Abstract
BackgroundNational Institute for Health and Clinical Excellence (NICE) clinical guidelines and subsequent NICE issued ‘recommendation reminders’ advocate discontinuing two fertility procedures and caesarean sections in women with hepatitis. We assess whether NICE guidance in 2004 and recommendation reminders were associated with a change in the rate of clinical procedures performed.MethodsRoutine inpatient Hospital Episode Statistics (HES) data were extracted from the HES database for 1st April 1998 to 31st March 2010 using OPCS procedure codes for varicocele operations in infertile men, endometrial biopsies in infertile women and caesarean sections in women with hepatitis B or C. We used Joinpoint regression to identify points in time when the trend in procedure rates changed markedly, to identify any influence of the release of NICE guidance.ResultsBetween 1998-2010, planned caesarean sections in women with and without hepatitis B or C increased yearly (annual percentage change (APC) 4.9%, 95% CI 2.1% to 7.7%) in women with hepatitis, compared with women without (APC 4.0% [95% CI 2.7% to 5.3%] up to 2001, APC -0.6% [95% CI -2.8% to 1.8%] up to 2004 and 1.3% [95% CI 0.8% to 1.8%] up to 2010). In infertile women under 40 years of age, endometrial biopsies for investigation of infertility increased, APC 6.0% (95% CI 3.6% to 8.4%) up to 2003, APC 1.5% (95% CI -4.3% to 7.7%) to 2007 followed by APC 12.8% (95% CI 1.0% to 26.0%) to 2010. Varicocele procedures remained relatively static between 1998 and 2010 (APC -0.5%, 95% CI -2.3% to 1.3%).ConclusionsThere was no decline in use of the three studied procedures, contrary to NICE guidance, and no change in uptake associated with the timing of NICE guidance or recommendation reminders. ‘Do not do’ recommendation reminders may be ineffective at improving clinical practice or achieving disinvestment.
Highlights
National Institute for Health and Clinical Excellence (NICE) clinical guidelines and subsequent NICE issued ‘recommendation reminders’ advocate discontinuing two fertility procedures and caesarean sections in women with hepatitis
There were 10 caesareans in women with hepatitis B or C in 1998, compared with 93 in 2010; the model-based estimates suggest that the underlying planned caesarean section rate in women with hepatitis B or C increased by 4.9% annually (APC 4.9%, 95% CI 2.1% to 7.7%)
There was no evidence of a change in the underlying trend of increased uptake of planned or unplanned caesarean section delivery in women with hepatitis when the NICE guidance was published in 2004, nor at any time between 1998 and 2010 (Figure 1)
Summary
National Institute for Health and Clinical Excellence (NICE) recommendation reminders identify practices that should be discontinued where they are not evidence based. The caesarean section guideline has been updated (Nov 2011) with no changes to the above recommendations The impact of these recommendation reminder prompts has never been formally evaluated, it is clear that there is variable adherence to NICE clinical guidelines and technology appraisals in a range of clinical practice areas [4,5,6,7,8,9,10]. Our hypothesis is that NICE clinical guidelines and reminders should precede a reduction in the trend of procedure uptake, in line with the best evidence
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