Journals Watch - Miscarriage, LARCs and HIV

Too busy to read all the journals? Let Dr Gwen Lewis keep you up to date on the latest research.

Cost of medical or surgical treatment for miscarriage BJOG 2009; 116(7): 984-90
In my experience, fewer women now undergo surgical treatment following a miscarriage than some years ago. I had wondered if this might be due to cost factors, but apparently not if the results of this study from Finland can be extended to the UK.

A total of 98 women experiencing a miscarriage were studied. Although primary costs of surgical treatment were higher, once the more frequent complications in the medically managed group - pain, patient dissatisfaction or unsuccessful medical treatment - were factored in, the costs were comparable.

As this is the case, the researchers felt that choice of treatment should be based on patient preference.

Repeat abortion J Fam Plann Reprod Health Care 2009; 35(2): 93-5
Abortion rates rose from 186,400 in 2005 to 193,700 in 2006. Reduction in teenage pregnancy rate is a big issue in the UK. One in four abortions was a repeat episode.

This study from Oldham looked at the database of patients attending family planning services over a five-year period from 2001. Some 2.3 per cent of women attended with a second request for termination of pregnancy (TOP) within 24 months of the first episode.

Financial circumstances were the most common reason for seeking a TOP. The combined Pill and condoms were the most common forms of contraception used prior to first TOP, while long-acting methods of contraception (LARC) were used by only 8 per cent prior to TOP.

Most worrying was that although 58 per cent accepted LARC following TOP, only 2 per cent continued to use these and, sadly, 50 per cent of women were using no contraception at the time of the second TOP request. Surely it must be worth investing time and effort to discuss contraception, particularly LARC, after a TOP to avoid the need for a second.

Cost of Implanon provision J Fam Plann Reprod Health Care 2009; 35(2): 75-9
We are encouraged both by NICE guidelines and now financially in QOF to promote LARCs to our patients. Implanon is the most cost-effective LARC according to NICE, which estimates the cost to be £103.

A review of all Implanon insertions - 493 in 2003 - in clinics in Newport, south Wales showed this cost to be even lower, at £77.49. Information recorded was duration of use of Implanon, the average being 2.02 years, the number of pregnancies during use, the number of visits to doctors and nurses and the cost of treatment of side-effects.

Side-effects may be treated at very little cost. There were three pregnancies during the study but it was thought that all three women had conceived prior to Implanon insertion, even though they had negative pregnancy tests. Thirty per cent of patients had Implanon removed because of side-effects.

So Implanon provision is even more cost-effective than NICE's estimate and does seem to be an excellent contraceptive option.

Interarm BP difference in type-2 diabetics Br J Gen Pract 2009; 59(563): 428-32
We all know that strict management of BP in patients with type-2 diabetes is vital to reduce cardiovascular risk.

In some previous studies, it was found that there may be significant difference in the BP recorded between the arms and that this may result in an error in diagnosis and result in under-treatment of diabetics.

To test this further, 101 type-2 diabetics from three general practices in Devon were recruited. Their mean BP was 138/79mmHg.

Patients underwent bilateral simultaneous BP measurements. It was found that 10 per cent of participants had a systolic interarm difference of >10mmHg and 29 per cent a difference >5mmHg.

Failure to recognise this difference could lead to under-treatment if the BP were taken from the arm with the lower BP.

It is suggested that new patients should be screened for interarm BP difference. Yet more work for us and our nurses.

HIV testing of new patients Sex Transm Infect 2009 Online first doi:10.1136/sti.2008.033233
HIV treatment has improved, so testing rates for the disease need to increase. All pregnant women are now tested, but how can this be expanded to other groups of patients?

All patients aged 18-55 years attending a large inner London general practice for a new patient health check were offered a rapid HIV saliva test.

Of those eligible, 45 per cent accepted the test, the main reason given for accepting the test being that it was offered as 'part of a check-up'.

Black African and Black Caribbean patients were more likely to take up the test compared with those from other ethnic backgrounds.

At follow-up interviews, the rapid HIV test was felt to be acceptable, but concerns were voiced about support and follow up in positive cases.

This study was small, involving only 85 patients, but could be a way of increasing testing rates. It requires time and so would need appropriate funding.

Anxiolytics and hypnotic prescribing Br J Gen Pract 2009; 59(563): 409-14
As GPs we are generally discouraged from prescribing anxiolytic and hypnotic drugs and are encouraged to offer alternative non-drug treatments.

The prescribing of anxiolytics and hypnotics by all general practices in England, a total of 8,459 practices, was studied for the years 2004/5.

There was an eight-fold difference in the prescribing of these drugs between the lowest and highest prescribing practices.

Higher prescribing practices were located in more deprived areas but also in areas with a lower proportion of ethnic minorities-black or black British and Asian or Asian British.

Higher volumes were also prescribed by practices with lower QOF scores and in non-training practices. In general prescribing by female GPs was lower than that of males.

  • Dr Lewis is a GP in Windsor, Berkshire, and a member of our team who regularly review the journals.

The Quick Study

  • After miscarriage surgical or medical treatment costs about the same.
  • Following TOP, greater emphasis should be placed on future contraception to avoid the need for a second.
  • Implanon is a cost-effective method of contraception - even cheaper than NICE estimates.
  • BP in type-2 diabetics should be measured in both arms because of inter-arm differences.
  • HIV testing of new patients may be a way of increasing testing rates.
  • Anxiolytic and hypnotic prescribing varies widely across England, with patient demographics thought to have the greatest influence.

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