Primary Care Pharmacy November 2001 Vol 2 No 3 p83-84

Journal Club

What is 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 picks out a few articles that may be useful in day-to-day practice or that are particularly relevant to the primary care role.

Respiratory

Roberts CM, Ryland I, Lowe D, Kelly Y, Bucknall CE, Pearson MG. Audit of acute admissions of COPD: standards of care and management in the hospital setting. Audit sub-committee of the Standards of Care Committee of the British Thoracic Society and the Clinical Effectiveness and Evaluation Unit at the Royal College of Physicians. Eur Respir J 2001;17:343–9.

Data collected from 1400 acute COPD admissions in 38 UK hospitals were compared against British Thoracic Society guidelines.

Large variation was found in the care process between the different centres and the median standards of care fell below the minimum recommended in the guidelines. Of particular interest to the primary care sector is that reversibility with bronchodilators was measured in only 27 per cent of patients, and reversibility with steroids in only 7 per cent of patients.

Hassell K, Whittington Z, Cantrill J, Bates F, Rogers A, Noyce P. Managing demand: transfer of management of self limiting conditions from general practice to community pharmacies. BMJ 2001;323:146–7.

The authors examined whether the availability of medicines to treat acute self-limiting health problems free of charge from the pharmacy, to patients who would normally be exempt from prescription charges, would affect general practitioner work load. Over a six-month period overall GP workload remained unchanged, however visits relating to the twelve simple study conditions decreased.

Shekelle P, Eccles MP, Grimshaw JM, Woolf SH. When should guidelines be updated? BMJ 2001;323:155–7.

A flowchart based on expert opinion and focused literature reviews is advocated as a model to assess when guidelines need updating. Situations where an update might be considered appropriate include:

changes in the evidence base
changes in important outcomes
availability of new interventions
current practice becomes optimal
changes in values placed on outcomes
changes in resource availability

A multidisciplinary group recruited from the original guideline development group complemented by experts and generalists with expertise in critical appraisal should be challenged with the task.

Gastrointestinal

Weijnen CF, Numans ME, de Wit NJ, Smout AJPM, Moons KGM, Verheij TJM, et al. Testing for Helicobacter pylori in dyspeptic patients suspected of peptic ulcer disease in primary care: cross sectional study. BMJ 2001;323:71–5.

A cross-sectional study of 565 Dutch patients consulting their general practitioner with dyspeptic symptoms of at least two weeks duration was undertaken to determine whether Helicobacter pylori testing adds value to history taking when trying to determine the presence of peptic ulcers. The conclusion was that the presence of H pylori was only a useful predictor of ulceration in patients who were already at high risk because they smoked, reported pain on an empty stomach or had a previous history of ulceration.

Routine H pylori testing was not considered to be of additional value across the board for patients with dyspepsia in primary care.

Lewin-van den Brock NT, Numans ME, Buskens E, Verheij TJM, de Wit NJ, Smout AJPM. A randomised controlled trial of four management strategies for dyspepsia: relationships between symptom subgroups and strategy outcome. Br J Gen Prac 2001;51:619–24.

The aim of this study was to assess the relationship between symptom subgroups and the effect of management strategies on primary care patients with dyspepsia. This was done by randomly assigning all patients presenting with a new episode of dyspepsia to one of four strategies: empirical treatment with therapy based on presenting symptoms; empirical treatment with omeprazole; empirical treatment with cisapride, regardless of presenting symptoms; and prompt endoscopy followed by appropriate treatment.

No statistically significant differences between symptom subgroups were identified, leading the authors to conclude that the sensible approach to management of dyspepsia was to choose a treatment strategy based on presenting symptoms.

Cardiovascular

Qureshi MD, Suri MFK, Guterman LR, Hopkins LN. Ineffective secondary prevention in survivors of cardiovascular events in the US population. Arch Intern Med 2001;161:1621–8.

The authors investigated the adequacy of risk factor modification in survivors of myocardial infarction (MI) and/or stroke. Results indicated that 53 per cent of hypertension was uncontrolled. Previously undiagnosed hypertension was detected in 11 per cent of patients. Serum glucose control was inadequate in 49 per cent of diabetics. About 18 per cent of patients smoked and 4 per cent had high alcohol intakes. Cholesterol levels were poorly controlled in 46 per cent of those known to have hypercholesterolaemia and a group of previously undetected cases accounted for 13 per cent.

It was concluded that to implement risk factor modification strategies after MI and stroke effectively, requires considerable effort.

Nuesch R, Schroeder K, Dieterle T, Martina B, Battegay E. Relation between insufficient response to antihypertensive treatment and poor compliance with treatment: a prospective case-control study. BMJ 2001;323:142–6.

Poor compliance with antihypertensive medication is often suggested as the reason for failure to control blood pressure adequately. The authors studied 110 consecutive outpatients attending a Swiss hospital clinic. Patients had been prescribed at least two antihypertensive medicines for a minimum of four weeks. These were supplied in pill boxes that electronically recorded each time the container was opened. Blood pressure was monitored using 12-hour daytime ambulatory monitoring. Results indicated that 82 per cent of patients with treatment resistant hypertension were compliant with Ž80 per cent of their prescribed doses, while 85 per cent of patients responsive to treatment were compliant.

They concluded that non-compliance with therapy was not more prevalent in patients unresponsive to antihypertensive medication than in patients who respond.

Marshall T, Rouse A. Meeting the national service framework for coronary heart disease: which patients have untreated high blood pressure? Br J Gen Prac 2001;51:571–4.

A modelling exercise was carried out to estimate the number of patients eligible for blood pressure assessment, the number of preventable cardiovascular disease events and the relative efficiency of the strategy in different age groups. In a hypothetical population of 100,000, about 79,607 would be eligible for assessment, with 5,888 eligible for treatment, which could prevent 101 to 139 events per year. In the over-65 age group, 4,655 treatments would prevent 85 to 117 events, and in the under-45s no events would be prevented. Confining assessment to the 16 per cent of the population aged over 65 years, prevents 85 per cent of avoidable cardiovascular disease.

The authors therefore recommend primary care teams should assess and treat patients aged over 65 years before assessing younger patients and that no benefit is gained from assessing the under-45s.

Hippisley-Cox, Pringle M. General practice workload implications of the national service framework for coronary heart disease: cross sectional survey. BMJ 2001;323:269–70.

To estimate the workload that will be involved before practices meet standards one to four in the national service framework for coronary heart disease, the authors reviewed computerised data in 18 randomly selected practices. They extracted details of ischaemic heart disease, comorbidity with diabetes, stroke and hypertension, drug treatment and other coronary risk factors including age, sex, family history, smoking status, body mass index, blood pressure, glycated haemoglobin and fasting lipid concentrations. They estimated that in an average practice population of 10,000 around 904 items will require to be recorded on the practice computer together with 2221 disease control measures. This is a conservative estimate and has a major workload implication for primary care.

The Editorial comment (BMJ 2001;323:246–7) questions if the increased workload is matched by benefits gained and, with more NSFs promised at a time of low morale and limited workforce, how realistic achieving the ambitious goals can be.

Hickley JA, Nazareth I, Rogers S. The barriers to effective management of heart failure in general practice. Br J Gen Prac 2001;51:615–8.

The authors collected data on the investigation and treatment of heart failure in ten Medical Research Council General Practice Framework practices in North Thames region and presented the data back to the 49 GPs and ten practice nurses. Of the 674 patients requiring echocardiography only 34 per cent were referred while less than half (47 per cent) with probable heart failure were prescribed ACE inhibitors. Many barriers were identified including lack of open access to echocardiography and GP concerns about possible adverse effects with ACE inhibitors, especially in elderly patients with co-existing pathology and polypharmacy where perceived benefit was also considered to be lower.

Despite studies showing tolerance rates of 80–90 per cent with ACE inhibitors the need for dose titration, renal monitoring and follow up reduced initiation, again confirming that research findings are not always implemented into clinical practice.