Primary Care Pharmacy September 2000 Vol 1 No 4 p114-115

Journal Club

What is in the medical press?

Cardiac disease

Hansson L, Hedner T, Lund-Johansen P, Kjeldsen SE, Lindholm LH, Syvertsen JO, et al for the Nordic Diltiazem (NORDIL) study. Lancet 2000;356:395

Brown MJ, Palmer CR, Castaigne A, de Leeuw PW, Mancia G, Rosenthal T, et al. Morbidity and mortality in patients randomised to double-blind treatment with a long-acting calcium channel blocker or diuretic in the International Nifedipine GITS study: Intervention as a Goal in Hypertension Treatment (INSIGHT). Lancet 2000;356:366
Until recently, evidence of effects of blood pressure-lowering drugs on cardiovascular risks came from trials on diuretics and beta-blockers. These two papers report the effects of calcium channel blockers. In the first, the effects of diltiazem are compared with diuretics and beta-blockers on both on cardiovascular morbidity and mortality in patients with hypertension. It concludes that diltiazem was as effective as diuretics and beta-blockers in preventing the combined primary endpoint of all stroke, myocardial infarction and other cardiovascular death.

The second study compared the efficacy of once daily nifedipine with co-amilozide on cardiovascular mortality and morbidity in high-risk patients with hypertension. Both were found to be equally effective in preventing overall cardiovascular and cerebrovascular complications.

Cromheecke ME, Levi M, Colly LP, de Mol BJM, Prins MH, Hutten BA, et al. Oral anticoagulation self-management and management by a specialist anticoagulation clinic: a randomised cross-over comparison. Lancet 2000;356:97-102.
A randomised, crossover study which compared self-management of oral anticoagulant therapy with conventional management by an anticoagulant clinic. Self-management was preferred by patients and resulted in better anticoagulation control.

Williams DM, Newsom JF, Brock TP. An evaluation of smoking cessation-related activities by pharmacists. J Am Pharm Assoc 2000;40:366-70.
Using a mailed questionnaire, the authors identified smoking cessation intervention activities performed by community pharmacists in two US states, together with the perceived barriers to intervention. Despite being a US-based study, with limited applicability to the UK, pharmacists involved in smoking cessation initiatives, particularly following the launch of bupropion, who aim to provide appropriate patient support, may find this an interesting study.

Gray J, Majeed A, Kerry S, Rowlands G. Identifying patients with ischaemic heart disease in general practice: cross sectional study of paper and computerised medical records. BMJ 2000;321:548-50.
The national service framework requires general practitioners to create disease registers for patients with ischaemic heart disease by April, 2001. The authors compare different methods of identifying these patients using Read codes and drug searches and show how searching can be improved by including aspirin, atenolol, digoxin and statins in addition to nitrates. A useful paper for pharmacists involved in using drug searches to identify groups of patients for specific review.

Diabetes

Stratton IM, Adler AI, Neil HAW, Matthews DR, Manley SE, Cull CA. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000;321:412-9.

Adler AI, Stratton IM, Neil HAW, Yudkin JS, Matthews DR, Cull CA, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 2000;321:405-12.
These are two papers from the UKPDS study, which aimed to determine the relationship between glycaemia exposure (UKPDS 35) or systolic blood pressure (UKPDS 36) over time, and the risk of macro- or microvascular complications in patients with type 2 diabetes.

The risk of diabetic complication was associated with previous hyperglycaemia and raised blood pressure. Risks were reduced by any decrease in HbA1c and blood pressure. Lowest risks were found in patients with HbA1c values of less than 6 per cent and with systolic blood pressure below 120mmHg.

Lifestyle

Lawlor DA, Keen S, Neal RD. Can general practitioners influence the nation’s health through a population approach to provision of lifestyle advice. Br J Gen Pr 2000;50:455-9.

This paper identifies reasons why general practitioners do not give lifestyle advice to all patients, preferring to target high-risk groups instead. This trend is contrary to the assumption by policy-makers that lifestyle advice from GPs can have an important effect on overall population health.

Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med 2000;343:16-22.
The authors followed up women over a 14-year period to assess the relationship between the risk of coronary heart disease and lifestyle-related risk factors. They found that adherence to lifestyle guidelines involving diet, exercise and smoking abstinence was associated with a very low relative risk (0.17) of coronary heart disease.

Gastrointestinal

Hernandez-Diaz S, Rodriguez LAG. Association between nonsteroidal anti-inflammatory drugs and upper gastrointestinal tract bleeding/perforation. Arch Intern Med 2000;160:2093-9.

The authors provide a systematic overview of epidemiological studies published in the 1990s using MEDLINE.

Prescribing issues

Campbell SM, Cantrill JA, Roberts D. Prescribing indicators for UK general practice: Delphi consultation study. BMJ 2000;321:425.

Health authority medical and pharmaceutical prescribing advisers participated in a modified, two-round Delphi questionnaire to identify prescribing indicators based on PACT data, which are useful in the measurement of quality or cost minimisation. Three conclusions were reached:

1. Indicators are not measures of poor performance but identify potential problems that may require investigation

2. It is important to be clear as to what the indicators are intended to measure and what conclusions can be drawn from them

3. If indicators are to be useful for quality assessment or improvement, the data should be consistent and comparable across relevant health care organisations

Avery AJ, Rodgers S, Heron T, Crombie R, Whynes D, Pringle M, et al. A prescription for improvement? An observational study to identify how general practices vary in their growth in prescribing costs. BMJ 2000;321:276-81.

An observational study, which compared changes in prescribing costs for areas in which the Audit Commission had suggested savings might be made. Three groups of practices with low, average and high growth in costs were compared. This is a paper that will be of interest to any pharmacist trying to support practices in achieving cost-effective prescribing.

McColl A, Roderick P, Smith H, Wilkinson E, Moore M, Exworthy M, et al. Clinical governance in primary care groups: the feasibility of deriving evidence-based performance indicators. Quality in Health Care 2000;9:90-7.

The authors devised 26 evidence-based process indicators, which could be used to improve quality of patient care within a primary care group, including low-dose aspirin therapy, detection and control of hypertension, smoking cessation and use of lipid-lowering medicines. Incomplete and inconsistent computerisation, together with incompatibility between computer software and poor skills of practice staff made

Smith J, Regen E, Shapiro J, Baines D. National evaluation for general practitioner commissioning pilots: lessons for primary care groups. Br J Gen Pr 2000;50:469-72

The authors monitored the development of 40 national pilot sites using semi-structured, face-to-face interviews with general practitioners, health authority managers and pilot managers. They also held focus group discussions with nurses, social services officers and community health council officers. The main achievements and obstacles are summarised and reveal important messages for primary care groups.

Nau DP, Reid LD, Lipowski EE, Kimberlin C, Pendergast J, Spivey-Miller S. Patients’ perspectives of the benefits of pharmaceutical care. J Am Pharm Assoc 2000;40:36-40.

The authors investigated patients’ perceptions of a pharmacist-run anticoagulant clinic. They concluded that it might be possible to enhance patient participation in services providing pharmaceutical care if patients were better educated about the risks of medication-related problems. Monitoring of important clinical indicators might help reduce those risks.
Rosen R. Clinical governance in primary care — Improving quality in the changing world of primary care BMJ 2000;321:551-4.

This is the first article in a series of five. The series will explore the meaning of clinical governance for primary care and will cover:

• Quality definitions and early approaches to implementation of clinical governance in primary care
• Accountability for quality
• The need for organisational and professional development to facilitate change
• Improvements in clinical knowledge, skills and leadership
• Knowledge and information required for successful implementation carrying out the study difficult.

What's in the medical press? - The rapidly changing situation in primary care means that it is often difficult to keep up to date with what is happening politically and clinically. This section of Primary Care Pharmacy will try to pick out a few articles that may be useful in day-to-day practice or have importance for the primary care role.