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Issue 57 – January 2014 

Dear

This month in Eyes on Evidence

MRI in follow-up assessment of sciatica treatment
A randomised controlled trial comparing surgery with conservative care for sciatica after lumbar disc herniation suggests that MRI at follow-up does not distinguish between patients with favourable and unfavourable outcomes after treatment.

Antibiotics and community-associated Clostridium difficile infection
A meta-analysis finds that recent use of antibiotics is associated with an increased risk of Clostridium difficile infection in adults who have not been admitted to a healthcare facility. Some classes of antibiotic are associated with a greater risk than others. 

Interventions to improve physical activity in socioeconomically disadvantaged women
A systematic review and meta-analysis finds that group interventions are better than individual or community interventions at improving physical activity among socioeconomically disadvantaged women.

Impact of smoke-free legislation on population health
Two population-based studies record small but significant reductions in the incidence of both preterm birth and emergency hospital admissions for asthma after the introduction of smoke-free legislation.

Effect of housing improvements on health
A systematic review finds some evidence that warmth and energy efficiency improvements to housing produce health benefits for the inhabitants.

Case study from the Quality, Improvement, Productivity and Prevention (QIPP) collection
We highlight 1 new example from the QIPP collection demonstrating how NHS organisations have implemented new local practices that have both cut costs and improved quality.
  • Stratified cancer pathways – redesigning services for those living with or beyond cancer 
Evidence Update
NICE has recently published an Evidence Update on:
  • Post-traumatic stress disorder  
 
MRI in follow-up assessment of sciatica treatment
Overview: Sciatica is the term for symptoms of pain, tingling and numbness caused by compression or irritation of the root of the sciatic nerve. In about 90% of cases, sciatica is caused by a herniated disc in the lumbosacral spine (Koes et al. 2007). In most patients, sciatica resolves spontaneously within 6–12 weeks with conservative treatment, such as over-the-counter painkillers and exercise. Those with persistent or recurrent sciatica might benefit from surgery to remove the symptomatic disc herniation and decompress the nerve.

MRI is commonly used to diagnose lumbar disc herniation and in patients with persistent or recurrent signs of sciatica. However, the value of repeating MRI in patients with ongoing sciatica is questionable because around half of people without symptoms have signs of disc herniation on imaging (Jensen et al. 1994).

See the NICE Evidence Services topic page on sciatica for a general overview of this condition.

Current advice: The NICE Clinical Knowledge Summary on sciatica (lumbar radiculopathy) recommends initial management with self-care advice, analgesia (paracetamol and stronger analgesics if necessary), or a standard non-steroidal anti-inflammatory drug. If pain or disability remain for more than 1–2 weeks, referral for physiotherapy or epidural injection of corticosteroid should be considered. If sciatica is still disabling and distressing after 6–8 weeks, the patient should be referred to specialist low back pain and sciatica services. For continuing pain or disability despite appropriate treatment (including surgery), referral to a multidisciplinary back pain service or chronic pain clinic should be considered.

Clinical judgement should be used to decide if and when to follow up, although advice should be given to seek urgent review for symptoms suggesting cauda equina syndrome. Most people will only need to return for follow-up when necessary. When following up, the diagnosis should be reviewed (checking for red flags for serious conditions and signs and symptoms of other conditions that can cause sciatica), and how pain and disability have responded to treatment should be assessed.

NICE has a guideline (currently being updated) and pathway on management of low back pain, but neither cover management of sciatica.

New evidence: el Barzouhi et al. (2013) studied MRI findings at 1-year follow-up in patients from a randomised controlled trial (n=283) comparing surgery with conservative care in people with a 6-to-12-week history of sciatica and radiologically confirmed lumbar disc herniation (Peul et al. 2007). Patients from 9 hospitals in the Netherlands were randomly assigned to early surgery, or to prolonged conservative treatment for 6 months with surgery in patients whose symptoms did not improve or became worse.

el Barzouhi et al. (2013) looked at 267 patients (94% of those originally randomised) who had available MRI results 1 year after randomisation (131 randomised to surgery and 136 to conservative care). Two neuroradiologists and 1 neurosurgeon assessed all follow-up scans for definite absence of disc herniation or definite, probable or possible herniation. Patients completed a 7-point Likert scale of global perceived recovery at 1 year after treatment, with 'favourable outcome' defined as complete or nearly complete disappearance of symptoms.

At follow-up, fewer patients were considered to have a herniated disc on MRI after surgery (21%) than after conservative treatment (60%, p<0.001). Overall, 84% of patients reported having a favourable outcome at 1 year (85% in the surgery group and 83% in the conservative treatment group, p=0.65). Rates of favourable outcome were similar among patients with disc herniation (85%) and with no herniation (83%, p=0.70).

Presence of disc herniation was not significantly different between those with a favourable outcome (35%) and those with an unfavourable outcome (33%, p=0.70). The presence of disc herniation on MRI did not discriminate between patients with a favourable outcome and those with an unfavourable outcome (area under the receiver-operating-characteristic curve=0.48, 95% confidence interval [CI] 0.39 to 0.58). The authors concluded that anatomical abnormalities on follow-up MRI did not distinguish between patients with favourable and unfavourable outcomes after treatment for symptomatic disc herniation.

Commentary: "MRI has an important role in people with sciatica (radicular pain) that is not resolving after about 6 weeks. It helps identify people for whom surgery should be considered. The role of repeat MRI scans in those whose sciatica symptoms continue, or whose symptoms recur, has not been defined.

"The finding that there is no relationship between clinical outcome and MRI findings after 1 year in a population with sciatica and disc prolapse at baseline is most striking. This suggests that there is little point in requesting further MRI scans in people with previous disc prolapse and persistent sciatica, regardless of treatment. These data were derived from a very specific population and may not be generalisable to all people with chronic sciatica. Nevertheless, the data do not support the use of MRI for people with chronic sciatica.

"Undertaking MRI scans that are not going change treatment is a poor use of available resources. Although there is no radiation risk from MRI, using this imaging technique in sciatica can put patients at increased risk of harm by increasing rates of surgery. In the absence of progressive neurological deficits, it is difficult to see a routine role for MRI in the management of chronic sciatica." – Professor Martin Underwood, Director, Warwick Clinical Trials Unit, Warwick Medical School. Professor Underwood was chair of the Guideline Development Group for the NICE clinical guideline on early management of persistent non-specific low back pain

Study sponsorship: The Netherlands Organization for Health Research and Development and the Hoelen Foundation.

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Antibiotics and community-associated Clostridium difficile infection
Overview: Clostridium difficile is an anaerobic bacterium that is present in the gut of up to 3% of healthy adults and 66% of infantsC difficile rarely causes problems in healthy people because it is kept in check by the normal bacterial population of the intestine. However, certain antibiotics – especially broad spectrum antibiotics – can disturb the balance of bacteria in the gut, which allows C difficile to multiply rapidly and produce toxins. The symptoms of C difficile infection include diarrhoea, fever and abdominal cramps. In more serious cases, infection can cause severe inflammation of the bowel (pseudomembranous colitis) and may be life-threatening. 

In 2012–13, 14,687 cases of C difficile infection in children and adults were reported in England, a rate of 27.7 cases per 100,000 population (Public Health England 2013). This rate reflects a year-on-year decrease in the number of cases, from 108.6 cases per 100,000 population in 2007–8 when mandatory reporting began. 

See the NICE Evidence Services topic page on C difficile for a general overview of this condition. 

Current advice: Public Health England guidance states that supportive care should be given to people with C difficile infection, including hydration, electrolytes and nutrition. Antiperistaltic agents should be avoided in people with acute infection. The precipitating antibiotic should be stopped wherever possible; agents with less risk of inducing C difficile infection can be substituted if an underlying infection still requires treatment. Consideration should be given to stopping or reviewing the need for proton pump inhibitors (PPIs) in people with or at high risk of C difficile infection. 

People with mild infection may not require specific C difficile antibiotic treatment. Mild or moderate disease can be treated with oral metronidazole, but oral vancomycin is preferred for severe infection. Fidaxomicin should be considered for people with severe C difficile infection who are at high risk for recurrence. Fidaxomicin may also be considered in severe cases that have not responded to oral vancomycin (see the NICE Evidence summary: new medicine on fidaxomicin). The addition of oral rifampicin or intravenous immunoglobulin may also be considered in such cases. In life-threatening disease, high dose oral vancomycin plus intravenous metronidazole is recommended. 

New evidence: Deshpande et al. (2013) conducted a meta-analysis of studies on the risk of community-associated C difficile infection in adults using antibiotics. The authors identified papers and conference abstracts on comparative, observational, community-based studies in any language. Eight high quality case–control studies (n=30,184) from the UK, the USA and Canada were included in the meta-analysis. Cases had been exposed to antibiotics in the 30–180 days before diagnosis, and neither cases nor controls had been admitted to a healthcare facility in the previous 8 weeks to 1 year. 

Antibiotic exposure was associated with a significantly higher risk of C difficile infection than no exposure to antibiotics (odds ratio [OR]=6.91, 95% CI 4.17 to 11.44, p<0.00001). The risk of infection was greatest with clindamycin (OR=20.43, 95% CI 8.50 to 49.09; 2 studies), followed by fluoroquinolones (OR=5.65, 95% CI 4.38 to 7.28; 3 studies), cephalosporins (OR=4.47, 95% CI 1.60 to 12.50; 3 studies), penicillins (OR=3.25, 95% CI 1.89 to 5.57; 4 studies), macrolides (OR=2.55, 95% CI 1.91 to 3.39; 3 studies) and sulphonamides or trimethoprim (OR=1.84, 95% CI 1.48 to 2.29; 3 studies). Tetracyclines were not associated with a significantly increased risk of infection (OR=0.91, 95% CI 0.57 to 1.45; 3 studies). 

The authors noted that their findings should be interpreted with caution given that significant heterogeneity was present among the studies included, fewer than 10 studies were analysed and all the studies were observational, so cannot prove causation. However, they suggested that patients and healthcare professionals should be aware of the risk of C difficile infection associated with antibiotic prescriptions in outpatient settings and should, where possible, select drugs associated with a lower risk. 

Commentary: "In 2007–08, non-hospital cases of C difficile infection reported in patients aged 2 years and over comprised approximately 40% of the total cases in England. In 2012–13, this proportion had risen to approximately 60% (Public Health England 2013). This increase in community-associated cases coincides with likely increased awareness and ascertainment of community cases, due to the introduction of national testing guidelines, increasing use of PPIs (which are a risk factor for C difficile infection [Cunningham et al. 2003]) and better control of hospital-acquired C difficile infection. Therefore, the use of lower risk antibiotics in the community, particularly among elderly patients on PPIs, is likely to be of increasing importance. 

"Antibiotic use also drives the development of resistance. Inter-country (as well as within-country) variations in prescribing suggest that the total quantities of antibiotics prescribed could be reduced, particularly for infections likely to be of viral aetiology. Set against this is the need to treat promptly and appropriately to avoid morbidity and mortality from C difficile infection and reduce the likelihood for the need for hospital admission. 

"The findings of Deshpande et al. (2013) are consistent with previous papers showing that clindamycin, fluoroquinolones and cephalosporins are the highest risk antibiotics for C difficile, with commonly used antibiotics such as penicillins and macrolides also a risk. Bearing in mind the limitations expressed by the authors, this article provides useful additional knowledge for practitioners trying to select the best antibiotics to treat infection in those at risk of C difficile." – Dr Philippa Moore, Consultant Medical Microbiologist, Gloucestershire Hospitals NHS Foundation Trust 

Study sponsorship: This study was not funded. 

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Interventions to improve physical activity in socioeconomically disadvantaged women
Overview: Lack of physical activity is a risk factor for chronic diseases, such as heart disease, stroke and diabetes. Physical inactivity in the UK has been estimated to have cost the NHS £0.9 billion in related ill health in 2006–07 (Scarborough et al. 2011). 

Women are less likely to take part in physical activity than are men: only 28% of women in England meet the current recommended level of physical activity, compared with 40% of men (Start Active, Stay Active 2011). In addition, people from low socioeconomic groups have low rates of participation in physical activity (Kavanagh et al. 2005). 

See the NICE Evidence Services topic page on physical activity for a general overview of the subject. 

Current advice: The chief medical officers for the 4 UK nations recommend that all adults should aim to be active daily (UK physical activity guidelines 2011). Adults aged 19 years and over should do at least 150 minutes (2.5 hours) of moderate intensity physical activity a week, such as walking at 3–4 mph. Alternatively adults should complete 75 minutes of vigorous intensity activity spread across the week, such as cycling at 12–14 mph, or a combination of moderate and vigorous intensity activity. 

NICE guidance on physical activity for adults in primary care recommends that adults who are not currently meeting the UK physical activity guidelines should be advised to do the recommended level of activity. These people should be provided with information about local opportunities to be physically active for people with a range of abilities, preferences and needs. NICE also has public health guidance on four commonly used methods to increase physical activity.

The NICE Pathway on physical activity brings together all related NICE guidance and associated products on the topic in a set of interactive topic-based diagrams. 

New evidence: Cleland et al. (2013) did a systematic review and meta-analysis of trials that looked at interventions to increase physical activity in socioeconomically disadvantaged women. The authors searched for studies in women who had a low education status or a low income, were unemployed or in low status occupations, or who lived in an area of low socioeconomic status. A total of 19 studies, most of which were conducted in Europe and North America, were eligible for inclusion in the review. An initial random effects meta-analysis identified significant statistical heterogeneity, so the data could not be pooled to produce an overall measure of effect. Instead the authors conducted analyses of predefined factors that might influence the success of an intervention, such as setting and duration. 

Delivery mode was the only factor found to have a significant effect on the success of an intervention to increase physical activity. Studies in which the intervention had a group component – such as group education meetings or practical sessions – found a greater difference between intervention and control groups (standardised mean difference [SMD] 0.36, 95% CI 0.17 to 0.54, p=0.0002) than studies in which the intervention was delivered individually (SMD –0.02, 95% CI –0.35 to 0.31, p=0.90) or in a community setting (SMD –0.02, 95% CI –0.10 to 0.05, p=0.58). 

The authors estimated that this difference would be equivalent to an additional 70 minutes of physical activity a week for women in group interventions or an extra 1000 steps a day. The authors noted that most studies in their analysis used self-reported measures of physical activity and that only 5 of the 19 studies included had a low or medium risk of bias. Nevertheless they suggested that the use of group-based approaches is a key factor in interventions that successfully improve physical activity in socioeconomically disadvantaged women. 

Commentary: "Evidence exists to support group interventions being successful for other public health measures compared with other interventions; for example, for people quitting smoking. However, it should be noted that group interventions are the format least likely to engage people in quitting, so personal preference needs factoring in. The level of preference for group interventions among the participants in the studies analysed here is not clear, because recruitment and drop out data are not included in a number of the studies. 

"In addition, it is unclear whether the effect noted in this study was specifically the result of group approaches or whether the holistic nature of the intervention was the significant factor. Any future work should separate these aspects of intervention delivery. 

"Practice in terms of approaches to increasing physical activity should not be changed solely on the basis of this study. The findings do, however, provide useful information for healthcare professionals considering options for increasing physical activity in communities of disadvantaged women. It would be helpful to have comparative cost effectiveness data between individual and group interventions to further support these deliberations." – Elaine Michel, Director of Public Health, Derbyshire County Council 

Study sponsorship: This study was not funded. 

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Impact of smoke-free legislation on population health
Overview: In 2004, more than a third of non-smoking adults worldwide (33% of male non-smokers and 35% of female non-smokers), and 40% of children, were exposed to second-hand smoke. This exposure is estimated to have caused 379,000 deaths from ischaemic heart disease, 165,000 from lower respiratory infections, 36,900 from asthma and 21,400 from lung cancer (Öberg et al. 2011). Passive smoking can also affect fetal health, increasing the risk of low birth weight and premature birth if the mother is exposed to second-hand smoke during pregnancy (Crane et al. 2011).

By July 2007, smoking in enclosed public spaces, such as pubs and restaurants, and in workplaces had been banned throughout the UK. Similar legislation in Scotland resulted in a large reduction in exposure to second-hand smoke, which has been greatest in non-smokers living in non-smoking households (Haw and Gruer 2007). Early evidence suggests that the introduction of regional and national legislation banning smoking in public places around the world has reduced the incidence of diseases associated with second-hand smoke (Tan et al. 2012).

Current advice: The NICE public health guidance on tobacco and harm-reduction approaches to smoking and the associated NICE Pathway discuss the risks of exposure to second-hand smoke. 

NICE guidance on quitting smoking in pregnancy and following childbirth recommends that healthcare professionals should in their first consultation with a pregnant woman discuss her smoking status and measure her carbon monoxide levels. Women who don't smoke but have high levels as a result of exposure to second-hand smoke should be provided with information about the hazards of passive smoking.

New evidence: Cox et al. (2013) assessed whether bans on smoking in Belgium introduced successively in public spaces and workplaces (January 2006), restaurants (January 2007) and bars serving food (January 2010) affected the risk of preterm birth. The authors undertook logistic regression analysis of all live-born singleton births delivered at 24–44 weeks' gestation in the Flanders region (n=606,877), adjusting for various infant, maternal and environmental factors.

Of the 448,520 spontaneous births that took place between January 2002 and December 2011, 32,123 (7.2%) occurred before gestational age of 37 weeks. The three types of smoking ban introduced were all associated with an immediate and sustained reduction in the risk of spontaneous preterm delivery (p<0.05 for all). The reduction was greatest for the ban on smoking in restaurants (step change –3.13%, 95% CI –4.37% to –1.87%, p<0.01) and then the ban on smoking in bars serving food (annual slope change –2.65%, 95% CI –5.11% to –0.13%, p=0.04). The risk of all types of preterm birth also showed a step decrease after 2007 (–3.18%, 95% CI –5.38% to –0.94%, p<0.01) and gradual drop after 2010 (–3.50%, 95% CI –6.35% to –0.57%, p=0.02 respectively). However, none of the smoke-free legislation had any effect on the risk of low birth weight (<2500 g), small for gestational age deliveries (birth weight below the 10th centile for the gestational age and sex of the baby) or average birth weight.

Sims et al. (2013) assessed whether emergency admissions for adults with asthma were affected by the introduction of legislation banning smoking in enclosed public spaces and workplaces in England. Hospital Episode Statistics were used to identify 502,000 emergency admissions for asthma in people aged 16 and over between 1997 and 2010. After adjusting for season, variation in population size and long-term trends in admissions, the introduction of smoke-free legislation in 2007 was associated with a 4.9% (95% CI 0.6% to 9.0%) drop in emergency admissions for asthma. The authors estimated that the legislation prevented approximately 1900 emergency admissions for asthma in the first year after implementation, and avoided a similar number of cases in the second and third years after introduction.

Commentary: "Both of these studies add to the growing evidence that smoke-free legislation is effective at reducing poor health. Cox et al. (2013) reported reductions in preterm deliveries following the phased introduction of legislation in Belgium, in line with the findings of previous studies conducted in Scotland and USA. Although Cox et al. (2013)'s findings are not novel, they add to the relatively small evidence base and reinforce the existing NICE guidance that pregnant women should be advised of the hazards of exposure to second-hand smoke. Antenatal visits usually start around the end of the first trimester of pregnancy, so this advice could be extended to women planning pregnancies.

"Sims et al. (2013) reported a reduction in emergency admissions for asthma in adults after introduction of smoke-free legislation in England. Millett et al. (2013) have recently reported reductions in childhood asthma in England after implementation of the legislation. These studies corroborate findings from other jurisdictions – including Scotland, the USA, Canada and Ireland – and demonstrate the effectiveness of existing UK legislation protecting from exposure in enclosed public places. More legislation is needed to encompass places not currently covered by English law, in particular private vehicles." – Professor Jill Pell, Henry Mechan Professor of Public Health, University of Glasgow

Study sponsorship: The Flemish Scientific fund, the European Research Council and Hasselt University sponsored Cox et al. (2013) and the Sims et al. (2013) study was funded by the Department of Health's Policy Research Programme.

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Effect of housing improvements on health
Overview: In 2011, 6.8 million (29.8%) of the 22.8 million houses and flats in England did not meet housing standards (English housing survey 2011: homes report). One in ten (10.6%) were in substantial disrepair, 4.6% had damp, a quarter did not meet the 'decent home' standard (23.5%), and 15.3% had a serious health and safety hazard.

A large body of evidence suggests an association between poor housing and poor physical and mental health, but the nature of any causal links is complicated by the coexistence of poor housing with other determinants of poor health, such as unemployment and poverty. An analysis by the Health Development Agency (2005), now part of NICE, found review-level evidence that a number of housing interventions, such as housing subsidy programmes for low-income families and improving housing energy efficiency measures, improved health. However, the authors noted a number of methodological issues that might limit the validity of their findings.

Current advice: The Department for Communities and Local Government considers a house or flat 'decent' if it:
  • poses no serious health and safety hazards, as measured by the Housing Health and Safety Rating System
  • is in a reasonable state of repair
  • has reasonably modern facilities and services, such as kitchens, bathrooms and boilers
  • provides a reasonable degree of thermal comfort. 
Social houses and flats that do not meet the Decent Homes Standard should undergo refurbishment to bring them up to or above the standard. Homes in the private rented sector do not have to meet the standard but are required to meet Housing Health and Safety Rating System standards. Private landlords whose properties contain hazards as assessed by the system, in particular landlords with tenants on means tested or disability benefits, can be compelled to improve their properties by local authorities.

New evidence: A Cochrane systematic review by Thomson et al. (2013) sought to establish whether physical improvements to housing affected health and socioeconomic outcomes. The authors searched for studies of the effects of rehousing and any physical change to housing – for example, heating installation and general refurbishment – on physical or mental health, wellbeing or quality of life. Thirty-nine quantitative and qualitative studies were identified, but meta-analysis of the data was not possible because of extreme heterogeneity among the studies.

Assessment of the studies by intervention type suggested that warmth and energy efficiency improvements to housing (19 studies) benefited respiratory health and had some positive effect on general and mental health. The studies of rehousing or retrofitting houses mostly looked at housing-led neighbourhood renewal (14 studies) and had mixed results, with only one small study reporting a significant improvement in general health. The limited evidence available on provision of basic housing in low or middle income countries (3 studies) reported unclear or small health improvements, as did the poor evidence on rehousing from slums (3 studies). Three studies reported lower levels of school absence in children after housing improvements, with 1 additionally reporting a link between housing improvements and a significantly lower number of days off work among adults.

The authors generated a model using the 9 studies with the best available data to analyse the overall effect on health of modern day improvements to housing. These studies suggested that warmth or energy efficiency improvements, which are often part of rehousing or retrofitting projects, can lead to improvements in health in high income countries. Analysis of the qualitative data identified in the search suggested that improvements in thermal comfort and affordable warmth allow residents to use more of their indoor space, which can promote improvements in diet, privacy, and household and family relationships.

Commentary: "This study strengthens the evidence of the link between improvements in housing – particularly in warmth and affordable warmth – and improved physical and mental health. It shows the key role of housing in the dynamic between poverty and poor health, and how improving housing can benefit school attendance and reduce absenteeism from work; for example, through improved respiratory health and improved relationships within the home.

"The significance of this evidence for practice is that primary care health professionals and others with a responsibility for improving health and wellbeing should focus not just on individual lifestyle factors but also on supporting improvements in the environment. Such improvements might include interventions to tackle fuel poverty and to improve the energy efficiency of homes.

"Local authorities becoming responsible for public health, improved integration of health and social care in the care of the elderly, and local authorities taking commissioning responsibility for the public health of children ages 0 to 5 years will potentially support health and social care practitioners in improving the health of their patients, clients and communities." – Sabrina Fuller, Head of Health Improvement, NHS England

Study sponsorship: Chief Scientist Office, Health Department, Scottish Government; and Nordic Campbell Collaboration (NC2), Norway.

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QIPP case study: stratified cancer pathways – redesigning services for those living with or beyond cancer
The incidence of cancer in England is increasing, but so are survival rates. By 2030 there are likely to be over 3 million people in England living with or beyond their cancer (National Cancer Survivorship Initiative 2012). As a result, there is growing demand for cancer aftercare services. Routine 1- to 5-year follow-up of cancer survivors within the NHS costs approximately £250 million a year from an annual £6 billion budget.

These financial figures, and feedback from patients that they continue to have many unmet needs at the end of cancer treatment, prompted NHS Improving Quality to review the way aftercare services are delivered. The initiative aimed to improve aftercare services for those living with or beyond cancer by matching the level of support to individual patients' needs and preferences. It focused on redesigning follow-up pathways to stratify aftercare for people with breast, colorectal and prostate cancer.

In the stratified pathway, the clinical team and the person living with cancer make a decision about the best form of aftercare on the basis of their knowledge of the disease, the treatment and the person. Aftercare might then be:
  • Supported self-management, in which the patient is given information about self-management programmes or other types of support.
  • Shared care, in which the patient has face-to-face, phone or email contact with professionals as part of continuing follow-up.
  • Complex case management, in which the patient is given intensive support to manage his or her cancer, other conditions or both. 
Supporting patients to self-manage their own health and wellbeing can meet unmet needs and reduce demand on services. The resulting release of resources allows patients with complex needs to have more contact with their specialist team and those experiencing problems to re-access help more quickly.

Gilmour Frew, Programme Director, Delivery Team, NHS Improving Quality, said: "This approach produces significant improvements to patient experience because patients are given the support to manage their condition themselves and do not have to attend unnecessary appointments. Clinicians and patient groups have welcomed this change in approach and are enthusiastic in taking the initiative forward and developing similar pathways for other types of cancer."

The estimated net saving in England resulting from the initiative is £86 million, or £214,000 per 100,000 population.

Visit NICE Evidence Search for more details of this initiative and other QIPP examples.

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Evidence Update
NICE has recently published an Evidence Update on:
  • Post-traumatic stress disorder 
This Evidence Update highlights and provides commentary on selected new evidence published since the NICE guidance was issued. For each topic, the evidence was considered by an Evidence Update Advisory Group (EUAG): a panel of experts, most of whom were involved in developing the original NICE guidance.

The Evidence Update on post-traumatic stress disorder was published by NICE in December 2013. It includes commentary from the EUAG on 19 new articles (relevant to NICE clinical guideline 26), covering the following topics:
  • Recognition of post-traumatic stress disorder in young people with behavioural problems
  • Comorbidities in post-traumatic stress disorder, including drug or alcohol dependency, and comorbid depression and risk of suicide
  • Involving partners in therapy
  • Community-implemented trauma therapy
  • Early interventions and treatment
  • Interventions and treatment more than 3 months after a trauma
  • Complementary and alternative therapies
  • Post-traumatic stress disorder in children
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a change in clinical practice. It does not constitute formal NICE guidance. The commentaries
included are the opinions of contributors and do not necessarily reflect the views of NICE.
 
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