Online First articles may not be available until 09:00 (UK time) Friday.
Press releases Saturday 19 April 2008
Please remember to credit the BMJ as source when publicising an article and to tell your readers that they can read its full text on the journal's web site (http://bmj.com).
(1) £100 million a year spent on self monitoring in diabetes that may increase anxiety and depression (2) Will screening for aortic aneurysm be effective? (3) Palliative care and legal euthanasia can be mutually beneficial (4) Better integration between agencies could save lives in custody
(1) £100 million a year spent on self monitoring in diabetes that may increase anxiety and depression (Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial) www.bmj.com/cgi/content/short/bmj.39534.571644.BE (Cost effectiveness of self monitoring of blood glucose in patients with non-insulin treated type 2 diabetes: economic evaluation of data from the DiGEM trial) http://www.bmj.com/cgi/content/short/bmj.39526.674873.BE (Editorial: Self monitoring of blood glucose in type 2 diabetes) http://www.bmj.com/cgi/content/short/bmj.39538.469421.80
The National Health Service (NHS) in the UK is spending £100 million a year to help people with non-insulin treated type 2 diabetes monitor their own blood sugar levels, but the process is more likely to make them depressed than provide any long-term health benefits, according to a series of articles published ahead of print on bmj.com today.
Globally one in twenty people have diabetes. The majority (85-95%) have type 2 diabetes, in which the body has either stopped making insulin or has difficulty making enough to convert blood sugar into the fuel our bodies need. Cases of type 2 diabetes are on the increase in the UK.
It has been generally acknowledged that self monitoring of blood glucose levels is beneficial for patients who have type 1 diabetes and those with type 2 diabetes who use insulin to treat their condition. However, the majority of people with type 2 diabetes do not use insulin, and it is for this group of people that there has been debate over the effectiveness of self monitoring. Yet, despite a lack of evidence, self monitoring has been widely promoted for this group in clinical practice.
Dr Maurice O'Kane and colleagues from the University of Ulster, report on a randomised controlled trial to assess whether self monitoring has an effect on blood glucose levels and the incidence of hypoglycaemia* in people with newly diagnosed type 2 diabetes.
The researchers found no significant effect of self monitoring on blood sugar levels or cases of hypoglycaemia after a year. However, the patients in the self-monitoring group reported higher levels of depression and anxiety.
Evidence suggests that some patients find self monitoring "uncomfortable, intrusive and unpleasant". And the researchers suggest that the negative feelings reported in the study might be due to the enforced discipline of regular monitoring without any obvious benefit, rather than due to "feelings of powerlessness in the face of high blood glucose readings."
Self monitoring of blood glucose is the largest single management cost associated with implementing more intensive blood glucose control in the UK, with costs of providing test strips increasing from £85m to £118m between 2001 and 2003. Thus, it is important to establish if self monitoring represents a cost effective use of resources that could otherwise be used to finance other aspects of diabetes care.
In a separate study, Dr Judit Simon and colleagues from the University of Oxford, analysed the cost-effectiveness of helping patients with non-insulin treated type 2 diabetes self monitor their blood glucose levels in addition to standardised usual care, using data from the diabetes glycaemic education and monitoring (DiGEM) trial.
Their analysis confirms that self monitoring of blood glucose is significantly more expensive than the standardised usual care. They found that the additional healthcare costs of self monitoring were about £90 per patient each year. Furthermore, people who self monitored reported a lower quality of life probably owing to significant increases in their levels of anxiety and depression.
The authors say that self monitoring in addition to standardised usual care is unlikely to provide this group of patients with significant lifetime health benefits or be cost effective for the NHS. They conclude: "This study therefore provides no convincing evidence for routinely recommending self monitoring to patients with non-insulin treated type 2 diabetes."
In an accompanying editorial, Professor Martin Gulliford argues that the £100 million that is spent each year on self monitoring for this group of patients: "Represents a substantial opportunity cost in terms of alternative interventions that might have improved the health of people with diabetes…[such as] more effective disease control measures aimed not at blood glucose but also at blood pressure, cholesterol, smoking, body weight, and physical activity."
Notes to Editors: *Hypoglycaemia occurs when blood sugar levels drop below normal and brain function is affected.
Contacts: Judit Simon, Health Economist, Department of Public Health, University of Oxford, Oxford, UK Email: judit.simon{at}dphpc.ox.ac.uk Andrew Farmer, Lecturer, Department of Primary Health Care, University of Oxford, Oxford, UK Email: andrew.farmer{at}dphpc.ox.ac.uk Maurice O'Kane, Consultant in Chemical Pathology, Altnagelvin Hospital, Londonderry, Ireland Email: maurice.okane{at}westerntrust.hscni.net Editorial: Martin Gulliford, Department of Public Health Sciences, King’s College, London, UK Email: martin.gulliford{at}kcl.ac.uk
(2) Will screening for aortic aneurysm be effective? (Head to Head: Should we screen for aortic aneurysm?) Yes: www.bmj.com/cgi/content/short/336/7649/862 No: www.bmj.com/cgi/content/short/336/7649/863
Pilot screening programmes for abdominal aortic aneurysms* in men aged 65 are due to be launched in England this year, but is this move too hasty? Two experts debate the issue in this week's BMJ.
Around 90% of people with a ruptured aortic aneurysm die. But if the aneurysm is discovered before it ruptures and is repaired by an experienced vascular surgeon, mortality is around 7.4%, writes James Johnson, consultant surgeon at Halton General Hospital, Runcorn.
Around 5% of men aged between 65 and 74 have abdominal aortic aneurysms, but they rarely cause symptoms, so screening in this age group would potentially ensure that most aortic aneurysms are diagnosed and repaired.
But the case for screening is not clear-cut claims Johnson.
He points to wide variations in the mortality for surgical repair between hospitals in England. In addition, many patients will not be fit enough to have a repair-aneurysm is a disease that rarely exists in isolation. Most patients will also have hypertension, or a history of myocardial infarction, stroke or diabetes.
As a result, many patients will be left with the knowledge that they have a life threatening condition that is liable to cause sudden death and that nothing can be done about it, writes Johnson.
Aneurysms of less than 5.5cm in diameter are unlikely to burst, and because the mortality from operating on them is greater than the likelihood of rupture, people with an aneurysm of less than this size will have to be monitored and sent for regular ultrasound examinations. Many of these patients will find it intolerable to have a "timebomb" inside them which might go off at any time and without notice, he says.
In addition, screening will show up much more than aortic aneurysms, and the cost of dealing with the comorbidity needs to be included in the cost-benefit analysis, he argues.
At the very least, he concludes, any person being tested will need intensive counselling about the possible consequences that screening might have for their future lives and psychological wellbeing.
But Stephen Brearley, consultant general at Whipps Cross University Hospital, London, argues that a national screening programme has the potential to save up to 2000 lives a year in England and Wales at a similar cost to other screening programmes.
He points to a large body of scientific evidence that shows that aneurysm screening programmes are effective. For example, an analysis by the Centre for Reviews and Dissemination at the University of York concludes that the likelihood of such a screening programme being cost effective is greater than 95%.
Furthermore, recent data from four trials in the UK, Australia and Denmark showed that uptake of invitations to be screened ranged from 63% to 80%. And a review of the data from all four trials showed a highly significant reduction in aneurysm related mortality.
In light of these findings, the UK National Screening Committee has backed the abdominal aortic aneurysm screening programme.
The argument for screening has already been won, he concludes, and attention now needs to be focused on making the screening programme as efficient and effective as possible.
Notes to Editors: *An aortic aneurysm is a dilation (ballooning) of part of the aorta - the main artery carrying blood from the heart to the lower part of the body.
Contact: James Johnson, consultant surgeon, Halton General Hospital, Runcorn, UK Email: jnjohnson33{at}hotmail.com Stephen Brearley, consultant general, Whipps Cross University Hospital, London, UK Email: stephen.brearley{at}whippsx.nhs.uk
(3) Palliative care and legal euthanasia can be mutually beneficial (Development of Palliative Care and Legalisation of Euthanasia: antagonism or synergy?) www.bmj.com/cgi/content/short/336/7649/864
Supporters of legalising euthanasia and those who wish to develop better palliative care services can help each other, according to a study published today on bmj.com.
The traditional view that palliative care and euthanasia are two alternative and antagonistic causes is not necessarily the case, say researchers.
Jan Berheim and colleagues from the End-of-Life Care Research Group of the Vrije Universiteit Brussel, reviewed historical, regulatory and epidemiological evidence from Belgium, which was the second country to legalise euthanasia in 2002, and has some of the best developed provisions for palliative care, third only to Iceland and the UK.
The authors show that the movement for the legalisation of euthanasia promoted the development of palliative care and the existence of adequate palliative care made the legalisation of euthanasia ethically and politically acceptable.
According to the authors one of the reasons for the overall lack of acrimony in the Belgian debate was that the two movements developed side by side with shared workers. As the societal debate about euthanasia grew, so did the provisions for palliative care.
They found no evidence that legalising euthanasia resulted in harm to vulnerable patients or disabled people, or that it impeded the development of palliative care in Belgium - concerns voiced by The European Association for Palliative Care. In fact, ethically disputable practices, such as clandestine physician-assisted dying, actually decreased in the run up to the euthanasia law being enacted.
People advocating euthanasia law in Belgium supported palliative care and did not present euthanasia as an alternative but as a possible complement, an option at the end of the palliative care pathway, with the patient's preferences coming first.
The euthanasia law passed in Belgium stated that patients asking for euthanasia had to be informed of the possibilities of palliative care and it was passed at the same time as another Act which ensured people's right to palliative care in every hospital, nursing home and at home, while doubling its public funding.
The process of legalisation of euthanasia was ethically, professionally, politically and financially linked to the development of palliative care, says the study.
The authors conclude: "The societal debates made clear that most values of palliative care workers and advocates of euthanasia are shared. If Belgium's experience applies elsewhere, advocates of the legalisation of euthanasia have every reason to promote palliative care, and activists for palliative care need not oppose the legalisation of euthanasia."
Contact: Jan Bernheim, End-of-Life Care Research Group and Department of Human Ecology, Faculty of Medicine, Vrije Universiteit Brussel, Belgium Email: jan.bernheim{at}vub.ac.be
(4) Better integration between agencies could save lives in custody (Editorial: Deaths in custody) www.bmj.com/cgi/content/short/336/7649/845
It is now widely accepted that referral to prison may not be appropriate for some people, and risk factors associated with suicide are well known, so why are policy makers still not doing enough to prevent increasing numbers of deaths in custody, asks Alison Frater from the University of Southampton.
Suicide prevention strategies in prisons in England and Wales need to look at the appropriateness of interventions and best practice, but research into this is difficult because prisons are not linked by a national database and there are no routine national surveys that look at the health of prisoners, she argues.
Previous studies have identified risk factors associated with suicide in prison - including the vulnerability of younger people, drug use and mental illness - and have emphasised that preventive strategies should be tailored to meet the needs of the individual. For instance, better access to psychological support for people at risk of suicide and for preventative strategies in the wider prison environment such as safer cell design.
But despite this significant body of evidence, public policy is lagging behind, claims Frater.
Some preventive strategies, such as a more progressive drug policy and access to the Samaritans and trained listeners have already been introduced, but much more needs to be done, she argues.
The transfer of responsibility for medical care in prisons to the National Health Service (NHS) was widely expected to raise standards of health care, explains Frater, but primary care in prisons is still in the early stages of development and continues to differ to that available in the community. For example, general practitioners are contracted on a sessional basis, prisoners are not registered with them, and prison populations are not yet included in the quality and outcomes framework.
Further research is needed to determine the appropriateness of interventions and develop best practice within prison and for better integration of services with persistent follow up on release. But this is currently limited by the lack of routine information across the prison system and record linkage into the community, she says.
More precise measures of the effect of exposure to prison and its consequences are needed if lives are to be saved, Frater says. She concludes by calling for an integrated cross governmental strategy between prison authorities, health services, and other agencies.
Contact: Alison Frater, Public Health Sciences and Medical Statistics, University of Southampton, Southampton, UK Email: alison.frater{at}btinternet.com
FOR ACCREDITED JOURNALISTS
Embargoed press releases and articles are available from:
Public Affairs Division, BMA House, Tavistock Square London WC1H 9JR
(contact: pressoffice{at}bma.org.uk)
and from:
the EurekAlert website, run by the American Association for the Advancement of Science (http://www.eurekalert.org)
What's new
Latest blogs
Find BMJ on:
Services
Tools
Online poll
Resources
Print issues
