Primary Care Pharmacy December 2000 Vol 1 No 5 p142-143

Journal Club

What is in the medical press?

Cardiac disease

Pignone M, Phillips C, Mulrow C. Use of lipid lowering drugs for primary prevention of coronary heart disease: meta-analysis of randomised trials. BMJ 2000;321:983.

The authors used meta-analysis to review the effect of primary prevention with lipid lowering drugs on coronary heart disease events, coronary heart disease mortality and all-cause mortality. Drug treatment reduced the risk of a coronary heart disease event and coronary heart disease mortality by 30 per cent but not the risk of all-cause mortality. In trials that used statins, a slightly greater effect was suggested, but there was still no significant reduction in all-cause mortality.

Hippisley-Cox J, Pringle M. The cost effectiveness of lipid lowering in patients with ischaemic heart disease: an intervention and evaluation in primary care. Br J Gen Prac 2000;50:699-705.

The authors conducted a study in one rural training general practice to evaluate the feasibility and cost-effectiveness of screening and treating hyperlipidaemia in patients with ischaemic heart disease in primary care. They found that the majority of patients required lipid lowering therapy, despite dietary advice, and that many did not achieve target serum lipid concentrations after six months' treatment. They concluded that undertaking the programme was feasible in primary care but ongoing costs needed to be considered against the costs and benefits that could be achieved by targeting resources to smoking cessation, treatment of hypertension in the elderly, and improving control of diabetes.

Moher M, Yudkin P, Turner R, Schofield T, Mant D for the ASSIST (Assessment of Implementation Strategy) trial collaboration group. Br J Gen Prac 2000;50:706-9.

An observational study of 1,979 patients aged 55 to 75 with established coronary heart disease (CHD) was undertaken to assess the completeness of morbidity registers for CHD in primary care, the factors that predict inclusion on the register, or the relationship between registration and the level of care provided. There was wide variation between the 18 practices studied, which affected patient recall and which will need to be addressed by individual practices in order to implement the national service framework for CHD.

Hobbs FDR. Management of heart failure: evidence versus practice. Does current prescribing provide optimal treatment for heart failure patients? Br J Gen Prac 2000; 50:735-42.

This review article looked at the impact of heart failure and guidelines for management and drug treatments, including clinical trial outcomes for angiotensin converting enzyme (ACE) inhibitors and angiotensin-II receptor antagonists. It also reviewed physician prescribing patterns and looked at why treatments are underused.

Mason J, Young P, Freemantle N, Hobbs R. Safety and costs of initiating angiotensin converting enzyme inhibitors for heart failure in primary care: analysis of individual patient data from studies of left ventricular dysfunction. BMJ 2000;321:1113-6.

Individual patient data from two randomised, controlled trials in secondary care were analysed to identify complications during test dose and titration phases when patients were commenced on ACE inhibitors. During the test-dose phase, 7.8 per cent of patients reported side effects, with 1.8 per cent discontinuing treatment because of severe side effects. Compared with placebo in the titration phase, enalapril was associated with an increased risk of dose reduction due to hypotension, but overall there was no difference in side effect rates leading to reduction or withdrawal of treatment. The cost of diagnosing heart failure with ventricular systolic dysfunction and initiating and titrating with an ACE Inhibitor in primary care was estimated to be £300 to £400. An accompanying editorial (ibid, p1095) stated that fear of side effects was not why physicians failed to initiate ACE inhibitor therapy. A lack of resources and expertise might be the prime reason.

Derry S, Loke YK. Risk of gastrointestinal haemorrhage with long term use of aspirin: meta-analysis. BMJ 2000; 321:1183-7.

A meta-analysis of 24 randomised, controlled trial concluded that long-term therapy with aspirin is associated with a significant increase in incidence of gastrointestinal haemorrhage. Reducing the dose or using modified-release formulations did not reduce the risk.

Prescribing

Per L, Mitchell L, Marit A, Per H. Improving doctors' prescribing behaviour through reflection on guidelines and prescription feedback: a randomised controlled study. Quality in Health Care 2000;9:159-65 .

The authors studied the effect of combined intervention of individual feedback and deviation of quality criteria using guideline recommendations in peer review groups, on the quality of prescribing by 199 general practitioners. This is a useful article for pharmacists involved in peer review and medical education as it addresses prescribing trends and issues with GPs.

Majeed A, Bardsley M, Morgan D, O'Sullivan C, Bindman A. Cross sectional study of primary care groups in London: association of measures of socioeconomic and health status with hospital admission rates. BMJ 2000;321:1057-60.

The authors studied 66 primary care groups (PCGs) in London to calculate socioeconomic and health status measures and to examine the association between these and hospital admission rates. Rates of admission were found to be significantly correlated with measures of chronic illness and deprivation. They concluded it is possible to produce a range of measures for PCGs to use in needs assessment and in planning and monitoring health services. These need to be taken into account when assessing PCG performance.

Anderson IM, Nutt DJ, Deakin JFW on behalf of the Concensus Meeting and endorsed by the British Association for Psychopharmacology. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. J Psychopharmacol 2000;14:3-20.

This is a useful resource for pharmacists involved in the preparation of guidelines for the treatment of mild to moderate depression, particularly in a primary care setting by non-specialist doctors. It has been published following a consensus meeting at which experts in the field of depression and antidepressant treatment considered the strength of evidence and clinical implications of treatment. Guidelines were drawn up after extensive feedback from interested parties. The paper is intended as a resource to inform everyday practical guidelines and covers diagnosis, treatment choices, maintenance and discontinuation.

Cancer

Hobbs FDR. ABC of colorectal cancer: The role of primary care. BMJ 2000;321:1068-70.

This article in a series on the ABC of colorectal cancer, looks at the role of primary care. It particularly deals with the role of GPs in early diagnosis and referral guidelines.

Helicobacter pylori

Scheepers M, Duff M, Baddley P, Cooper M, Houghton M, Harrison J. Helicobacter pylori and the learning disabled. Br J Gen Prac 2000;50:813-4.

Of 110 patients with learning disabilities who were awaiting discharge into the community 91.82 per cent tested Helicobacter pylori positive with serological tests. While current guidelines suggest eradication only in patients with peptic ulcer disease or severe gastrointestinal symptoms this can be difficult to evaluate either because of communication problems or because this group does not co-operate well with endoscopy or breath testing. The authors discuss problems GPs might have to address as more long-stay patients are discharged from institutions to community care settings. They propose that when evaluating someone with a learning disability who has previously been living in an institution, the possibility of Helicobacter pylori causing distress should be considered.

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.