome:

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? Mostly affects hospital in-patients but it is likely that patients will be discharged on LMWH post operatively especially those who have undergone hip, knee & pelvic surgery. (target is 25,000 preventable deaths per year) Discussion points How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

Await local surgical policies

.Drafted by: N Smith Date: transcribed by: L Potter Date: 28 May 2010

X

yes yes



1RCT






2Systematic review







:


Quality:MK





What is the clinical significance of recent research on the relationship between visit-to-visit variability of blood pressure and risk of stroke?


Prognostic significance of visit-to-visit variability, maximum systolic blood pressure, and episodic hypertension (Rothwell, P M et al) The Lancet, Volume 375, Issue 9718, Pages 895 - 905, 13 March 2010

Type of evidence

1RCT, 2Systematic Review 3Qualitative Research 4Guideline Prognosis; review Prompts on how to appraise the different types of evidence, and space for comments are given on the back of this sheet.


Patients with a recent TIA; patients with treated hypertension. 4 studies were used – 1) UK-TIA randomised trial 1979-1985 [J Neurol Neurosurg Psychiatry 1991; 54: 1044-

54]; 1200mg vs 300mg aspirin vs placebo in 2435 patients with a recent TIA or ischaemic stroke; analysis of 2006 patients presenting with TIA only – 1438 men, mean age 60.3yrs, median time since TIA 23 days.

+ 3 other TIA and stroke cohorts 2) European Stroke Prevention Study (ESPS-1 [Lancet 1987; 330: 1351-54]; 2500

patients randomly assigned to dipyridamole plus 325mg aspirin vs placebo; analysis of placebo group only ? patients

3) Dutch TIA trial [N Engl J Med 1991; 325: 1261-66]; 3150 patients randomly assigned to 30mg aspirin vs 283mg aspirin; sub-group of 1473 patients randomly assigned to 50mg atenolol vs placebo

4) ASCOT-BPLA randomised control trial [Lancet 2005; 366: 895-906]; included 2011 patients with previous TIA or stroke; patients with hypertension, aged 40-79 yrs with 3 or more other vascular risk factors but no coronary heart disease randomly assigned to 2 antihypertensive regimes – amlodipine with perindopril as needed vs atenolol with bendroflumethiazide and potassium as needed

Intervention:


Outcome: Risk of stroke or other vascular event in relation to prognostic factors Prognostic factors: visit-to-visit variability in blood pressure, maximum systolic blood pressure, untreated episodic hypertension and residual variability

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? “More work is needed to identify measures that would combine the prognostic information associated with visit-to-visit variability in blood pressure with ease of use in routine clinical practice … “ (Rothwell p.904) No causal link between variability in blood pressure (or maximum SBP) and stroke – more research is needed using large-scale pooled analysis of multiple cohorts. See also ‘Rothwell, P.M. Effects of antihypertensive-drug class on interindividual varation in blood pressure and risk of stroke: a systematic review and meta-analysis. The Lancet, Volume 375, Issue 9718, Pages 906 - 915, 13 March 2010’


Predictor – SBP where the range of visit-to-visit readings ≥ 50 mm Hg. Anti-hypertensive drug class-specific effects on risk of stroke; calcium-channel blockers seem to reduce risk to a greater extent? Discussion points Report from GP Update where this paper was discussed – wait for results of prospective BPLTTC trial. How to plot SBP readings to determine whether range of variability between systolics ≥ 50 mm Hg Frequency of blood pressure measurements (electronic home monitoring) – 2 times/day over 7 days (or 5 or 6 times/day over 10 days?) Postural hypo/ertension? No action at present – await outcome of BPLTTC trial How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mkWhat action are we going to take Who by Date by

Await outcome of BPLTTC trial

.Drafted by: Linda Potter Date: 28/05/10 verified by: Date: Appraisal of different types of evidence

1RCT





UK-TIA – 66% (1324) of patients reached visit 7 Blood pressure measurements in the 4 studies UK-TIA – sitting after rest, mercury sphygmomanometer, measured once at every 4mth follow-up visit (? yrs); variables were calculated from visits 1-7 (0-24mths) and from 1-10 (0-36mths) ESPS-1 – sitting after rest, mercury sphygmomanometer, mean of left and right arm, measured at follow-up visits every 3mths for 2 years Dutch TIA - sitting after rest, mercury sphygmomanometer, measured at follow-up visits every 4mths for a mean of 2 . 6 years ASCOT-BPLA – sitting after 5 min rest, validated semi-automated oscillometric device, measured at every visit (baseline 6 wks, 3 mths, 6mths and every 6mths thereafter). Participants at 4 centres had yrly 24-h ABPM with readings every 30 min. Mean time-weighted daytime (0900 – 2100h), night time (0100-0600h) and 24-h SBP and DBP were calculated.



2Systematic review







:


Quality:MK




Practice/Group: Parkside Medical Centre Date: 15 June 2010 Question/Topic :

Review current NICE guidance on the management of LUTS in men and to check that current practice is consistent


NICE CG97 (May 2010) Management of lower urinary tract symptoms in men

Type of evidence



Intervention:


Outcome:

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? Confirms current practice

Discussion points No-one currently uses urinary frequency volume chart & we do not intend to Increase use of IPSS score at early stage in patient management Check PSA at earlier stage than advised by NICE as more convenient to do with early investigations

i.e. checking renal function + urinanalysis Discussion about appropriate medication & when to refer (i.e still symptomatic despite treatment)

How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mk What action are we going to take Who by Date by

LUTS management flowchart

NS 22/6/10

.Drafted by: N Smith Date: 15/6/10 transcribed by: L Potter Date: 24/6/10

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1RCT






2Systematic review







:


Quality:MK




Practice/Group: Stony Medical Centre Date: 16 June 2010 Question/Topic :

What is the evidence for the benefits & harms of long term use of SSRIs and newer anti-depressants in adults with major depression?


Reid, S. & Barbui, C. Long term treatment of depression with selective serotonin reuptake inhibitors and newer antidepressants BMJ 2010, 3 April, Vol 340, 752-756

Type of evidence



Severe spectrum of depression disorder.

Intervention: Antidepressant


Placebo

Outcome: Risk of relapse

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? Continuation of SSRI – agree continue for 12 months not 6 then review. Age – SSRIs associated with increased suicidal behaviours in under 25s Consider side effects – particularly GI effects & hyponatraemia in the over 80s.

Discussion points How long to continue SSRI? When to get advice from secondary care specialists Local services related to Mental Health Services & access to services How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mk What action are we going to take Who by Date by

.Drafted by: L Potter Date: 24/6/10 verified by: Date:

X

X



1RCT






2Systematic review





Review included 31 randomised trials (mainly discontinuation studies; most secondary care). NNT = 4 Need to look at risk factors ! Discontinuation can mimic symptoms of depression ? Was discontinuation tapered or abrupt (need to look at individual studies) most secondary care relative short follow-up of treatment; need longer longitudinal data



:


Quality:MK



Supplementary sheet 16/06/2010 Reid, S & Barbui, C. Long term treatment of depression with selective

serotonin reuptake inhibitors and newer antidepressants BMJ 2010, 3 April, Vol 340, 752-756

A What is the intervention (dose & frequency)? SSRIs B What is the intervention for? whether

continuing treatment with antidepressants reduces the risk of relapse

6mths 12mths 18mths 24mths 36mths

C What is the successful outcome (when, over what time did it occur)? Reduced risk of relapse

D How many had the intervention? 2527 442 1604 117 190 174 E How many had successful outcome with the intervention? 2044 377 1330 98 136 122 F Express as a percentage (100 x E/D) 81% 85% 83% 84% 72% 70% G What is the control or comparator? placebo H How many people had the control? 1883 296 1122 123 166 176 I How many had successful outcome with the control? 1073 187 707 64 65 50 J Express as a percentage (100 x I/H) 57% 63% 63% 52% 39% 28% ARR = F-J (ie absolute benefit of SSRIs is a 24% reduction in risk of

relapse)The absolute risk reduction (ARR) is the difference between the event rate in the experimental group and the event rate in the control group.

A low ARR indicates that there is a little difference in the frequency of the outcome between the control and new treatment groups.

24% 22% 20% 32% 32% 42%


NNT = 1/ARRNo. of patients who need to receive the new treatment to prevent one

adverse event occurring.

4.2 4.5 5.0 3.2 3.1 2.4

RR = (100 - F) 0.19 0.15 0.17 0.16 0.28 0.30 (100 - J) 0.43 0.37 0.37 0.48 0.61 0.72 (100 - F)/(100 - J) (ie relative risk of relapse in patients receiving SSRIs

compared to placebo)0.44 0.40 0.46 0.34 0.47 0.42

44% 40% 46% 34% 47% 42% RRR 1-RR 0.56 0.60 0.54 0.66 0.53 0.58 56% 60% 54% 66% 53% 58%

Quality:MK




Practice/Group: Wolverton Health Centre Date: 8 July 2010 Question/Topic :

Management of UTI – symptom severity, duration and use of antibiotics


Little, P. et al. Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial BMJ 2010, 3 April, Vol 340, 199

Type of evidence



Non-pregnant women aged 18-70

Intervention: 1. empirical (immediate) antibiotics 2. empirical delayed (48hrs) antibiotics 3. targeted antibiotics based on a symptom score 4. targeted antibiotics based on a dipstick result 5. targeted antibiotics based on a positive result on midstream urine analysis


Outcome: Symptom severity (days 2-4) and duration, and use of antibiotics

Is the evidence relevant to our practice? Is this a good source of evidence? Results, clinical bottom line: Is this new evidence ( or old evidence not yet acted upon) that could have an impact on patient care? Are the results credible and clinically significant? Is there a large variation in current practice? What barriers exist to its implementation? Dipstick testing with targeted antibiotic use & delayed prescription or empirical delayed prescription helps to reduce antibiotic use. Similar symptom control across different management strategies. Confirms current practice. Discussion points Value of MSU testing? Clinician’s judgement on case-by-case basis if dipstick test result is negative. Severity of symptoms – if mild, no harm in waiting [negative dipstick test] / delayed prescription. Patients self-help / self-advice (sachets, fluid intake, use of fruit juices) Patients presenting with recurrent UTI First-line antibiotic? How are we going to follow up e.g. Do we need to find more evidence / have training/ undertake an audit / take advice from specialists / spread to other practices / change our practice management / follow-up with health:mk What action are we going to take Who by Date by

.Drafted by: L. Potter Date:9/7/10 verified by: S Raju Date: 10/07/10

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X



1RCT






2Systematic review







:


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IMPACTE Groups - NHS Networks · 2 Glasziou, P. (2010) The impact of IMPACTE Groups: ... Created by Anne Gray ([email protected] ) and Ann Skinner