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In message <[log in to unmask]>, Adrian Midgley <[log in to unmask]> writes > >I am more and more coming to the view that the prescribing advisers >and public health doctors in HAs (perhaps N&E Devon more than most, >or perhaps they are generic) are just another group trying to >influence prescribers, for their own gain (in bonuses, promotions, >retention of jobs) but of course in the direction of _not_ >prescribing. > I think you are a little unfair here Adrian, but it's also my experience that prescribing advisers don't have a sophisticated approach to prescribing - they go for straight cost minimization. Moreover, although they avow an "evidence-based" approach they are sometimes not well equipped to ask the right questions and appraise the evidence for themselves (or, better with their target audience), so simply pass on somone else's opinion of the evidence. (Which may be wrong or incomplete - see the correspondence a few months back on prescribing for UTI and the SMAC guideline) >The question of quality has not yet entered this posting, and >indeed, the arguments appear to me solely financial in nature. > As you say... >Examples recently include an apparently authoritative leaflet, >citing no references or sources of evidence, but pressing GPs to >recommend combing hair with conditioner as a treatment for lous >infestations. > >On a little research it appears that this is a method unsupported by >evidence, and on questioning the relevant part of the HA the >admission that no evidence of effectiveness exists - contrasting >with the use of insecticides which is known to be highly effective - >although certain unidentified trials are apparently proceeding. > Yes, but. Absence of evidence of effectiveness is not the same as evidence of absence etc. It's true that the only good evidence on eradicating head lice is from RCTs of topical insecticides. But these RCTs represent individual cases and not the true situation in the community, where we often find families presenting children time after time with head lice. There's a reasonable review of head lice management at: http://www.fam-english.demon.co.uk/phmeghl.htm Moreover topical head lice preparations are available over the counter and we just don't know what are the effects of repeated use. Of course there isn't any evidence of toxicity from repeated use - but has anyone looked for it? Has anyone done a proper clinical trial of combing? What studies exist of control of head lice in schools? What we find is an unsatisfactory situation where the only valid evidence comes from manufacturers of chemicals, but where there are important alternative treatments which need to be properly assessed. But I suspect that research funding for non pharmacological treatments of head lice infestation would not be a high priority, and the problem is compunded by the methodological difficulties of the necessary studies. It would be very dangerous simply to base management on the only valid evidence without considering the completeness of the evidence base, and the need to re-evaluate research priorities. And I bet this isn't the only example! >A regular publication from the HA on prescribing costs - with no >concealment of the aim of reducing these - presents ski-slope graphs >demonstrating that the distribution of activity follows a normal >distribution among practices and practitioners, with no error bars >or confidence limits, and a complete refusal to contemplate adding >such items when requested. > quite! >Improper pressures? >Health Authorities, as de facto employers, are in an excellent >position to dissuade most doctors from commenting adversely on such >matters in public. > >Should we accept a standard of advertisment from HAs that we would >protest about from a drug company? I think not. However there is >no sign from the senior management of our local HA that they regard >any of it as questionable, except perhaps getting caught. And >probably not that either. > >Does it matter to EBM? >I think it does. If apparently official statements become clearly >seen to be presenting unreliable figures, to claiming that >unevaluated treatments are preferable to evaluated ones, and to be >intended purely to influence spending then the whole presentation >and gathering of evidence is discredited. > It's more that EBP matters to them. Very few people who need EBP skills actually have them, and I think that disseminating these skills, and getting people to reflect on how they should use them is the way forward. >My current interest is in trying to produce the infrastructure of a >knowledge service for our PCG of 60 GPs, 200 staff, 100 000 patients >(a task in which the HA distinguishes itself by what would have to >be massive incompetence were they actually trying to make progress, >or effective stonewalling in the more likely interpretation). > Good luck. >I suggest that the standards of publication by HAs or other parts of >the NHS - the NELH for instance - should be little different from >the peer-reviewed journals, and that publication of misleading or >incorrect data in an effort to manipulate prescribers should be >condemned rather more thoroughly when it is done by NHS officials >at public expense than when visibly interested commercial >organisations are doing it. > I disagree here. HAs, prescribing advisors etc have to make pragmatic decisions based upon whatever information they have. Often the information will be patchy and I doubt it will ever be so universally excellent that you could apply the standards you suggest. But the decisions still have to be made, resources are finite, and we have to get on with responding to patients' needs/demands one way or the other. The two things which can most improve this process are, I believe, wider dissemination of EBP skills and research funding more responsive to questions raised in practice (both of which are beginning to make progress) Toby -- Toby Lipman 7, Collingwood Terrace, Jesmond, Newcastle upon Tyne. Tel 0191-2811060 (home), 0191-2437000 (surgery) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%