Andrew Hutchings

BSR and BHPR guidelines for the management of giant cell arteritis

Scope and purpose GCA is the commonest of all the vasculitides. Visual loss occurs in up to one-fifth of patients, which may be preventable by prompt recognition and treatment [1,2]. The aim of these guidelines is to encourage the prompt diagnosis and management of GCA, with emphasis on the prevention of visual loss. Their scope is to provide evidence-based advice for the assessment and diagnosis of GCA, for initial and further management and for monitoring of disease activity, complications and relapse. This is a summary of the guidelines and the full guideline is available at Rheumatology online.

Challenges to implementing the national programme for information technology (NPfIT) : a qualitative study

Abstract Objectives To describe the context for implementing the national programme for information technology (NPfIT) in England, actual and perceived barriers, and opportunities to facilitate implementation. Design Case studies and in depth interviews, with themes identified using a framework developed from grounded theory. Setting Four acute NHS trusts in England. Participants Senior trust managers and clinicians, including chief executives, directors of information technology, medical directors, and directors of nursing. Results The trusts varied in their circumstances, which may affect their ability to implement the NPfIT. The process of implementation has been suboptimal, leading to reports of low morale by the NHS staff responsible for implementation. The overall timetable is unrealistic, and trusts are uncertain about their implementation schedules. Short term benefits alone are unlikely to persuade NHS staff to adopt the national programme enthusiastically, and some may experience a loss of electronic functionality in the short term. Conclusions: The sociocultural challenges to implementing the NPfIT are as daunting as the technical and logistical ones. Senior NHS staff feel these have been neglected. We recommend that national programme managers prioritise strategies to improve communication with, and to gain the cooperation of, front line staff.

BSR and BHPR guidelines for the management of polymyalgia rheumatica

PMR is the most common inflammatory rheumaticdisease in the elderly and is one of the biggest indicationsfor long-term steroid therapy. There are difficulties indiagnosis, with heterogeneity in presentation, responseto steroids and disease course.The aim of these guidelines is a safe and specificdiagnostic process for PMR, using continued assessment,and discouragement of hasty initial treatment. Their scopeis to provide advice for the diagnosis of PMR, manage-ment and monitoring of disease activity, complicationsand relapse. The management of GCA is not coveredand is published separately.The full guideline is available at Rheumatology online.

Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care?

Abstract Objectives: To determine the strength of evidence for the effectiveness of mental health interventions for patients with three common somatic conditions (chronic fatigue syndrome, irritable bowel syndrome, and chronic back pain). To assess whether results obtained in secondary care can be extrapolated to primary care and suggest how future trials should be designed to provide more rigorous evidence. Design: Systematic review. Data sources: Five electronic databases, key texts, references in the articles identified, and citations from expert clinicians. Study selection: Randomised controlled trials including participants with one of the three conditions for which no physical cause could be found. Two reviewers screened sources and independently extracted data and assessed quality. Results: Sixty one studies were identified; 20 were classified as primary care and 41 as secondary care. For some interventions, such as brief psychodynamic interpersonal therapy, little research was identified. However, results of meta-analyses and of randomised controlled trials suggest that cognitive behaviour therapy and behaviour therapy are effective for chronic back pain and chronic fatigue syndrome and that antidepressants are effective for irritable bowel syndrome. Cognitive behaviour therapy and behaviour therapy were effective in both primary and secondary care in patients with back pain, although the evidence is more consistent and the effect size larger for secondary care. Antidepressants seem effective in irritable bowel syndrome in both settings but ineffective in chronic fatigue syndrome. Conclusions: Treatment seems to be more effective in patients in secondary care than in primary care. This may be because secondary care patients have more severe disease, they receive a different treatment regimen, or the intervention is more closely supervised. However, conclusions of effectiveness should be considered in the light of the methodological weaknesses of the studies. Large pragmatic trials are needed of interventions delivered in primary care by appropriately trained primary care staff. What is already known on this topic Patients with functional somatic symptoms are common in primary care and may not receive effective mental health interventions What this study adds Research in secondary and primary care shows that cognitive behaviour therapy and behaviour therapy help patients with back pain and that antidepressants benefit patients with irritable bowel syndrome Effect sizes are larger in secondary care than in primary care Patients in secondary care with chronic fatigue syndrome may benefit from cognitive behaviour therapy Future research should focus on large pragmatic trials with longer term follow up and economic evaluation

A systematic review of factors affecting the judgments produced by formal consensus development methods in health care

Objectives: Formal consensus development methods are ways of obtaining and synthesising views of experts, opinion leaders and other stakeholders, and are increasingly being used to develop clinical practice guidelines. Our objective was to examine the impact that the characteristics of individual participants, groups and the consensus process have on the judgments produced by formal consensus development methods in health care. Methods: Studies were identified from an earlier methodological review and a search of five bibliographic databases for the period January 1996 to December 2004. Studies were eligible if they involved formal consensus development methods and reported differences in judgments between groups or participants. For studies comparing two or more groups overall percentage agreement, the kappa coefficient and the odds ratio for differences in judgments were calculated. Results: There were 22 studies comparing the impact of the characteristics of individual participants within groups and 30 studies comparing the results produced by two or more groups. Practitioners who perform a procedure tend to emphasise the appropriateness of the procedure compared with non-performing practitioners, and individuals from groups that were subject to performance criteria are more critical of those criteria than individuals from other groups. There was no clear pattern for the differences in judgments produced by participants and groups from different countries. Conclusions: Except for participant specialty there is little generalisable evidence for how the characteristics of participants and groups influence the judgments produced in formal consensus development methods. Multi-specialty groups are preferable to single-specialty groups because of their potential for taking account of a wider range of opinions.

2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative

Therapy for polymyalgia rheumatica (PMR) varies widely in clinical practice as international recommendations for PMR treatment are not currently available. In this paper, we report the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) recommendations for the management of PMR. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology as a framework for the project. Accordingly, the direction and strength of the recommendations are based on the quality of evidence, the balance between desirable and undesirable effects, patients’ and clinicians’ values and preferences, and resource use. Eight overarching principles and nine specific recommendations were developed covering several aspects of PMR, including basic and follow-up investigations of patients under treatment, risk factor assessment, medical access for patients and specialist referral, treatment strategies such as initial glucocorticoid (GC) doses and subsequent tapering regimens, use of intramuscular GCs and disease modifying anti-rheumatic drugs (DMARDs), as well as the roles of non-steroidal anti-rheumatic drugs and non-pharmacological interventions. These recommendations will inform primary, secondary and tertiary care physicians about an international consensus on the management of PMR. These recommendations should serve to inform clinicians about best practices in the care of patients with PMR.

Evaluation of modernisation of adult critical care services in England: time series and cost effectiveness analysis

Objective To evaluate the impact and cost effectiveness of a programme to transform adult critical care throughout England initiated in late 2000. Design Evaluation of trends in inputs, processes, and outcomes during 1998-2000 compared with last quarter of 2000-6. Setting 96 critical care units in England. Participants 349 817 admissions to critical care units. Interventions Adoption of key elements of modernisation and increases in capacity. Units were categorised according to when they adopted key elements of modernisation and increases in capacity. Main outcome measures Trends in inputs (beds, costs), processes (transfers between units, discharge practices, length of stay, readmissions), and outcomes (unit and hospital mortality), with adjustment for case mix. Differences in annual costs and quality adjusted life years (QALYs) adjusted for case mix were used to calculate net monetary benefits (valuing a QALY gain at £20 000 (

A comparison of formal consensus methods used for developing clinical guidelines.

33 170, €22 100)). The incremental net monetary benefits were reported as the difference in net monetary benefits after versus before 2000. Results In the six years after 2000, the risk of unit mortality adjusted for case mix fell by 11.3% and hospital mortality by 13.4% compared with the steady state in the three preceding years. This was accompanied by substantial reductions both in transfers between units and in unplanned night discharges. The mean annual net monetary benefit increased significantly after 2000 (from £402 (

Reporting ethics committee approval and patient consent by study design in five general medical journals

667, €445) to £1096 (

The relative risk of aortic aneurysm in patients with giant cell arteritis compared with the general population of the UK

1810, €1210)), indicating that the changes were relatively cost effective. The relative contribution of the different initiatives to these improvements is unclear. Conclusion Substantial improvements in NHS critical care have occurred in England since 2000. While it is unclear which factors were responsible, collectively the interventions represented a highly cost effective use of NHS resources.