NICE issues guidance to tackle multimorbidity

Wise, J. BMJ 2016;353:i1864

GPs should offer a tailored approach for people with multiple long term conditions to reduce the number of prescribed medicines and minimise side effects, new draft guidance from the National Institute for Health and Care Excellence (NICE) has said.

The number of people in England with three or more long term health conditions is predicted to rise from 1.9 million in 2008 to 2.9 million in 2018. Care for people with multiple conditions is often complicated because the conditions themselves, and their treatments, interact in complex ways, and care can be fragmented across many different services.

The guideline, Multimorbidity: Clinical Assessment and Management, says that doctors should put patients at the centre of decisions about their care and should take into account the patients’ preferences. GPs should stop treatment if it is of limited benefit. For example, some preventive medicines may not benefit patients who are nearing the end of their life; rather, the medicine may only add to the treatment burden.

Read the full commentary here

Read the full guidelines here

9 in 10 don’t link alcohol and cancer

Cancer Research UK. Published online: 1st April 2016


Almost 90 per cent of people in England don’t associate drinking alcohol with an increased risk of cancer, according to a new report commissioned by Cancer Research UK.

Drinking alcohol is linked to an increased risk of seven different cancers – liver, breast, bowel, mouth, throat, oesophageal (food pipe), laryngeal (voice box) – but when people were asked “which, if any, health conditions do you think can result from drinking too much alcohol?” just 13 per cent of adults mentioned cancer.

The survey also highlighted a lack of understanding of the link between drinking alcohol and the risk of developing certain types of cancer. When prompted by asking about seven different cancer types, 80 per cent said they thought alcohol caused liver cancer but only 18 per cent were aware of the link with breast cancer. In contrast alcohol causes 3,200 breast cancer cases each year compared to 400 cases of liver cancer.

The report, produced by researchers at the University of Sheffield, comes ahead of the consultation closing on how well new drinking guidelines proposed by the UK’s Chief Medical Officers in January 2016, are communicated. These drew attention to the link between alcohol and cancer, and highlighted the need for greater public awareness of this risk. The findings are based on a nationally representative online survey of 2,100** people conducted in July 2015.

The study also showed that only one in five people could correctly identify the previous recommended maximum number of units that should not be exceeded in a day, as recommended at that time in 2015. Among drinkers, as few as one in 10 men (10.8 per cent) and one in seven women (15.2 per cent) correctly identified these recommended limits and used them to track their drinking habits.

Read the full commentary here

What surgeons tell patients and what patients want to know before major cancer surgery: a qualitative study

McNair, A.G.K. et al. BMC Cancer2016 16:258.

The information surgeons impart to patients and information patients want about surgery for cancer is important but rarely examined. This study explored information provided by surgeons and patient preferences for information in consultations in which surgery for oesophageal cancer surgery was discussed.

Methods: Pre-operation consultations in which oesophagectomy was discussed were studied in three United Kingdom hospitals and patients were subsequently interviewed. Consultations and interviews were audio-recorded, transcribed in full and anonymized. Interviews elicited views about the information provided by surgeons and patients’ preferences for information. Thematic analysis of consultation-interview pairs was used to investigate similarities and differences in the information provided by surgeons and desired by patients.

Results: Fifty two audio-recordings from 31 patients and 7 surgeons were obtained (25 consultations and 27 patient interviews). Six consultations were not recorded because of equipment failure and four patients declined an interview. Surgeons all provided consistent, extensive information on technical operative details and in-hospital surgical risks. Consultations rarely included discussion of the longer-term outcomes of surgery. Whilst patients accepted that information about surgery and risks was necessary, they really wanted details about long-term issues including recovery, impact on quality of life and survival.

Conclusions: This study demonstrated a need for surgeons to provide information of importance to patients concerning the longer term outcomes of surgery. It is proposed that “core information sets” are developed, based on surgeons’ and patients’ views, to use as a minimum in consultations to initiate discussion and meet information needs prior to cancer surgery.

Read the full article here


avoid long stay
Image source: NHS England 

NHS England and partners have published a series of quick guides to support local health and care systems. The guides provide practical tips, case studies and links to useful documents, which can be used to implement solutions to commonly experienced issues. Use the information to manage upcoming winter pressures and plan for 2016 and beyond.

This guide has been produced by stakeholders [including hospital discharge teams; local authority adult services commissioners; continuing healthcare commissioners; independent care sector providers, including voluntary and housing sectors; patients; and carers] and provides:

• A checklist for local areas to use to identify areas for improvement;

• Information on existing solutions to common problems, including links to useful resources;

• A template policy and template patient letters to be adopted locally

avoid long stay2

Other guides include:

Better use of care at home (PDF, 257kb) Clinical input to care homes (PDF, 208kb)
Identifying local care home placements (PDF, 971kb) Improving hospital discharge into the care sector (PDF, 201kb)
Technology in care homes (PDF, 213kb) Sharing patient information (PDF, 723kb)

More information available here

NICE recommends exercise and not acupuncture for low back pain

Wise, J. BMJ 2016;352:i1765
Image source: Mark de Fraeye – Wellcome Images // CC BY-NC-ND 4.0

Acupuncture is no longer recommended for the management of non-specific low back pain with or without sciatica because evidence shows that it is no better than sham treatment, says new draft guidance from the National Institute for Health and Care Excellence (NICE).1

The guideline recommends exercise such as stretching, yoga, or aerobic exercise as the first step in managing low back pain, and people should also be encouraged to continue with normal activities as much as possible. It recommends that manipulation, mobilisation, and massage should be used only alongside exercise because of insufficient evidence to show their benefit when used alone.

The draft guideline uses a stepped care approach to managing low back pain. Paracetamol on its own is no longer the first option: instead, oral non-steroidal anti-inflammatory drugs (NSAIDs) should be offered at the lowest effective dose for the shortest possible time. Opioids should not be routinely offered, but weak opioids with or without paracetamol may be offered if an NSAID is either contraindicated, not tolerated, or ineffective.

Combining physical treatment with psychological treatment such as cognitive behavioural therapy is recommended for people who have not seen an improvement in their pain or who have significant psychosocial barriers to recovery, the draft guideline says.

Read the full article here

Primary Care Corner with Geoffrey Modest MD: Abrupt vs. Gradual Smoking Cessation

BMJ Evidence-Based Medicine blog. Published online: 28th March 2016
Image source: Alex Williamson – Wellcome Images // CC BY-NC-ND 4.0

An English study tested two strategies to achieve smoking cessation: a gradual vs abrupt approach (see doi:10.7326/M14-2805). The background is that most guidelines recommend abrupt cessation (“setting a quit date and then stopping cold turkey”), though many smokers report stopping more gradually.

Results, comparing the gradual vs abrupt quit rates:

  • At 4 weeks, 39.2% (34.0-44.4%) vs 49.0% (43.8-54.2%); RR 0.80 (0.66-0.93)
  • At 6 months, 15.5% (12.0-19.7%) vs 22.0% (18.0-26.6%); RR 0.71 (0.446-0.91)
  • Fewer people made a quit attempt (>24 hours of self-reported abstinence) in the gradual cessation group (61.4% vs 71% in the abrupt group; though in the gradual group, they had reduced their cigarette consumption by 48% by the end of the first pre-cessation week (target 50%) and by 68% by the end of the second week (target 75%)
  • ​And, participants who preferred gradual vs abrupt cessation prior to randomization were less likely to be abstinent at 4 weeks (38.3% vs 52.2%)
  • No significant study-related adverse events

Read the full analysis here