The management of Pneumocystis carinii pneumonia.
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Adrenal Cortex Hormones↗
Biomedical subjects
T Walley
Publications and source records attributed to T Walley.
Challenges in changing to non-chlorofluorocarbon inhalers in the treatment of asthma.
The chlorofluorocarbon (CFC)-based metered dose inhaler, which has been the mainstay of the management of obstructive lung diseases, will soon be phased out world wide and replaced by CFC-free devices. Patients will have to be changed to the devices in a co-ordinated manner to avoid any risk to their health and safety. The different shapes and aerosol delivery characteristics of the new inhalers, as well as their distinctive taste, could add to the levels of poor drug use already experienced in asthma. From previous change scenarios in disease management, the potential for unstable asthma control is a real possibility with all the attendant costs. By using the time available before CFC-based inhalers are withdrawn, there is an opportunity to enhance asthma management during this period of change.
Administrative Personnel↗
Review of therapeutically equivalent alternatives to short acting beta(2) adrenoceptor agonists delivered via chlorofluorocarbon-containing inhalers.
BACKGROUND: To study the transition from metered dose inhalers using chlorofluorocarbons as propellants (CFC-MDIs) to non-CFC containing devices, a systematic review was conducted of clinical trials which compared the delivery of salbutamol and terbutaline via CFC-MDIs and non-CFC devices. METHODS: Papers were selected by searching electronic databases (Medline, Cochrane, and BIDS) and further information and studies were sought from pharmaceutical companies. The studies were assessed for their methodological quality. RESULTS: Fifty three relevant trials were identified. Most were scientifically flawed in terms of study design, comparison of inappropriate doses, and insufficient power for the determination of therapeutic equivalence. Differences between inhaler devices were categorised according to efficacy and potency. Most trials claimed to show therapeutic equivalence, usually for the same doses from the different devices. Two commercially available salbutamol metered dose inhalers using a novel hydrofluorocarbon HFC-134a as propellant were equally as potent and efficacious as conventional CFC-MDIs, as were the Rotahaler and Clickhaler dry powder inhalers (DPIs). Evidence suggests that a dose of 200 microg salbutamol via CFC-MDI may be substituted with 200 microg and 400 microg of salbutamol via Accuhaler and Diskhaler DPIs, respectively. Terbutaline delivered via a Turbohaler DPI is equally as potent and efficacious as terbutaline delivered via a conventional CFC-MDI. CONCLUSIONS: When substituting non-CFC containing inhalers for CFC-MDIs, attention must be given to differences in inhaler characteristics which may result in variations in pulmonary function.
Adrenergic beta-Agonists↗
Prescribing at the interface between primary and secondary care in the UK. Towards joint formularies?
The current divisions in managing prescribing between primary and secondary care in the UK arise from separate budgetary arrangements. These divisions are neither sensible, organisationally efficient nor cost effective. Transition of patients across the interface of primary and secondary care has always been problematic, hindered by poor communication and coordination. Joint formularies would improve overall care and raise awareness of the need to consider overall costs within a unified National Health Service (NHS). There are, however, few examples of successful working of a joint formulary in the UK. It is likely that harmonisation of drug use in hospitals and in primary care will come about because of contracting and commissioning, and that it will largely be led by primary care, through the developing primary care groups (PCGs). Local decisions around availability and use of drug therapies will increasingly be superseded by the national decisions emanating from the newly formed National Institute for Clinical Effectiveness.
Drug Prescriptions↗
Therapeutic substitution and therapeutic conservatism as cost-containment strategies in primary care: a study of fundholders and non-fundholders.
BACKGROUND: General practice (GP) fundholders contained prescribing costs by restricting the rise in volume of prescribing and by increasing generic prescribing. It is uncertain whether they used more sophisticated approaches to medicine choice in attempts to contain costs. AIM: To examine whether fundholding practices have adopted medicine-specific strategies to contain prescribing costs--i.e. switching to less expensive but equally effective medicines or resisting the uptake of newer more expensive medicines--by examination of the prescribing of ulcer-healing and antidepressant medicines in the period before and after practices became fundholders. METHOD: Comparison of prescribing data of 52 fundholding practices before fundholding and after fundholding with that of matched non-fundholding practices. Measures examined were prescribing costs (net ingredient cost in each therapeutic area per ASTRO-pu); prescribing volume (defined daily doses per ASTRO-pu); the proportion of all ulcer-healing medicines prescribed as cimetidine, ranitidine, nizatidine, and as proton pump inhibitors; and the proportion of all antidepressant medicines prescribed as selective serotonin re-uptake inhibitors. RESULTS: In comparison with non-fundholding practices, fundholders increasingly prescribed less expensive medicines (cimetidine and nizatidine) within the class of histamine2 receptor antagonists. However, fundholders adopted proton pump inhibitors or selective serotonin re-uptake inhibitors at the same rate as non-fundholders. CONCLUSION: Fundholders have used therapeutic substitution with medicines of equal effectiveness to contain prescribing costs. There is no evidence that fundholders have been slower than non-fundholders to use newer, more expensive medicines.
Aged↗
Addressing barriers to change: an RCT of practice-based education to improve the management of hypertension in the elderly.
BACKGROUND: In the future, primary care groups (PCGs) will have to consider how best to apply audit and education to fulfil their commitment to clinical governance and to facilitate the implementation of research findings. AIM: To establish whether an exploration of 'barriers to change' can enhance the effectiveness of an educational intervention designed to improve the management of hypertension in the elderly. METHOD: A parallel-arm, randomized, single-blind, controlled trial of practice-based educational visits in 18 practices. These practices had previously taken part in a multipractice audit of the management of hypertension in the elderly. Both groups received outreach visits in their own practice, during which they received the results of the previous audit. The nine 'intervention' practices were encouraged to explore barriers that would prevent them from implementing pertinent research findings. The control group was not encouraged to do this. The main outcome measure of the trial was determined in advance as 'the stated management of systolic hypertension in patients aged 70 to 79'. A secondary endpoint was the stated management of a specific patient scenario. The endpoints were tested by questionnaire before and after the educational intervention. RESULTS: For the primary endpoint, there was a statistically significant difference in the stated threshold for treating systolic hypertension between intervention and control groups after the visits (161.8 mmHg versus 167.2 mmHg; P = 0.007). For the secondary endpoint, there was also a statistically significant difference between the two groups, after the visits, in their willingness to treat a 70-year-old male with mild hypertension (89% of doctors would treat in the intervention group versus 57% in the control group; P = 0.047). CONCLUSION: The effectiveness of an educational intervention is significantly improved by addressing the barriers preventing practitioners from implementing the findings of research.
Aged↗
Prescription charges: change overdue? Britain can learn from systems of copayments based on drugs' effectiveness.
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Drug Prescriptions↗
Topical NSAIDs are better than placebo. Safety, efficacy, and therapeutic role of nsaids must be clarified.
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Administration, Topical↗
The influence of practice characteristics on the prescribing of benzodiazepines and appetite suppressant drugs.
BACKGROUND: The prescribing volume of benzodiazepines and of appetite suppressant drugs have been suggested as possible indicators of prescribing quality. OBJECTIVE: To investigate the variation among general practices in the prescribing of benzodiazepines and appetite suppressants by examining the contribution to this variation of training status, partnership status, fundholding status and the level of deprivation in the practice population. METHODS: Prescribing data (PACT) were analysed for 350 practices in the former Mersey Regional Health Authority, for the year ending March 1991 and the year ending March 1994. Data were first standardized for variation in practice population demography. Multiple linear regressions were used to investigate the variation among practices in standardized prescribing volume in both years. RESULTS: For benzodiazepines, training status and partnership status contributed to all models and level of deprivation contributed to some (percentage of variation explained for year ending March 1991: 10% to 21%, year ending March 1994: 8% to 20%). For appetite suppressant drugs fundholding status and an interaction between training status and level of deprivation contributed to all models in both years (percentage of variation explained for year ending March 1991: 19% to 20%, year ending March 1994: 20% to 21%). CONCLUSION: The prescribing of benzodiazepines is lower in training practices, in multi-partner practices and in practices serving a less deprived population, while the prescribing of appetite suppressant drugs is lower in training practices and in fundholding practices. Variation in prescribing knowledge, organizational and management capabilities and patient demand may be explanatory factors.
Journal Article↗
Hypertension in the elderly: attitudes of British patients and general practitioners.
The perceptions of patients and GPs of the risk of stroke in treated and untreated elderly hypertensives, and their attitudes towards anti-hypertensive therapy were examined. To explore attitudes of patients to the management of hypertension a qualitative approach was used, employing semi-structured interviews, with subsequent thematic analysis of the transcriptions. A questionnaire study of GPs' attitudes to the same subject was also conducted. The elderly (n = 75) greatly overestimate the risks of hypertension and the benefits of treatment. Most would accept anti-hypertensive therapy despite being informed of the true risks, citing confidence in their doctor as the major determinant in their decision. GPs (n = 121) were well informed of the risks and benefits, but less than half adhere to current guidelines. GPs should be aware how much the elderly overestimate the risks of hypertension and the benefits of its treatment. When considering treating hypertension in this group, patient contributions in the treatment decision-making process should be actively encouraged, especially as many elderly hold a deferential attitude towards their doctor. Patients should be informed of the risks of their disease and the benefits of treatment in terms they understand. The use of visual aids helps patients to grasp the difficult concepts of risk and benefit.
Adolescent↗
Haemodynamic responses in young and elderly, healthy subjects during ambient and warm head-up tilt.
1. Postural hypotension is common in elderly people and is usually multifactorial in origin. In young subjects increased ambient temperature is associated with postural symptoms. We hypothesized that such increases in skin temperature due to the use of bed clothes might contribute to nocturnal postural hypotension in the elderly. We therefore studied haemodynamic responses to head-up tilt in healthy elderly and young subjects, with and without passive heating induced by covering with blankets. 2. Nine young (28.7 +/- 1.5 years; mean +/- S.E.M.) and nine elderly (71.9 +/- 1.8 years) subjects were studied. All had been carefully screened to exclude factors likely to affect responses to tilt. All subjects underwent a standard head-up tilt procedure at ambient room temperature while haemodynamic responses were monitored. The subjects were then covered in blankets for 55 min and the tilt repeated. Skin temperature before the second tilt had increased from approximately 32.5 degrees C to approximately 35.2 degrees C (P < 0.001). 3. The elderly subjects maintained higher blood pressures throughout both tilts (P < 0.001) and both groups showed similar qualitative responses to tilt. Supine heart rates were higher in the elderly group (P < 0.01) with a tendency to increase more in the young group in response to tilt, especially while warm (P = 0.370). Stroke volumes and cardiac indices were consistently higher in the young group who showed larger changes during both head-up tilts. In both groups the haemodynamic responses to ambient and warm tilt were essentially the same. 4. Healthy elderly subjects, who are carefully screened to exclude individuals with cardiovascular pathology, respond to head-up tilt in the same qualitative fashion as young subjects. Quantitative responses in older subjects are 'damped'. Short-term natural body warming does not impair the reflexes in young or old subjects.
Adult↗
Review article: current treatment and optimal patient management in pancreatic cancer.
This review analyses the current state of knowledge and understanding concerning the optimum treatment and therapeutic management of patients who suffer from pancreatic cancer. It outlines recent advances in scientific understanding and assesses their potential future value to clinicians in confronting this disease. Despite a significant expansion in scientific knowledge relating to factors underlying the early development of pancreatic carcinoma, the clinician continues to be restricted to a severely limited therapeutic armoury for this disease. Local therapies (surgery and radiation) are inevitably of limited value in the face of a disease that is normally encountered at a stage where metastasis is already highly developed. Despite such limitations, however, surgery performed in specialist units may be of value for 10-20% of patients, with a 5-year survival rate in such units of between 10 and 24%. This may be improved even further by appropriate use of adjuvant treatment. The advanced stage of the disease when normally encountered emphasizes the potential value of systemic treatment in this therapeutic area. Unfortunately systemic treatment (chemotherapy) has been found to be ineffective to date in significantly extending survival, with a low rate and duration of remission being identified in most trials. The challenge for both the health service and the pharmaceutical industry is to harness recent and future developments in scientific knowledge to the practical benefit of clinicians. Where cure is possible it should be vigorously pursued; where it is not, in this field above all others, clinicians have a duty of care. To achieve this it is necessary to abandon the therapeutic nihilism that has characterized the attitudes of clinicians towards this disease in the past. It is time that such nihilism was replaced by a recognition of the challenges and the opportunities available to clinicians in enhancing the quantity and quality of life available to patients. The dictum of 'curing whenever possible but caring always' should be the future therapeutic philosophy used to guide clinicians in this important and rapidly changing therapeutic area.
Antineoplastic Agents↗
Review article: current practice and future perspectives in detection and diagnosis of pancreatic cancer.
Pancreatic cancer is the tenth most prevalent malignancy and the fifth most common cause of cancer death in the developed world. Less than 10% of patients survive for more than 1 year following diagnosis and the 5-year survival rate (0.4%) is the lowest of any cancer. The poor prognosis associated with this diagnosis led in the past to therapeutic nihilism on the part of clinicians who were all too aware of the limitations of their available therapeutic strategies. Breaking this therapeutic impasse requires a significant expansion in the knowledge of clinicians concerning the pathogenesis and behaviour of pancreatic cancer. Recent advances in the scientific understanding of the aetiology of pancreatic cancer has facilitated progress towards the development of promising and innovative approaches to the early detection and diagnosis of pancreatic cancer. While acknowledging that pancreatic cancer will continue to present significant challenges to both scientists and clinicians in the foreseeable future, it is becoming increasingly clear that recent advances in our scientific knowledge base holds the potential to significantly improve prognosis for patients. The challenge facing both scientists and clinicians is how best to translate such promising scientific advances into survival and quality of life benefits to patients.
Biomarkers↗
Health technology assessment--the role of the pharmaceutical panel.
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Pharmaceutical Services↗
Clinical guidelines: ways ahead.
Clinical guidelines are essential in promoting the implementation of evidence-based practice within the NHS. But there are two broad schools of thought about their development and implementation: the first argues that guidelines should be entirely evidence-based and tolerates a degree of complexity which may make the guideline impractical; the second argues that we need simple guidelines, and sacrifices the strength of evidence in favour of ease of application and dissemination. Both arguments have merits and flaws, which are discussed, and ways to integrate the strengths of both are considered.
Evidence-Based Medicine↗
Development of an economic model for the management of upper gastrointestinal disease in primary care. Preliminary findings.
Health economic models for identifying therapeutic options that maximise health benefits from limited healthcare resources are being developed in a number of therapeutic areas. The development of such a model for upper gastrointestinal (UGI) symptoms to support decision-making by primary care clinicians is of particular importance, given the prevalence of this symptomatology. This economic model was based upon the clinical guidelines aimed at improving the management of UGI disorders at the primary care level that were developed by the International Gastro Primary Care Group. This paper discusses the derivation, methodology and results of the economic model developed to assess the resource implications arising from these clinical guidelines. In order to construct the economic model, it was necessary to identify the following: every therapeutic pathway followed by patients resource use along each pathway the probabilities of following alternative pathways. One crucial factor underlying the interpretation of results obtained from any economic model is the time period covered by the model. The model presented here analysed the initial 12-month treatment period of 'new' patients presenting with UGI symptoms. In order to test the implications of a longer term perspective, the model is currently being developed to analyse resource use over a 24-month period. The model demonstrates that utilising the predominant symptom approach to the diagnosis and treatment of patients with UGI disorders appears to provide significant benefits in terms of patient management and effective resource use. This factor, together with the more intensive use of Helicobacter pylori eradication therapy, provides the potential to reduce the cost of drugs for the treatment of UGI disorders by approximately 15% in the UK. A major strength of the model is its adaptability to a wide range of clinical and cost scenarios. Such adaptability enables the model to effectively reflect the potential resource implications in countries exhibiting significantly different levels of cost and patient management. In this manner, the model provides one valuable method by which clinicians can be supported in optimising the management of UGI disorders within current resource constraints.
Cost-Benefit Analysis↗
The management of hypertension in the elderly by general practitioners in Merseyside: the rule of halves revisited.
BACKGROUND: Treatment of hypertension in the elderly significantly reduces cardiovascular events and confers greater absolute benefit compared with treating younger adults. However, this group has been undertreated in the past. AIM: To perform a reliable and valid multipractice audit of the current management of elderly hypertensive patients. METHOD: An observational study conducted as multiple standardized audits in general practices. The notes of 6139 patients aged 65 years or over from 76 general practices in Merseyside were examined to determine the percentage of elderly patients who had their blood pressure recorded. The percentages of hypertensive patients who were diagnosed, treated, and controlled was also recorded. RESULTS: Eighty-one per cent of the sample had their blood pressure recorded. Fifty-three per cent of patients over the age of 65 were identified as hypertensive; 64% of hypertensive patients are receiving antihypertensive medication and 54% of treated hypertensive patients can be considered controlled. However, very small changes in the criteria used to define blood pressure control have dramatic effects on the results. Digit preference and the number of available blood pressure recordings also significantly affect the results. CONCLUSION: The management of hypertension in the elderly by Merseyside general practitioners (GPs) gives better results than predicted by the 'rule of halves'. Elderly hypertensive patients are more likely to be detected and treated, but only half achieve control to 160/90. The results are particularly sensitive to the degree of digit preference, the number of available recordings, and to the precise definition used for control.
Aged↗
Auditing the management of hypertension in British general practice: a critical literature review.
Hypertension is a common condition almost exclusively managed by general practitioners (GPs), making it an ideal subject for practice-based audit. However, the conduct and interpretation of such audits is complex. Even minor variations in methodology can produce dramatic differences in results obtained. We used a focus group of seven GPs with a special interest in audit to establish a standardized method for the planning and reporting of audits for the management of hypertension. In order to enhance the reliability and comparability of hypertension audits, 13 key areas of audit methodology were produced by the focus group. Eleven audits were identified in a literature search using pre-determined selection criteria. These were then assessed to compare their methodology with the criteria produced by the focus group. None of the recently published audits in this subject covered all of the key areas (range: 27-65% of the areas covered). One key area, that of digit preference, was not mentioned by any. Other problematic key areas included the selection of patient records without bias, the determination of the prevalence of hypertension, the number of recordings used to determine the diagnosis of hypertension and its subsequent control, the time period examined by the audit, and the approach taken to notes containing an inadequate number of blood pressure recordings. Significant variability in the methods used by different authors in these key areas calls into question the reliability of their results and makes comparisons between them very difficult. We propose a standardized method for hypertension audits comprising 13 key areas, which will enhance the reliability of results and facilitate such comparisons.
Family Practice↗