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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

6. Menstrual and Perimenopausal Migraine Guidance

National Waiting Times Board - Centre for Sustainable Delivery

Background

Oestrogen levels vary throughout a women’s life with greater fluctuations happening during puberty and the perimenopause. 

There is an increase frequency of migraine associated to periods of oestrogens fluctuations1.  

The oestrogens level mirror changes in migraine prevalence. Migraine may dissappear around or after menopause and there may be a worsening frequency of migraine or menstrual migraine during the perimenopause.  

Menstrual migraine refers to the episodes of migraine that start on day - 2 to +3 of menstruation in at least 2 or 3 menstrual cycles. If there are no other migraine attacks during the cycle, such migraine is called pure menstrual migraine. If there are migraine attacks at other times, then it is called menstrually related migraine2. 

Menstrual migraine is usually more severe, more prolonged and more refractory to treatment than non-menstrual migraines3.  

It is during the oestrogen withdrawal that happens at the menstrual phase of the cycle when there is an increased risk of migraine. The increase uterine prostaglandin release may also have a role in the risk of migraine4. 

Treatment of menstrual migraine

Treatment of menstrual migraine starts by optimising acute treatment, bearing in mind that menstrual migraine tends to be more severe, prolonged and refractory.  

When acute treatment is not effective, then one may consider different prophylactic approaches.  

Standard prophylactic medication can be used in menstrually related migraine when there are other migraine attacks during the cycle; but it may not be effective for pure menstrual migraine, when targeted prophylactic approach is likely to be more adequate.  

Targeted perimenstrual prophylaxis can only be used when menstruation is regular and predictable because the prophylaxis has to be started before the onset of the menstrual attack5.  

Examples include:  

  • Frovatriptan on day -2 at 5mg twice a day followed by 2.5mg twice a day for 5 days 
  • Naproxen 500mg daily from day -14 to day + 7 or shorter courses from day -1 to day +7
  • Estradiol gel 1.5mg daily from day -5 for 7 days.  

Another approach would be to supress menstruation  

A) by supressing all ovarian activity: Examples include: 

  • Continous combined hormonal contraceptive (Ethinylestradiol). This also treats menopausal symptoms and healthy women can take it up until age 50. It is contraindicated in migraine with aura.  
  • Injectable progestin-only contraceptives (Medroxyprogesterone acetate) 
  • Oral progestin-only contraceptives (Desogestrel 75mg) 

 

B) by supressing prostaglanding release (reducing menstrual bleeding) with progestin-releasing intrauterine device. Oestrogen withdrawal still occurs with this option.  

 

Hormonal replacement treatment during perimenopause:

As opposed to contraceptive hormones (Ethinylestradiol), hormonal replacement therapy (Estradiol) does not supress ovarian activity and can increase hormone fluctuations and therefore the risk of migraines during perimenopause.  

Hormonal replacement treatment postmenopause:

Transdermal oestrogen (estradiol) or continuous progestogen option may be used in the postmenopause to help minimising hormone fluctuations.  

Estradiol is not contraindicated in migraine with aura. Transdermal route is preferred over oral tablets due to more stable serum hormone levels associated with nonoral routes6.  

Referral to secondary care

Migraine is the most likely diagnosis for a patient attending primary care with headache. Many of these patients will be successfully managed in primary care. If there is a clear diagnosis of migraine we recommend acute +/- preventative treatment (as detailed in acute and prophylactic sections).  

Where prophylactic treatment is not successful after three prophylactic drugs, consider referral to relevant secondary care services as per local arrangements. 

If there is diagnostic uncertainty or concern about a secondary cause, at this point consider open access CT as an alternative to secondary referral. 

Editorial Information

Last reviewed: 11/10/2023

Next review date: 01/04/2025