Clinical round-up: January
Top journal papers for January
Lower prediabetes cut-off ‘prevents CVD’
Lowering the threshold for intervening in prediabetes may reduce CVD risk in patients with impaired fasting glucose.
Researchers in China found those with prediabetes, defined using current WHO-recommended glucose levels of 6.1 to 6.9mmol/l, also used by NICE, had a 13% increased risk of death and 26% increased risk of CVD, compared with patients without prediabetes, following lifestyle interventions.
The risk of death remained the same when interventions were guided by the lower American Diabetes Association values of 5.6 to 6.9mmol/l, but CVD risk dropped to 13%.
The researchers argued that their findings ‘strongly support the lower cut-off point for impaired fasting glucose proposed by the 2003 ADA guideline’, adding that there are important public health implications.
Lead author Professor Yuli Huang, associate professor of cardiology at Shunde Southern Medical University, said: ‘Considering the high prevalence of prediabetes, successful intervention in large populations could have major impacts on public health.’
BMJ 2016, online 23 Nov
Referral criteria ‘slow dementia diagnosis’
Complex referral criteria are delaying dementia diagnoses, new research claims.
The study at Imperial College London also found a primary care-led process could speed up diagnosis by having practice nurses carry out assessments.
The researchers found that GPs referring to seven London memory clinics had to satisfy a combination of requirements in order to meet varying referral criteria – for example, performing cognitive tests, blood tests and urine tests.
They concluded that memory clinic referral criteria were often ‘complex and time consuming, contributing to long consultations’.
Lead author Dr Benedict Hayhoe, a GP and investigator at Imperial College, said: ‘A primary care-led process, perhaps staffed by practice nurses carrying out assessments according to protocols, may speed up diagnosis while reducing pressure on GPs and specialists.’
J R Soc Med 2016, online 8 Nov
Offer more preventive stroke drugs, GPs told
Around one third of stroke and TIA patients could be missing out on preventive drugs, according to researchers at the University of Birmingham.
Looking at GP records for 29,043 patients who had a stroke or TIA between 2009 and 2013, they found six out of 10 had clinical indicators suggesting they should have received an anticoagulant, antihypertensive or statin.
But half of this group did not receive a prescription, meaning a third overall missed out on preventive drugs.
Applying these data to the wider population, researchers estimated about 12,000 patients experience a preventable first stroke each year in the UK due to suboptimal prescribing by GPs.
Lead author Dr Grace Turner, research fellow at the university, said: ‘Substantial numbers of strokes and TIAs could potentially be prevented through improving prescription of these drugs in primary care’.
GPSI in cardiology Dr Chris Arden says the findings reinforce the fact that GPs can miss opportunities for early prevention of stroke.
He said: ‘I’d like to think prescription rates have improved since 2013. There’s been a lot of work done with atrial fibrillation patients in particular. But these data are important as they will help GPs make patients more aware of the risk involved with these conditions.’
PLOS Medicine 2016, online 15 Nov
CBT ‘better than usual care’ for weight loss
A task-based weight-loss programme based on CBT and held in GP practices is more effective than a standard nurse-led approach, research suggests.
A team at Queen Mary University of London studied the Weight Action Programme at two GP practices in east London, and found patients lost around 2kg more than those who followed a ‘best practice’ nurse-led programme.
After one year, patients on the task-based programme, who all had a BMI of 30 or more, had lost an average of 4.2kg compared with 2.3kg in the nurse-led one-to-one group.
The researchers calculated that this showed the programme would be cost effective, at £7,742 for each QALY gained.
The programme involved eight weekly group sessions where patients received diet and exercise advice, and CBT-based motivation interventions encouraging them to set themselves concrete exercise goals, such as increasing pedometer targets.
Lead author Professor Hayden McRobbie, smoking cessation physician and researcher at Queen Mary, concluded the programme was ‘more cost effective than nurse-based treatment, although both would be deemed highly cost effective based on the current NICE recommendations’.
Health Technol Assess 2016, online Oct
NICE cancer guidance ‘delaying diagnoses’
GPs should not refer to dentists if they suspect oral cancer, researchers suggest.
Investigators at Leicester Royal Infirmary found that current NICE guidance may cause delayed diagnoses of oral cancers, as it recommends that, under certain criteria, GPs should refer patients for assessment by a dentist rather than use the two-week-wait pathway.
In a retrospective audit, they looked at how many patients given a two-week-wait referral fit the NICE criteria, and found 33, nine of whom were eligible to be referred for initial assessment by a dentist. One of those nine patients went on to be diagnosed with cancer.
But the authors acknowledge larger studies are needed to confirm the finding.
Lead author, consultant physician Dr David Grimes, said: ‘Our data, combined with the epidemiological evidence, the lack of access to primary dental care and a quality-assessed referral pathway between primary care providers means the current guidance has the potential for more delays than the one it replaces’.
Br J Oral Maxillofac Surg 2016, online 4 Nov