Scanning the Horizon, August 09 - Newsletter - Service Planning and New health Intervention Assessment (SPNIA)

Scanning the Horizon: Recent Developments in Health Innovations and Technologies

August 2009

This newsletter provides links to systematic reviews and important research on health innovations and emerging new technologies. It is aimed to help District Health Boards and health care providers keep up to date with information to help them improve performance around the Ministry of Health's Health Targets and other relevant topics. The back issues can be found at http://www.moh.govt.nz/moh.nsf/indexmh/spnia-resources-newsletter

In each issue, there are links to:

recent horizon scanning reports
health technology assessments
guidelines
research reports.

In this current issue, areas of particular interest are:

Reducing Emergency Department Waiting Times	Nurses and Diabetes/Cardiac Health
Emergency Department Diagnoses	Primary Care
Tobacco	Dementia
Disability Services	Maintaining Cardiac Health
Transplantation

In some cases, we have provided links to journal articles for journals to which your organization might not subscribe. If you can not link directly to the full article and you want to order it, you can coordinate an interloan through your local library

HIGHLIGHTED ISSUE: REDUCING EMERGENCY DEPARTMENT WAITING TIMES
Emergency Department overcrowding and length of stay are top priority issues for the Minister of Health. District Health Boards are focusing on them as they develop their District Annual Plans which will describe how DHBs will achieve the new ED Health Target.

Systematic Review of Emergency Department Crowding: Causes, Effects, and Solutions (www.sciencedirect.com)
“Emergency department (ED) crowding represents an international crisis that may affect the quality and access of health care. [These researchers] conducted a comprehensive PubMed search to identify articles that (1) studied causes, effects, or solutions of ED crowding; (2) described data collection and analysis methodology; (3) occurred in a general ED setting; and (4) focused on everyday crowding… The results illustrated the complex, multifaceted characteristics of the ED crowding problem. This structured overview of the literature may help to identify future directions for the crowding research agenda.”

Models of Emergency Departments for Reducing Patient Waiting Times (www.ncbi.nlm.nih.gov)
[This article describes] “both agent-based models and queuing models to investigate patient access and patient flow through emergency departments…[according to the authors], the models' utility lies in their ability to provide qualitative insights into the relative sensitivities and impacts of model input parameters, to illuminate scenarios worthy of more complex investigation, and to iteratively validate the models as they continue to be refined and extended.”

Efficacy of a holding unit to reduce access block and attendance pressure in the emergency department (www.ncbi.nlm.nih.gov)
“Access block, the inability of patients in the emergency department (ED) to access hospital beds, is a contributing factor to overcrowding in the ED. The effect of a holding unit (HU) on access block and some medical management indicators is presented. [The findings reveal that] the opening of an HU has led to an improvement in the access block.”

Access Block and Overcrowding: A Literature Review (PDF, 352 KB)
“Access Block and Emergency Department (ED) Overcrowding are well defined phenomena that have been described as the most serious issue confronting EDs. This paper provides a summary of the current evidence on the subject from around the world.”

Streaming by case complexity: Evaluation of a model for emergency department fast track (www.ncbi.nlm.nih.gov)
The objective of this study was to “to evaluate a patient flow streaming system within a teaching hospital's ED, using functional principles to separate patients into two streams on the basis of complexity rather than acuity, severity or disposition… Key features in the success of the system included use of dedicated senior staff for Fast Track patients, and quarantining of clinical resources. The ED aiming to improve their waiting times and throughput should consider using complexity as a key criterion for triaging patients into separate streams.”

A Guide to Good Practice: Unscheduled and Emergency Care (PDF, 2.19 MB)
“The Delivering Emergency Care Service (DECS) document published in February 2008 is designed to provide a framework within which the most appropriate care is made available, at the right time for patients to ease the pressure on vital parts of the unscheduled care system and to modernise the delivery of unscheduled care services.”

Building The Clockwork Pediatric Emergency Department (www.childrenshospitals.net)
This summary reports the results of poster presentation that described “the implementation of toggled rapid triage practice and bedside registration in the ED and the impact on key operational measures.”

HIGHLIGHTED ISSUE: EMERGENCY DEPARTMENT DIAGNOSES

Misdiagnosis of transient ischemic attacks in the emergency room (content.karger.com)
“Distinguishing TIA from nonischemic causes is difficult in the emergency room, with 60% of suspected TIA patients having nonischemic causes on inpatient evaluation. We found 3 clinical features that may be useful in the emergency room triage of transient neurologic attacks: gradual symptom onset, prior history of unexplained transient neurologic, and presence of nonspecific symptoms.”

Diagnostic accuracy of neurological problems in the emergency department (www.ncbi.nlm.nih.gov)
The results of this study indicate that “misdiagnosis or diagnostic uncertainty occurred in over one-third of all neurological consultations in the emergency department setting. Benign neurological conditions, such as migraine, syncope and peripheral vertigo are frequently mislabeled as seizure or stroke. Educational strategies that emphasize emergent evaluation of these common conditions could improve diagnostic accuracy, and may result in better patient care.”

Misdiagnosis of spontaneous cervical epidural haemorrhage (www.ncbi.nlm.nih.gov)
“Spontaneous spinal epidural haemorrhage is a rare condition. The initial clinical manifestations are variable. Nonetheless, most spinal cord lesions result in paraparesis or quadriparesis, but not hemi-paresis, if motor function is involved. We report on a 69-year-old man who presented initially with right-side limb weakness. He was initially misdiagnosed at emergency room with a cerebral stroke and treated inappropriately with heparin. [The authors] draw the misdiagnosis to the attention of the reader because early recognition of spontaneous spinal epidural haematoma is very important for prompt and appropriate treatment to improve the overall prognosis.”

REDUCING THE HARM CAUSED BY TOBACCO

The effectiveness of interventions to increase the delivery of effective smoking cessation treatments in primary care settings - the ABCs (PDF, 2.96 MB)
“This systematic review provides a summary of the evidence pertaining to the effectiveness of interventions aimed at increasing the likelihood of Health Care Professionals initiating elements of the ABC approach for smoking cessation in a primary care setting. That is, any intervention that aims to increase the documentation of smoking status (Ask), provision of brief advice to stop smoking (Brief advice), and/or the offer or provision of smoking cessation treatments or services (Cessation support), compared to usual care. The purpose of the ABC approach is to make the health sector’s approach to smoking cessation more systematic, and ultimately, to get more smokers to see the importance of stopping as soon as possible, and to use the proven effective treatments available.”

Effect of adding a virtual community (bulletin board) to smokefree.gov: randomized controlled trial (www.pubmedcentral.nih.gov)
“Web-assisted tobacco interventions (WATIs) offer a potentially low-cost way to reach millions of smokers who wish to quit smoking... [The researchers] primary aim was to determine the utilization of and satisfaction with 2 versions of a smoking cessation website (smokefree.gov). A secondary goal was to measure changes in smoking behavior 3 months after enrollment in the study. Satisfaction with the website was high, with the most favorable [cessation] outcomes demonstrated by smokers ready to quit at the time of enrolling in the trial and smokers using pharmacotherapy.”

A Digital Smoking Cessation Program Delivered Through Internet and Cell Phone Without Nicotine Replacement (Happy Ending): Randomized Controlled Trial (www.jmir.org)
“This 12-month trial documents a long-term treatment effect of a fully automated smoking cessation intervention without the use of nicotine replacement therapy. The study adds to the promise of using digital media in supporting behavior change.”

Comparing internet assistance for smoking cessation: 13-month follow-up of a six-arm randomized controlled trial (www.jmir.org)
These researcher’s “findings show that Internet assistance is attractive and potentially cost-effective and suggest that tailored, interactive websites may help cigarette smokers who do not report an indicator of depression at baseline to quit and maintain cessation.”

Using the internet to assist smoking prevention and cessation in schools: a randomized, controlled trial (www.ncbi.nlm.nih.gov)
“A five-stage interactive Web site, the Smoking Zine intervention provided cessation motivation for smokers most resistant to quitting at baseline and prevented nonsmoking adolescents from becoming heavy smokers at 6 months. By providing an accessible and attractive method of engaging young people in smoking prevention and cessation, this interactive and integrated program provides a novel vehicle for school- and population-level health promotion.”

Comparing two web-based smoking cessation programs: randomized controlled trial (www.ncbi.nlm.nih.gov)
These researchers “describe the 6-month follow-up results of a randomized controlled trial in which participants recruited online were randomly assigned to either a Web-based smoking cessation program (Quit Smoking Network; QSN) or a Web-based exercise enhancement program (Active Lives) adapted somewhat to encourage smoking cessation… Contrary to [the researcher’s] hypothesis, [their] test of two Web-based smoking cessation conditions failed to show differences at 3- and 6-month assessments.”

DISABILITY SERVICES

The impact of adaptive seating devices on the lives of young children with cerebral palsy and their families (www.ncbi.nlm.nih.gov)
“The introduction of adaptive seating devices for young children who need support to sit had a meaningful, positive impact on child and family life. Removal of the study devices showed a concomitant negative impact on key aspects of child and family life.”

Power-assisted wheels ease energy costs and perceptual responses to wheelchair propulsion in persons with shoulder pain and spinal cord injury (www.sciencedirect.com)
“Use of [pushrim-activated power-assisted wheelchairs] by persons with paraplegia and tetraplegia having shoulder pain significantly lowers energy cost responses and perceived exertion compared with manual wheelchair propulsion while significantly increasing the distanced propelled.”

Wheelchair curb climbing: randomized controlled comparison of highly structured and conventional training methods (www.ncbi.nlm.nih.gov)
“In comparison with a conventional method for curb-climbing, a highly structured method seems to require less than 50% of the training time for able-bodied participants, although this finding is only a trend statistically. This has implications for clinical training.”

A prospective multi-centre study of the benefits of bilateral hearing aids (www.ncbi.nlm.nih.gov)
“In a number of respects bilaterally fitted hearing aids offered a benefit relative to unilaterally fitted hearing aids (the so-called bilateral benefit), both subjectively (questionnaire) and objectively (speech perception in noise and localization). However, we found large interindividual differences and not all differences were clinically relevant. The results of the diagnostic tests showed that it was not possible to predict the bilateral benefit from a priori information based on headphone tests. At the end of the trial period 93% of the participants preferred a bilateral fitting.”

Reforming Long-term Care: Recent Lessons from Other Countries (PDF, 310KB)
“The study focused on a small number of purposively selected countries and critically examined current reforms to the funding and/or allocation of resources for care for older and/or younger disabled people that aim to improve the sustainability of existing arrangements, critically examined evidence on the impact of cash or voucher-based options in generating a supply of responsive, high quality service options, and discussed the implications for reform in England.”

HIGHLIGHTED ISSUE: TRANSPLANTATION

Intestinal Transplants A rapid scan of the literature (PDF, 584 KB)
This report provides a brief summary of the literature available on the role of intestinal transplants in the treatment of intestinal failure. With no relevant RCTs in the area, the review presents evidence from case series reports, data from an intestinal transplant registry and non-randomised prospective studies. Identified publications have been grouped by study type, with key results discussed in detail.

The potential impact of an opt out system for organ donation in the UK: an independent report from the Organ Donation Taskforce (www.dh.gov.uk)
“This independent report from the Organ Donation Taskforce about the potential impact of changing to an opt out system of consent provides an in-depth examination of this complex question. The Taskforce has had discussions and engagement with academics, health professionals, members of the public, organ recipients, families of donors and faith leaders and the report reflects the wide range of views heard.”

Kidney transplantation using incompatible blood group donors (PDF, 156 KB)
“Evidence from three comparative studies suggests that ABO-incompatible kidney transplant is feasible, safe and effective to use in addition to ABO-compatible kidney transplant in order to improve the current management and treatment of patients with ESKD. Antibody titers appear to be a useful way of predicting a patients likelihood of graft survival.”

Nutrition support for bone marrow transplant patients (www.mrw.interscience.wiley.com)
“Bone marrow transplant patients can experience prolonged poor appetite with vomiting and diarrhoea. Malnutrition is a consequence. To prevent this, patients can receive nutritious fluids orally or via a nasogastric tube, or intravenously as parenteral nutrition. The benefits of either route are unclear. Studies were found that compared these interventions but missing data prevents proper assessment of the benefits. However, the limited data available indicates that when patients undergo bone marrow transplantation and are given intravenous fluids and are encouraged to have an oral diet they are less likely to experience infections and are more likely to go home earlier than if they are given standard parenteral nutrition routinely. In the event that patients nutritional intake is inadequate because of an inadequate oral intake or because they are unable to tolerate tube feeding and are given parenteral nutrition with added glutamine they are likely to have less infections but may not necessarily leave hospital earlier.”

Antiviral medications for preventing cytomegalovirus disease in solid organ transplant recipients (www.mrw.interscience.wiley.com)
“Prophylaxis with antiviral medications reduces CMV [cytomegalovirus] disease and CMV-associated mortality in solid organ transplant recipients. They should be used routinely in CMV positive recipients and in CMV negative recipients of CMV positive organ transplants.”

HIGHLIGHTED ISSUE: NURSING AND DIABETES/CARDIOVASCULAR HEALTH

An evaluation of a Diabetes Specialist Nurse prescriber on the system of delivering medicines to patients with diabetes (www.ncbi.nlm.nih.gov)
“A medicines management intervention, provided by a Diabetes Specialist Nurse prescriber, had a positive effect on the system of delivering medicines to patients with diabetes and significantly reduced the number of errors. This reduction had some effect on length of stay. The cost saving was sufficient to finance a Diabetes Specialist Nurse prescriber post.”

Preventing coronary heart disease and stroke with aggressive statin therapy in older adults using a team management model (www.ncbi.nlm.nih.gov)
“The purposes of this review were to highlight recent clinical trial results on the safety and efficacy of statin therapy in adults aged 65 years and older and to examine how nurse practitioners (NPs) and physician assistants (PAs) working together with physicians as a team can better serve the needs of this fastest growing subset of the U.S. population who are at high risk for cardiovascular events including stroke…The researchers found that [NPs and PAs are both well educated and well placed to manage patients with chronic stable cardiovascular disease (CVD).”

The cost-effectiveness a disease management programme for secondary prevention of coronary heart disease and heart failure in primary care (heart.bmj.com)
“The use of a nurse led disease management programme is associated with increased costs in other coronary heart disease related services as well as for the costs of the clinics. They are also associated with improvements in health. Even in the short term these disease management programmes may represent a cost-effective service as additional QALY are generated at an acceptable extra cost.”

HIGHLIGHTED ISSUE: PRIMARY CARE

Cost-effective primary care-based strategies to improve smoking cessation: more value for money (www.ncbi.nlm.nih.gov)
“Three smoking cessation treatments were tested: (1) GP training plus GP remuneration for each abstinent patient, (2) GP training plus cost-free nicotine replacement medication and/or bupropion hydrochloride for the patient, and (3) a combination of both strategies…Intervention 1 was not effective compared with treatment as usual (TAU). Interventions 2 and 3 each proved to be cost-effective compared separately with TAU.”

Addressing general practice workforce shortages: policy options (www.mja.com.au)
“Evidence-based strategies that could increase the number of doctors choosing general practice as a career include longer and higher-quality general practice attachments during medical school and the early postgraduate years, and emphasising the positive aspects of general practice, such as flexibility.”

Cancer care: what role for the general practitioner? (www.mja.com.au)
“There is now an explicit recognition that GPs should be involved in all stages of the cancer journey, from first presentation to palliative care, and that service reforms must incorporate more significant roles for primary care. This has found its way into policy and practice in the United Kingdom and Australia, where service guidance…urges all those involved in delivering cancer services to better connect the various stages of the cancer journey and to provide care that is accessible and convenient — all predicated upon significant primary care input.”

Does general practice Google? (PDF, 256 KB)
“Computers are now available in most general practices. The internet has impacted upon the traditional doctor-patient relationship. More research is needed into how GPs can better search and use the information available on the internet.”

HIGHLIGHTED ISSUE: DEMENTIA

Effect of physical activity on cognitive function in older adults at risk for Alzheimer disease: a randomized trial (www.ncbi.nlm.nih.gov)
“Many observational studies have shown that physical activity reduces the risk of cognitive decline; however, evidence from randomized trials is lacking. In this study of adults with subjective memory impairment, a 6-month program of physical activity provided a modest improvement in cognition over an 18-month follow-up period.”

Effect of bright light and melatonin on cognitive and noncognitive function in elderly residents of group care facilities: a randomized controlled trial (www.ncbi.nlm.nih.gov)
These researchers sought “to determine whether the progression of cognitive and noncognitive symptoms may be ameliorated by individual or combined long-term application of the 2 major synchronizers of the circadian timing system: bright light and melatonin…[They found that] light has a modest benefit in improving some cognitive and noncognitive symptoms of dementia. To counteract the adverse effect of melatonin on mood, it is recommended only in combination with light.”

Alcohol, dementia and cognitive decline in the elderly: a systematic review (aging.oxfordjournals.org)
“To evaluate the evidence for any relationship between incident cognitive decline or dementia in the elderly and alcohol consumption, a systematic review and meta-analyses were carried out… Because of the heterogeneity in the data these findings should be interpreted with caution. However, there is some evidence to suggest that limited alcohol intake in earlier adult life may be protective against incident dementia later.”

HIGHLIGHTED ISSUE: MAINTAINING CARDIAC HEALTH

Statins for secondary prevention in elderly patients: a hierarchical Bayesian meta-analysis (www.crd.york.ac.uk)
“This review looked at the effectiveness of statins in the elderly and concluded that statins reduce mortality by more than was thought previously. The authors' conclusions are likely to be reliable.”

Daily walking performance as an independent predictor of advanced heart failure: Prediction of exercise capacity in chronic heart failure (www.ncbi.nlm.nih.gov)
“Daily walking performance is a clear determinant of maximal and functional exercise capacities in patients with CHF [chronic heart failure]. Walking intensity in particular is an independent predictor in discriminating patients with advanced heart failure. Monitoring of daily walking performance might aid in detecting disease.”

Physical activity during leisure time and primary prevention of coronary heart disease: an updated meta-analysis of cohort studies (www.ncbi.nlm.nih.gov)
“The current meta-analysis reports significant protection against the occurrence of CHD resulting from moderate-to-high levels of physical activity. These results strengthen the recommendations of guidelines that indicate the protective effect against cardiovascular disease of physical activity profiles that are attainable by ordinary people.”

HIGHLIGHTED WEBSITE

TRIP (Turning Research into Practice) Database (www.tripdatabase.com)
“The aims of the TRIP Database have remained the same since 1997 - allow health professionals to easily find the highest-quality material available on the web - to help support evidence based practice.”

HEALTH SERVICES ASSESSMENT COLLABORATION

The Health Services Assessment Collaboration (HSAC) is working on a number of projects at present and those are noted below. A list of upcoming projects is also provided.

New Publications:

Current projects:

Treatments for borderline personality disorder (review of evidence-based practice guidelines)
CT angiography for the investigation of patients with suspected coronary artery disease (systematic review update)
Non-pharma interventions for dementia (systematic review)
Grading evidence for scoring evidence based practice projects (briefing report)

LINKS TO HEALTH TECHNOLOGY NEWSLETTERS

ANZHSN Bulletin: Issue 10 – April 2009 (PDF, 480 KB)
ANZHSN Bulletin: Issue 11 – August 2009 (PDF, 1.21 MB)
This newsletter highlights “new health technologies identified through the Australia and New Zealand Horizon Scanning Network (ANZHSN)”. Areas of particular interest in issue 10 include discussions of new technologies for breast cancer screening, as well as glucose monitoring for diabetic, pregnant women. Amongst other areas, issue 11 provides discussions of kidney transplantation and screening for Helicobacter Pylori.

Health Technology Update – Issue 11 (PDF, 1.73 MB)
“The issue’s feature article addresses the current global crisis in isotope production in medical imaging. The solutions explored are those that could be adopted within a 5 to 10 year time frame... [The authors] also bring you an update on the expanding distribution of positron emission tomography or PET scanners in Canada; PET imaging is one of several alternatives to isotope use. Additionally, this issue provides a cross-section of emerging genetic tests, and we look at a group that supports the development and implementation of an evidence-based process for evaluating genomic applications.”

OTHER USEFUL LINKS

Medical Services Advisory Committee (MSAC)(www.msac.gov.au)
Canadian Agency for Drugs and Technologies in Health (CADTH) (www.cadth.ca)
INAHTA (International Network of Agencies for Health Technology Assessment) (www.inahta.org)
EuroScan (www.euroscan.org.uk)
The Canadian Partnership against Cancer (www.partnershipagainstcancer.ca)

The information available on or through this website is intended to provide general information to the health sector and the public, and is not intended to address specific circumstances of any particular individual or entity. All reasonable measures have been taken to ensure the quality and accuracy of the information available on this website. If you find any information on this website that you believe may be inaccurate, please send an email to webmaster@moh.govt.nz