Handbook of Non-Drug Interventions making effective non-drug treatments more visible and easier to use

Transcription

1 Handbook of Non-Drug Interventions making effective non-drug treatments more visible and easier to use Paul Glasziou Centre for Research in Evidence-Based Practice, Bond University For RACGP HANDI Team

2 A brief history The Pharmacopoeia Chinese edition 3000 BC Nuovo Receptario, 1498 Pharmacopeia, Occo 1564 The Non-Pharmacopoeia Patterson Lecture GP10 RACGP initiates 2011 Pilot version 2013 Nuovo Receptario Composito Florence in 1498

3 What about didgeridoo playing? Rx Didgeridoo t.d.s (1) Dr Paul Glasziou

4 The HANDI Committee 4 GPs, Physiotherapist, Occupational Therapist, Physician, and RACGP staff

5 HANDI development process 1. Is there clear evidence of effectiveness? Member presents evidence to committee Systematic review of 2+ trials or equivalent 2. Draft Entry with details of practicalities Detailed descriptions Handouts, links, etc Videos for some processes

6 HANDI Entries in AFP, Jan/Feb

7 Handbook of Non-Drug Interventions

8 Learning the how to of Epley 1. Bookmark the video (on YouTube) 2. Tip: watch with patient first!!

9 Exercise for chronic illnesses COPD ( pulmonary rehab ) Claudication Future topics? Heart Failure Chronic Fatigue Depression? Anxiety? 1-day conference, 1 st May

10 Pulmonary Rehabilitation is effective Great but what is pulmonary rehabilitation??

11 Some treatments with dramatic effects also included

12 Where now? Three years funding from BUPA 15+ new entries per year Some Future topics: insomnia intervention, Mediterranean diet, pelvic floor exercises, sleep intervention for infants, FODMAP diet for IBS, exercise for. Your ideas, tips, and comments please!

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14 Found: a good description of pulmonary rehabilitation My consultant at King s offered me pulmonary rehabilitation. I didn t know what that was, so I asked and he said it was an exercise program. I thought the man was mad because I couldn t get out of a chair. (Later interview she is much improved)

15 3. Information & Self-Management Depression BeyondBlue; several books LUTS Irritable Bowel Syndrome Weight loss tips

16 Lower Urinary Track Symptoms 60 year old man with symptomatic BPH asks about pros and cons of surgery What things have you tried so far?

17 Lower Urinary Tract Symptoms BMJ 2006 Advise a daily fluid intake of ml (minor adjustments made for climate and activity), avoid inadequate or excessive intake on the basis of a frequency / volume chart Advise fluid restriction when symptoms are most inconvenient e.g. long journeys or when out in public Avoid caffeine by substituting with alternatives e.g. decaffeinated or non-caffeinated drinks Avoid alcohol in the evening if nocturia is bothersome Advise bladder retraining. Using distraction techniques (predetermined mind exercise, perineal pressure or pelvic floor exercises) aim to increase the minimum time between voids to 3 hours

18 LUTS trial: lower failure at 1 year %Failure (new treatment) P< Months after Randomization Self-Management Control

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20 What is the treatment? BMJ paper s description of sodium reduction "Individual and weekly group counseling sessions were offered initially, with less intensive counseling and support thereafter, specific to sodium reduction."??????? TOHP Study BMJ, Apr 2007; 334: 885

21 What is sodium reduction? The paper s description "Individual and weekly group counseling sessions were offered initially, with less intensive counseling and support thereafter, specific to sodium reduction." Previous reference (i) an individual session followed by 10 weekly group 90 minute sessions with a nutritionist, followed by a transitional stage of some additional sessions (ii) Topics in the weekly sessions included Getting Started, sodium basics, the morning meal, midday sources of sodium, the main meal, planning ahead, creative cooking, eating out, food cues, and social support, (iii) the sessions included sampling of foods, discussion of articles on sodium reduction, and problem-solving, (iv) patients kept diaries at least 6 days per week, and urine sodiums were measured.

22 What do the guidelines say?

23 Descriptions in 80 treatment studies selected for EBM were inadequate Description sufficient to replicate 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Overall Trials Metaanalysis Drug Non drug Initial Final Glasziou et al BMJ, 2008

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25 HANDI overview Evidence-Based non-drug treatments Include sufficient details of treatment Handouts Video links to show processes

26 HANDI some issues Work needed to get full descriptions and written up clearly Poor descriptions in trials But authors will often hand over Intellectual property Need a public access repository where authors can put FREE materials RACGP can build handbook from this

27 Leaflet: 10 tips for weight loss 104 adults BMI 31; randomized to Leaflet & weekly weigh Leaflet & monthly weigh Control International Journal of Obesity (2008) 32,

28 Chronic Fatigue Syndrome Graded Exercise improves fatigue Cochrane Review 2004

29 Exercise for CFS Prescription for graded exercise Exercise every 2 nd day Target RPE of > Every 2 weeks increase duration by 2-5 minutes Wallman. Med J Aust Aug 1;183(3):142-3.

30 Example: a patient with COPD Long term smoker with chronic obstructive airways disease has recently quit smoking. Has tried medications but does not like any. Asks: are any breathing exercises I can recommend?

31 Pulmonary rehabilitation integrates 3 excepts from the Description of Included Studies

32 The (missing) guidebook for IBS TRIAL: Self-help interventions in patients with a primary care diagnosis of irritable bowel syndrome. Gut At one year, patients in the guidebook group had a 60% reduction in primary care consultations (p,0.001) and a reduction in perceived symptom severity (p,0.001) compared with controls. PROBLEM: Missing details of guidebook. No response from author to 3 s Colleague said booklet was on sale Google search found the book Price: 8.99

33 Diet & Nutrition Weight loss tips Cranberry for UTI Salt for Blood Pressure Oral rehydration

34 Cranberry Juice for UTIs? Cranberries for preventing urinary tract infections Main results: Ten studies (n = 1049) were included. Cranberry products significantly reduced the incidence of UTIs at 12 months (RR 0.65, 95% CI 0.46 to 0.90) compared with placebo/control. Cranberries for treating urinary tract infections Main results: No studies were found which fulfilled all of the inclusion criteria. Two studies are currently being undertaken.

35 Non-pharmacological interventions Procedures Exercise particularly for the ill Information / self-management Diet & Nutrition

36 Update: By GPs for GPs

37 Common Cold and physical methods

38 Alexander technique

39 CBT self-help

40 Repository of intervention descriptions is needed A Handbook of Non-Drug Interventions

41 Trials of non-drug treatments in UK Chalmers bmj.com2003;327:1017

42 1. Procedures Epley for BPPV Mother s Kiss Knee taping for OA Alexander Technique Counterpressure for syncope Nit combs for lice Light box for SAD

43 The Epley for BPPV (Vertigo) STUDY: Self-treatment for benign paroxysmal positional vertigo of the posterior semicircular canal. Neurology TREATMENT: Each head position has to be maintained for more than 30 seconds. Patients received illustrated instructions for the specific maneuver All agreed useful 3 months later only 2 doctors did it Put video in intranet Another 3 months later Still only 2 doctors Trained each person to do

44 HANDI Entries in AFP, Jan/Feb