Preview of the Autumn 2014 Hot Topics GP Update Course

We are all very excited about our upcoming Autumn series of the Hot Topics GP Update course starting next month. We have been working very hard trawling through all the guidelines, research and papers for you finding the evidence which is recent, reliable and above all relevant to primary care.

Compared to previous editions of the course we will be covering slightly fewer topics, but in more detail.  When discussing controversial new guidelines (they’ve been a few recently!) we shall focus  on the primary research that underpins them, to help you and your patient make informed decisions about changes to practice.

All the presented Hot Topics will be new compared to Autumn  2014  so if you last came a year ago, do come back.

Topics which we will be presenting will include:

•  Polypharmacy, taking a safe, effective and evidence-based approach
• Cardiovascular disease

o   The new guidelines for Atrial Fibrillation, Statins & Lipids and Hypertension and the primary evidence that underpins them

•  Kidney: Chronic Kidney Disease and Acute Kidney Injury
• Diabetes

o   Personalizing HbA1c targets

o   What next after metformin?

•  End of Life Care and Palliative Care
•   Cancer, early diagnosis 
• Mental illness

o   Psychosis and Schizophrenia

o    The serotonin syndrome

o   Obsessive compulsive disorder

• Medically unexplained symptoms
• Chronic pain
• Simple musculoskeletal problems e.g. carpal tunnel syndrome, gout
• Paediatrics

o   Asthma and allergic rhinitis

• Gastroenterology

o   GORD and dyspepsia

• Abnormal blood tests

o   A new section on management of abnormal blood tests, including of Vit B12 deficiency

In addition:

• We have streamlined the paper book, and included more of our ever popular KISS (keep it simple) summaries.
• The electronic version of the book has been developed to become an invaluable resource to use during your working day. It is a PDF you can download onto all of your devices (computer, phone, tablet etc). It is instantly searchable. Original sources are hyperlinked, and the KISS summaries contain direct links to resources for you and your patients to make life easier for you.
• You will be emailed pre and post course MCQs so that you can test your knowledge and demonstrate your learning
• We have summarized the evidence in important areas related to service provision e.g. reducing unplanned admissions, efficacy of health checks and telephone triage

We focus on the things which are most likely to have an impact on your practice. A survey from our Spring 13 courses showed that 97% of our delegates changed practice as a result of the course, and over 70% use the course material at least weekly to find an evidence-based answer to a clinical problem.

As ever we also want you to have a relaxing and fun day out of the practice, so we will keep the atmosphere light, with some good new funny clips and we really hope you have an enjoyable day. With GPs being so busy, we are convinced that this model provides us the best way of practising patient-centred evidence based medicine. So, do come along and we look forward to seeing you next month!

Simon, Neal, Gail and Kevin

Levels of Evidence

To help you to make more informed decisions, from Autumn 2014 on the Hot topics course we will grade the level of the evidence (from research studies) and the strength of recommendations (from guidelines) wherever possible. 

Grading of evidence

This is an internationally recognized ranking system used in evidence based medicine to rank the quality of the evidence and therefore the strength of the conclusion you can take from it.

Evidence level	Evidence is from:
1a	A systematic review & meta-analysis of randomized controlled trials
Ib	At least one randomized controlled trial
11a	At least one well-designed study, but not randomized e.g. prospective cohort study
11b	At least one well designed experimental, but not controlled, trial
111	Well designed descriptive studies e.g. case-control, comparative studies and case series
1V	A panel of experts

Grading of recommendations

Guidelines then use a grading hierarchy to grade the strength of the recommendations they make. Confusingly, there are several different models in use but the most accepted one (which we have tried to follow) is the GREG (Guideline Recommendation and Evidence Grading) system:

Grade of recommendation	Based on:
A (Recommendation)	There is robust evidence to recommend a pattern of care (based on level 1 evidence)
B (Provisional recommendation)	On balance of evidence, a pattern of care is recommended with caution (usually based on hierarchy 11 evidence)
C (Consensus opinion)	On absence of directly applicable studies of sufficient quality, a pattern of care is recommended by consensus

For simple guidance on Evidence Based Medicine (e.g. how to tell your ARR from your RRR, different study types, how to calculate a NNT and what it means, how to interpret confidence intervals etc) please download our free KISS Guide to Evidence Based Medicine.

 For more on evidence levels, there is an excellent PatientPlus summary and see also the Centre for Evidence Based Medicine

Patient-Based Medicine

PBM: Patient-Based Medicine

"The art of medicine is a literary art. One that requires of the practitioner the ability to listen in a particular way, to empathise, but also to imagine. To try to feel what it must be like to be that other person lying in the sick bed, or sitting across the desk from you. To try to understand the storyteller, as well as the story." Cecil Helman, GP

'Clean clear water transformed health in 19thC; clean clear knowledge will transform health in the 21st Century', Sir Muir Gray

Inspired by both Helman and Gray we aim to practise, and teach, what we apologetically call Patient-Based Medicine. 

For those unfamiliar with it, Suburban Shaman is a wonderful book by the late great GP Cecil Helman (obituary, BMJ2009:339;b2904). He made his name with Culture, Health and Illness but Suburban Shaman is an autobiographical celebration and affirmation of General Practice, an entertaining and funny read. Helman firmly believes in a non-medicalised whole-person model of care, in which the patient’s unique cultural background and circumstances are inseparable from their experience of illness. He sees many similarities with the role we play in the community with that of healers, or shamans, in traditional cultures. He writes ‘beyond the disease is the person, but beyond the person are always the time and place and particular circumstances in which they live and die’.  

We mention this here because NB Medical’s Hot Topics course is all about helping GPs with keep up with ‘the knowledge’: clinical evidence, guidelines and all the other new developments that come our way. We agree with Muir Gray, and believe we really do need to be aware of this information so that we can offer our patients the best treatments available, but all has to be interpreted in the light of the unique circumstances in which we and our patient find yourself.  EBM is often criticized for being reductive, de-personalizing ‘cook book’ medicine but  this is not so as its definition makes clear: ‘EBM is the integration of the best available evidence with our clinical expertise and our patients’ unique values and circumstances’ (EBM2007:12:1).  As patients we want our doctors to consider us as unique people, rather than conditions, and to try to understand us in our context. But at the same time we really do want them to know that if we turn up with Bell’s Palsy that 50mg of prednisolone for 10 days is an effective treatment. And, if we don’t know, where and how we can find the answer.

We at NB passionately believe in Patient Based Medicine. This is personalised, patient-centred care based on the best available scientific evidence. Our role is to try to understand our patients, to help them to make sense of their problems and to empower them to make informed choices. These choices should be evidence-based, but ultimately it’s ALWAYS the patient’s call.

Simon

KISS: Unplanned Admissions in Scotland, Wales and Northern Ireland

Reducing unplanned admissions is very much on the agenda throughout the UK, and not just in England where there is a major new contractual requirement to identify those at high risk and optimise their care. This is the current situation elsewhere in the UK. Do let us know if there are other initiatives in your area.  

Scotland

Scotland is leading the way on the reducing unplanned admissions agenda, in terms of both primary research and implementation.

The key primary research came from Nairn showing that risk identification and use of anticipatory care plans ACP Study reduced unplanned admissions and hospital bed days. A key part of the success is a rapidly responsive, multi-disciplinary case management team and integration between health and social care. Health and Social Care partnerships and integrated community support teams have been established, and are a key part of an ambitious programme of reform in Scotland

Instead of the English Enhanced Service, in Scotland there are significant changes in the Quality and safety domain of the  Scottish QOF  which focus on reducing unplanned admissions:

•   Reviews on emergency admissions, including external peer review
• GP practices to identify a liaison GP for health and social care integration within the new Health and Social care partnership
• GPs to produce a list of 5% of patients in the practice identified as high risk of admission, using a risk stratification tool (such as SPARRA or equivalent
• Anticipatory care plans should be completed for 30% of these patients
• The ACP should include a polypharmacy review and be shared with OOH care
• There should be quarterly meetings to discuss these patients with ACPs

There is already evidence accruing (awaiting publication, Dr Conrad Harvey personal communication) that implementation of this programme has lead to a 50% reduction in unplanned admissions and a 36% reduction in bed days.

Northern Ireland

In NI this is apart of the Quality & Productivity (QP) scheme to

·      Review emergency admissions and A&E attendances

·      There is work going on at present looking at risk stratification. This is at an early stage at present, but is highly likely to come in shortly

Wales

In Wales ‘complex’ cases have had to be reviewed, as part of QOF, with the aim of reducing unplanned admissions with quarterly meetings. As far as we know, there is no plan at this stage to introduce risk stratification and case management.

KISS: The Unplanned Admissions ES for England

KISS Guide to the Unplanned Admissions Enhanced Service for England

Proactive Case Finding and Care Review for Vulnerable People

The Unplanned Admissions Enhanced Service is now upon us. It replaces the work of parts of QOF and the QP domain. It also replaces the Risk Profiling Enhanced Service, but it builds on this concept so that the ideas and work that needs to be done are not be entirely new. The BMA have produced an excellent BMA Guide for Practices, and we summarize the main points below.

Templates for care plans, letters to patients etc. are available to download (these are optional, you can use your own)

Why are we doing this?

It may be called ‘avoiding unplanned admissions’, but the subtitle ‘proactive case finding and care review for vulnerable people’ really defines our role. There is general consensus that to avoid unplanned admissions requires a system wide approach that co-ordinates social care, community nursing, rehabilitation and NHS 111. For case management to work and reduce admissions all these components need to be in place,  Kings Fund Report on Case Management. We are an important part of this picture, but only a part, and our role is to explicitly identify our most vulnerable patients and to optimize and co-ordinate their care.

What do practices need to be doing now?

• Establish the at-risk ‘case management’ register
• The 2% of the practice population aged over 18 at highest risk of unplanned admission
•   CCGs should provide GPs with a risk stratification tool to do this, but if not available practices should use clinical judgement
• We would recommend the QAdmissions tool as this is the best research validated   tool. It can be integrated into any GP system and costs c. £600 per practice. (please note that NB Medical has NO financial interest in QAdmissions or any other tool)

•  Inform patients that they are on the register & of their named accountable GP and care co-ordinator
• The named accountable GP will have the responsibility of developing the care plan & appointing the care co-ordinator
• The accountable GP will be responsible for the patient’s care but patients should be reassured that this GP is not their sole care provider and that they will continue to see other members of the team as they currently do
• The care co-ordinator will be the main point of contact for the patient & also check the care plan is being delivered. This could be a clinician, practice nurse or community nurse
• Patients need to be informed by the end of July 2014 (unless patients aged over 75 have already been informed of their named GP as part of the 2014 GMS Contract Changes)

• Ž Put a personalised care plan in place
•   By the end of September
• Optional Templates are available and the BMA Guide for Practices indicates the key details that need to be included which include
• The key biographical information, the key people involved in care, key relevant medical information, individual preferences (e.g. end of life wishes) and key action points (e.g. early signs of deterioration with agreed action plan)
• Note that if a patient has dementia, serious mental illness or learning disability they should already have a care plan in place

•  Offer a by-pass number for other care providers
•  Available for hospital, carers, nursing homes, paramedics etc. to use for urgent matters

•  Offer same day telephone access to patients on the register with an urgent problem
• Which we would be doing anyway...
• 
  
• Follow-up patients on the register following discharge from hospital
• Ditto…but follow up within 3 days of the discharge note being received

• ’ Regular review of emergency admissions & A&E attendances of
• Patients on the at risk register on a monthly basis
•   Patients from care and nursing homes should also have their admissions reviewed (practices with large numbers of these may look at samples and negotiate the terms of this locally with their Area Team)

• “ Complete a quarterly report
• To be submitted to the Area team and CCG each quarter
• Payments will be based on a maximum of £2.87 per registered patient (i.e. so for a 10,000 patient practice it will be worth nearly £30K pa), 45% upfront and the remainder based on the quarterly reports and an additional 15% end-year payment for undertaking regular internal review of all unplanned admissions for vulnerable patients
•  See the BMA Guide for Practices for payment information

It is clear that most of the work will be in identifying the patients, setting up the care plans and reviewing admissions. This is a lot of work, and the care co-ordinator role will be key to manage the workload. Although the concept is new, it formalises a lot of the core, traditional values of General practice: maximising continuity and co-ordinating care for our most vulnerable patients.

Good luck!!

Simon & the NB Team