Good technologies going to waste

Britain is at the forefront of designing and manufacturing medical technology. The industry employs around 60,000 people in the UK, and Britain is a net exporter of medical technologies.
    
This expertise, however, does not always result in patients receiving the best possible care. Only 4.5 per cent of the NHS budget is spent on medical technology compared to the European average of 6.3 per cent, which means that important innovations do not always reach those who need them most, and patients can miss out on vital treatments.
    
The Medical Technology Group (MTG) works to end such discrepancies. Three of the group’s technologies are described here, illustrating some of the most common reasons for technology’s under-use. They show the need for a greater connection between NICE guidance and NICE implementation. The MTG welcomes the opportunity to help any NHS, NGO or patient stakeholder to implement these changes in order to improve patient outcomes.

Implantable Cardioverter Defibrillators

Implantable cardioverter defibrillators (ICDs) are used to correct heart arrhythmias. This small device is implanted in the chest, and is connected into the heart to continuously sense its rhythm. When it detects that an abnormality has occurred, it delivers a tiny electric shock to restore normal beating. ICDs are used for those at risk of sudden cardiac death, in patients with some form of heart failure, and those who have undergone surgical repair for congenital heart conditions. Sudden cardiac death alone affects around 50,000-70,000 people in the UK each year, including many lives that could be saved by increased use of ICDs.
    
ICDs are very effective, when used with anti-arrythmic drugs they can result in a 50 per cent reduction in cardiac deaths. They are recommended by NICE in some specific circumstances, yet their use is not widespread in the UK. They are implanted at a rate of around 65 per million in the UK, compared with a European average of around 95 per million.
    
Use varies wildly even within the UK, in East Anglia only 26 per million are implanted, compared to 73 per million in Dorset and Somerset (data from 2006). This means many people could be dying unnecessarily due to lack of access to vital technology.  
    
The main barriers to access are two-fold. Funding in some areas is focused on the initial cost of ICDs rather than their cost-effectiveness over the lifetime of the treatment. In addition, there are multiple delays in the patient pathway.

Uterine Fibroid Embolisation
Fibroids are benign tumours on the uterus wall that can cause heavy periods, pelvic pain, pressure and bladder symptoms and reproductive problems. They are the most common gynaecological problem in the UK, affecting around 30-40 per cent of women.
    
Fibroids are typically treated by hysterectomies, and there are around 30,000 carried out each year for this reason. Hysterectomies usually require around five days in hospital, and two to three months recovery at home.
    
MTG member Boston Scientific markets an alternative to hysterectomy: Uterine Fibroid Embolisation (UFE). This is a minimally invasive treatment that involves blocking blood supply to the fibroid, causing it to die, shrink and eventually disappear.
    
UFE usually requires one night in hospital. Many women resume light activities in a few days and the majority of women are able to return to normal activities within one week. On average, 90 per cent of women who had the procedure experience significant or total relief of heavy bleeding, while it is about 85 per cent effective for pain. Patient satisfaction for the procedure is consistently high (91-95 per cent). Fertility is maintained and it leaves no scar.
    
This less invasive treatment not only reduces the trauma for patients and their families, it can also give the NHS significant cost and capacity savings as the length of stay is significantly reduced. Furthermore, hysterectomy, unlike UFE, is associated with additional costs in primary care for supportive Hormone Replacement Therapy, antidepressants and incontinence support.
    
NICE Clinical Guidelines on Heavy Menstrual Bleeding were published in January 2007. This states that a range of options including UFE must be considered for women with symptomatic fibroids of greater than 3cm.
    
Access to UFE is, however, still far from consistent across the country. The main barrier to access is the lack information and choice given to women by consultant gynaecologists and consequently low referrals to interventional radiologists who perform the procedure. Additional barriers include GPs being unaware of the treatment, and a lack of interventional radiologists able to carry it out.
    
Health service professionals need to be more widely educated about alternatives to hysterectomy, at the moment this lack of professional knowledge may limit patients’ choices. In a survey carried out by in 2005 by FEmISA, an MTG member that campaigns for greater access to UFE, none of the 59 fibroid sufferers questioned had been offered the procedure despite its NICE recommendation. Medical technology is complex and fast-changing field, thus it is vital that healthcare professionals’ knowledge is kept up to date if patients are to be offered the best possible treatment.

Insulin pumps
Insulin pump therapy, also known as continuous subcutaneous insulin infusion (CSII), offers an alternative to frequent injections for type 1 diabetes patients. An insulin pump is a computerised insulin delivery device a little larger than a pager, which delivers insulin into the subcutaneous tissue. The MTG member INPUT works to ensure appropriate access to insulin pumps for diabetes patients in the UK.     
    
Insulin pumps supply the body with insulin in a way that closely mimics the physiology of someone without diabetes. Pumps offer many benefits over frequent insulin injections, enabling patients to live a more normal life. The technology’s flexibility in dosing can significantly reduce hypoglycemic episodes. While frequent blood glucose testing remains necessary to optimise therapy, patients on pumps can work, eat or exercise without adhering to a strict schedule of meals and injections.  
    
NICE recommends that insulin pumps be used when patients with type 1 diabetes suffer from disabling hypoglycaemia, or when HbA1c levels are high despite the patient trying carefully to manage their condition with adequate healthcare provider support. However, six years after the first NICE Technical Appraisal on CSII, there is large variation in pump use across the UK, suggesting the guidance is not being implemented consistently. Less that 4 per cent of patients with type 1 diabetes in the UK use pumps, compared with up to 35 per cent in the US and at least 20 per cent in most EU countries.
    
Considered in isolation, insulin pump therapy appears more costly than frequent insulin injections. However, insulin pumps can generate savings. First, by decreasing the risk hypoglycemic episodes and other complications, insulin pumps can reduce acute hospital admissions and the long-term costs of uncontrolled diabetes. Diabetes complications can require expensive treatments like laser surgery for retinopathy and dialysis or even transplant for kidney disease. Second, by enhancing patients’ lifestyle flexibility and their capacity to attend school and work, pumps can help people with type 1 diabetes remain fully active in society, without recourse to incapacity benefits.  
    
NICE does not currently take cost savings outside the NHS into account when making recommendations. The MTG is campaigning for this situation to change, so treatments’ ‘real’ costs and benefits can be taken into account. Access to technologies that enhance or prolong life can simultaneously reduce suffering and create financial efficiency.

About the MTG
The Medical Technology Group (MTG) is a coalition of patient groups, research charities and medical devices manufacturers launched in 2000 to campaign for patient access to effective medical technologies. The group is committed to supporting wide uptake of proven technologies such as urinary catheters, pacemakers, radio-frequency ablation of tumours, diagnostic equipment, orthopaedic implantable devices and cataract treatments, as well as ensuring the delivery of new innovations which make a huge difference to the quality of life of people with long-term conditions. MTG also seeks a conducive research environment in which new innovations can be developed, and best practice spread throughout.

For more information
Web: www.mtg.org.uk