National Institute For Health And Care Excellence Clinical Guideline Research Articles

Impact of NICE clinical guidelines for prevention and treatment of neonatal infections on antibiotic use in very preterm infants in England and Wales: an interrupted time series analysis

ObjectiveTo assess the impact of publication of UK National Institute for Health and Care Excellence (NICE) guidelines on the prevention and treatment of early-onset infections (EOIs) in neonates (clinical guideline...

Acupuncture out, dogma in: The U.K. National Institute for Health and Care Excellence guideline for osteoarthritis 2022

The recently published National Institute for Health and Care Excellence (NICE) guideline for osteoarthritis (NG226) does not recommend acupuncture. However, high-quality evidence exists that indicates acupuncture is effective for osteoarthritis and not simply a placebo. NICE clinical guidelines, such as NG226, provide recommendations for the National Health Service (NHS) in the U.K. In this opinion article the author examines the rationale and evidence set out in the Guideline NG226 and the supporting documentation. Two interrelated issues are identified: problems of interpretation and problems of definition. The problems of interpretation have been discussed in relation to previous NICE guidelines, these include: the evidence review erroneously analyses sham acupuncture as inert; the minimal important difference criterion for efficacy trials is not applied consistently; insufficient weight is given to pragmatic comparative effectiveness evidence. The problems of definition have not been discussed to the same degree. The evidence review employs no operational definitions of acupuncture or sham acupuncture. As a result, highly similar procedures are classified as sham in one trial but verum in another. This is illogical and unscientific. The guideline rationale fails to engage with the scientific debate regarding acupuncture research and repeats the mistakes of earlier guidelines. The interpretation of the evidence is erroneous as it is based on the dogma that sham acupuncture is inert. This is compounded by a failure to have clear definitions for acupuncture or sham acupuncture. The committee's interpretation of the acupuncture evidence will have negative consequences for patients in practice and for those enrolled in future clinical trials.

Preoperative hip fracture analgesia: the case for nerve blocks—a retrospective audit and quality improvement project

Background: Hip fractures are associated with significant mortality1 within 1 month (10%) and 1 year (∼33%) with >65 000 hip fracture operations being carried out per year. Anaesthetists play crucial roles for these patients, including provision of effective analgesia to expedite postoperative ambulation (in-line with the DrEaMing concept2) and facilitation of effective multidisciplinary perioperative management, including rehabilitation. This is a retrospective audit of preoperative analgesia assessing prescriptions of paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and fascia iliaca compartment blocks (FICB) against National Institute for Health and Care Excellence (NICE) recommendations.1 Methods: A total of 47 patients were retrospectively identified using the Nottingham Hip Fracture Database, between November and December 2021. Case notes were reviewed to assess frequency of pain assessments, analgesic prescriptions, and conduct of FICB. A literature review was conducted to review the role of ultrasound guidance in the performance of FICB. An online survey was distributed to Emergency Department (ED) clinicians regarding familiarity and operator confidence in performing nerve block for patients with hip fractures. Focus groups identified areas for lasting organisational change to facilitate best patient care. Results: Pain assessments were most reliably performed at patient presentation. Paracetamol and opioids were often co-administered for initial analgesia, although in 48.6% of these cases opioids were potentially avoidable. NSAIDs were not prescribed to any patient. Nerve blocks were often considered in relevant patients, but with suboptimal analgesic benefit. The literature review demonstrated that ultrasound guidance would likely result in a more effective and safe procedure, compared with a landmark technique. The ED staff survey highlighted a desire to learn about ultrasound-guided FICB. Conclusion: Scope for improvement across all areas was identified, with the hospital engaging thoroughly with the audit to optimise patient experience and outcomes. Analgesia prescribing should follow a step-wise approach to reduce side-effects of opioid analgesia. Nerve blocks should be considered more and should be performed with ultrasound guidance. Multi-departmental consensus was to promote nerve block performance; this is being achieved through teaching, updating of visual reminders for ultrasound nerve blocks, and updating relevant paperwork for procedure performance and clerking. We plan to re-audit in the future. 1.National Institute for Health and Care Excellence. 2011. Hip fracture: management. (NICE clinical guideline No. 124). Available from https://www.nice.org.uk/guidance/cg124 (accessed 20/03/23)2.Oliver CM, Warnakulasuriya S, McGuckin D, et al. Br J Anaesth 2022; 129: 114–26

A Review of UK-based National and International Scientific Meeting Published Abstracts in Response to the Draft NICE Aortic Aneurysm Guidelines

UK National Institute for Health and Care Excellence (NICE) draft clinical guidelines (CG) (2018) regarding aortic aneurysm repair were disputed internationally. We aim to appraise the academic response to the draft CG in terms of quantity and scientific quality by reviewing published conference abstracts from three major national and international, UK meetings. Abstracts related to aortic practice from The Vascular Societies Annual Scientific Meeting, British Society for Endovascular Therapy (BSET) & Charing Cross (CX) meetings from 2019 were reviewed for methodology, sample size, data collection period, scientific quality and conclusions that supported or conflicted the draft guideline. A total of 549 abstracts were identified from VSGBI, BSET and CX abstract books of which, 226 (41.2%) were related to aortic practices. Of these, 115 (50.9%) were related to EVAR. Twenty-two of these abstracts (19.1%) were identified as having findings relevant to the draft guidelines. Eighteen (15.7%) were identified as findings that potentially conflict the draft CG and 4 (3.5%) that could support the initial recommendations. Six abstracts (5.2%) made direct reference to or challenged the draft CG. The median data collection period was 4 years. The median sample size was 102 patients. In general, scientific quality was poor, with 82% of selected abstracts were graded at level 2b. We have demonstrated a concerted response to the draft NICE clinical guidelines relating to the treatment of abdominal aortic aneurysms at three large scientific meetings. As a result of which and other factors, significant changes were made to the finalized NG156. There is still paucity in evidence regarding the long-term safety and cost-effectiveness of EVAR.

A Review of Guidelines for Antibiotic Prophylaxis before Invasive Dental Treatments

Bacteraemia associated with invasive dental treatments can propagate infective endocarditis in high-risk cardiac patients. Over the past decade, antibiotic prophylaxis before dental treatment has been questioned. This review aims to compare the variations between the UK, European and American antibiotic prophylaxis guidelines before dental treatments. Antibiotic prophylaxis guidelines by the National Institute for Health and Care Excellence (NICE)—Clinical Guideline 64, Scottish Dental Clinical Effectiveness Programme (SDCEP), American Heart Association (AHA), European Society of Cardiology (ESC), European Society of Endodontology (ESE) and Belgian Health Care Knowledge Centre (KCE) position statements were compared regarding the indications, high-risk patients and prophylaxis regimens before dental treatments. In the United Kingdom, the NICE—Clinical Guideline 64 and SDCEP—Implementation Advice do not advise the prescription of prophylactic antibiotics for the majority of high-risk cardiac patients undergoing routine dental treatments. On the contrary, the AHA, ESC and KEC recommend the prescription of antibiotics prior to invasive dental procedures in high-risk cardiac individuals. The ESE also indicates prophylaxis before endodontic procedures for patients with other conditions, including impaired immunologic function, prosthetic joint replacement, high-dose jaw irradiation and intravenous bisphosphonates. Among these guidelines, there are variations in antibiotic prophylaxis regimens. There are variations regarding the indications and antibiotic prophylaxis regimens before invasive dental treatments among these available guidelines.

A service evaluation: impact of nurse-led regional familial hypercholesterolaemia service on a hospital adult lipid clinic.

Patients with a lipid clinic diagnosis of definite and possible FH based on the SBR criteria were referred to a nurse-led regional service for FH genetic testing. 140 patients were referred for genetic testing. Six had SBR-definite FH due to the presence of tendon xanthomata and 134 had SBR-possible FH. A monogenic FH mutation was detected in all six patients (100%) with SBR-definite FH and in 34 (25%) of patients with possible FH. The appropriate use of molecular genetics in a lipid clinic will greatly facilitate the management of hyperlipidaemia and cardiovascular risk since the management of FH patients (National Institute for Health and Care Excellence (NICE) Clinical Guideline 71) is different from non-FH patients (NICE Clinical Guideline 181).

Rheumatoid Arthritis: The Impact of Mental Health on Disease: A Narrative Review.

Over 60% of rheumatoid arthritis (RA) patients achieve a good response after 12 months of treatment when following the European league against rheumatism (EULAR) guidelines for treatment. However, almost half of patients still suffer from moderate to severe disease activity despite this. In addition, mental health problems may remain despite reduced measures of inflammation systemically and within joints. Depression is two times more common in RA patients than in the general population, and intriguingly a bi-directional relationship with RA has been shown in cross-sectional studies. Chronic inflammation impairs the physiological responses to stress including effective coping behaviours, resulting in depression, which leads to a worse long-term outcome in RA. In RA patients, the pain score is not always solely related to inflammatory arthritis and immunological disease activity by Bąk et al. (Patient Prefer Adherence 13:223–231, [1]). Non-inflammatory pain secondary to anxiety, depression, sleep disturbance and the psychosocial situation needs to be considered whilst fibromyalgia, mechanical pain and neuropathic pain can also contribute to overall pain scores by Chancay et al. (Women's Midlife Health 5:3, [2]). Hence, the UK National Institute for Health and Care Excellence (NICE) guideline for the management of RA included psychological interventions for fatigue, low mood and social well-being (NICE NG100, 2018) [3], and the NICE clinical guidelines (CG91) [4] suggest managing mental health and depression in chronic medical conditions to improve treatment outcomes. This is a narrative review of the impact of mental health on RA disease activity in terms of patient-reported outcomes (PROs).

C-reactive protein testing reduces antibiotics prescription in a community setting

BackgroundOveruse of antimicrobials and the threats posed by resistance are concerning. Most patients in primary care with respiratory tract symptoms are prescribed antibiotics, amounting between 80–90% of all prescriptions. The National Institute for Health and Care Excellence (NICE) recommends point-of-care (POC) testing of C-reactive protein (CRP) where there is uncertainty about prescribing antibiotics. Studies evaluating the use of POC CRP to reduce antibiotic prescribing for self-limiting respiratory illness in primary care have demonstrated heterogeneity in their results.AimTo evaluate the impact of POC CRP testing on antibiotic prescribing.MethodA retrospective case analysis was undertaken at a GP practice. Alere Afinion AS100 was used for POC CRP testing. Data were collected on patients presenting with cough or sore throat who had POC CRP testing used in their clinical decision making. Eighty-four cases were selected for inclusion. NICE clinical guideline CG191 was used as a standard comparator for antibiotic prescribing and patients were followed up over a 2-month period.ResultsPatients presented with cough (n = 56) and sore throat (n = 28). At initial presentation 23/84 (27.4%) of patients were prescribed antibiotics. Over the 2-month follow-up period 15/84 (17.8%) of patients had at least one further consultation related to their initial respiratory complaint with 6/84 (7.1%) being prescribed antibiotics. The overall effect was a reduction of antibiotic prescriptions by 65.5%.ConclusionThe use of POC CRP testing helped GPs reduce the rate of antibiotic prescription and improve antimicrobial stewardship by being an addition to their diagnostic armoury. It has also shown potential role in patient reassurance and modifying health seeking behaviour.

Care of Women with Obesity in Pregnancy

Care of Women with Obesity in Pregnancy

Quality Measurement Recommendations Relevant to Clinical Guidelines in Germany and the United Kingdom: (What) Can We Learn From Each Other?

We conducted a systematic review of clinical guidelines (CGs) to examine the methodological approaches of quality indicator derivation in CGs, the frequency of quality indicators to check CG recommendations in routine care, and clinimetric properties of quality indicators. We analyzed the publicly available CG databases of the Association of the Scientific Medical Societies in Germany (AWMF) and National Institute for Health and Care Excellence (NICE). Data on the methodology of subsequent quality indicator derivation, the content and definition of recommended quality indicators, and clinimetric properties of measurement instruments were extracted. In Germany, no explicit methodological guidance exists, but 3 different approaches are used. For NICE, a general approach is used for the derivation of quality indicators out of quality standards. Quality indicators were defined in 34 out of 87 CGs (39%) in Germany and for 58 out of 133 (43%) NICE CGs. Statements regarding measurement properties of instruments for quality indicator assessment were missing in German and NICE documents. Thirteen pairs of CGs (32%) have associated quality indicators. Thirty-four quality indicators refer to the same aspect of the quality of care, which corresponds to 27% of the German and 7% of NICE quality indicators. The development of a standardized and internationally accepted methodology for the derivation of quality indicators relevant to CGs is needed to measure and compare quality of care in health care systems.

Impact of UK NICE clinical guidelines 168 on referrals to a specialist academic leg ulcer service.

Background Leg ulcers are a common cause of morbidity and disability and result in significant health and social care expenditure. The UK National Institute for Health and Care Excellence (NICE) Clinical Guideline (CG)168, published in July 2013, sought to improve care of patients with leg ulcers, recommending that patients with a break in the skin below the knee that had not healed within two weeks be referred to a specialist vascular service for diagnosis and management. Aim Determine the impact of CG168 on referrals to a leg ulcer service. Methods Patients referred with leg ulceration during an 18-month period prior to CG168 (January 2012-June 2013) and an 18-month period commencing six months after (January 2014-June 2015) publication of CG168 were compared. Results There was a two-fold increase in referrals (181 patients, 220 legs vs. 385 patients, 453 legs) but no change in mean age, gender or median-duration of ulcer at referral (16.6 vs. 16.2 weeks). Mean-time from referral to specialist appointment increased (4.8 vs. 6 weeks, p = 0.0001), as did legs with superficial venous insufficiency (SVI) (36% vs. 44%, p = 0.05). There was a trend towards more SVI endovenous interventions (32% vs. 39%, p = 0.271) with an increase in endothermal (2 vs. 32 legs, p = 0.001) but no change in sclerotherapy (24 vs. 51 legs) treatments. In both groups, 62% legs had compression. There was a reduction in legs treated conservatively with simple dressings (26% vs. 15%, p = 0.0006). Conclusions Since CG168, there has been a considerable increase in leg ulcer referrals. However, patients are still not referred until ulceration has been present for many months. Although many ulcers are multi-factorial and the mainstay of treatment remains compression, there has been an increase in SVI endovenous intervention. Further efforts are required to persuade community practitioners to refer patients earlier, to educate patients and encourage further investment in chronically underfunded leg ulcer services.

NICE clinical guideline NG39: Major trauma: assessment and initial management

Major trauma is the most frequent cause of death in the UK for children aged between 1 and 18 years. It is responsible for 31% of deaths in children aged...

General Practitioners’ use of and attitudes to acupuncture in relation to the UK’s National Institute for Health and Care Excellence (NICE) clinical guidelines—A pilot study

IntroductionUntil April 2016, acupuncture in the UK was recommended by the National Institute for Health and Care Excellence (NICE) as a potential treatment modality for three conditions, but use of this guidance in primary care is unknown. The aim of this study was to update the mapping of acupuncture on NICE clinical guidelines and to explore general practitioners’ (GPs’) awareness of those guidelines, as well as their views on and referral to acupuncture. It also examined the feasibility of research through electronic questionnaires administered to GPs. MethodsInitially, a literature search was conducted of NICE guidelines mentioning acupuncture (up to July 2015). Subsequently, a random sample of 57 GPs in North London was asked to complete an electronic survey. ResultsLiterature search identified one new “do not offer” recommendation (CG171: Urinary Incontinence). Four guidelines discussed acupuncture, concluding evidence was insufficient. The survey yielded 19 responses from 34 potential respondents. Patient demand appeared widespread but small; several GPs received enquiries but provided no access. The most common reason for enquiry was pain management. Importance assigned to guidance and awareness of guidance other than for pain varied significantly: GPs’ decision to offer access did not correlate with guideline awareness. GPs often expected recommendations where there were none. GPs professing least trust in guidance appeared more likely to offer acupuncture access. ConclusionNICE guidelines appeared not to reflect acupuncture provision in primary care. Electronic questionnaires are a feasible research method in primary care, although obtaining up-to-date contact details poses a challenge.

NICE clinical guideline: bronchiolitis in children

Bronchiolitis is a lower respiratory tract infection commonly seen in children less than 1 year of age.1 ,2 Predominantly occurring in winter months, bronchiolitis is in the majority managed in...

Postnatal care: a neonatal perspective (NICE guideline CG 37)

This 2015 National Institute for Health and Care Excellence (NICE) guideline outlines essential routine postnatal care of women and their babies up to 6–8 weeks post partum and offers advice...

Impact of NIHR HTA Programme funded research on NICE clinical guidelines: a retrospective cohort.

BackgroundIt is vitally important that there is a connection between health research and clinical practice. Indications as to the impact of the research on evidence-based practice and policy can be obtained by tracking the use of outputs of health research, especially its use in clinical guidelines (CGs). This study aims to assess the proportion of National Institute for Health and Care Excellence (NICE) CGs citing National Institute for Health Research Health Technology Assessment (NIHR HTA) studies and the impact of evidence from those studies on the included NICE CGs.MethodsThis is a retrospective cohort study assessing the proportion of NICE CGs from all NICE CGs issued between April 2001 and April 2012, which cited evidence from studies funded by the NIHR HTA Programme and the impact of those studies on the CGs as the primary and secondary outcome measures.ResultsOf the cohort of NICE CGs (n = 122), 3 (2%) CGs were based on previous NIHR HTA reports and would not have been issued in that form without those NIHR HTA studies, 90 (74%) included evidence from NIHR HTA studies, and 29 (24%) did not include evidence from NIHR HTA studies. The impact of NIHR HTA evidence on NICE CGs varied in the type and quantity of data used.ConclusionsFindings suggest that NIHR HTA funded research impacts on clinical guidance from NICE and hence is well connected to both clinical practice and policy.

Nalmefene for Reducing Alcohol Consumption in People with Alcohol Dependence: An Evidence Review Group Perspective of a NICE Single Technology Appraisal.

As part of its single technology appraisal process, the National Institute for Health and Care Excellence (NICE) invited the company (Lundbeck) marketing nalmefene (Selincro) to submit evidence of its clinical and cost effectiveness for reducing alcohol consumption in people with alcohol dependence. The School of Health and Related Research Technology Appraisal Group at the University of Sheffield was commissioned to act as the independent Evidence Review Group (ERG) and to produce a critical review of the company's submission to NICE. The clinical evidence was derived from three phase III, company-sponsored, randomised, double-blind, placebo-controlled trials in adults with a diagnosis of alcohol dependence comparing nalmefene, taken on an as-needed basis, in conjunction with psychosocial support with placebo in conjunction with psychosocial support. Psychosocial support was provided in the form of BRENDA, an intervention of lower intensity than that recommended in NICE Clinical Guideline 115 (NICE CG115). Post-hoc subgroup analyses were conducted in people who were drinking at high or very high risk levels at baseline and maintained this level of drinking during the screening phase prior to randomisation. This subgroup forms the licensed population. There were a number of limitations and uncertainties in the clinical evidence base which warrant caution in its interpretation. In particular, the post-hoc subgroup analyses and high dropout rates in the three nalmefene studies meant that the inference of treatment effects might be confounded. The company's economic evaluation showed that use of nalmefene in conjunction with psychosocial support in the form of BRENDA dominated the use of BRENDA in conjunction with placebo, providing more quality-adjusted life-years (QALYs) at a reduced cost. However, this evaluation did not meet the final scope issued by NICE, which specified that the comparator should be psychological intervention as defined in NICE CG115. The ERG produced alternative cost per QALY values for the comparison undertaken by the company and suggested three further comparisons deemed relevant: (1) nalmefene with psychological intervention as defined in NICE CG115; (2) delayed use of nalmefene in those who did not respond to psychological intervention as recommended in NICE CG115 alone; and (3) use of naltrexone outside of its marketing authorisation. The ERG thought it probable that using nalmefene in only those people who do not respond to psychological intervention alone was likely to be more cost effective compared with its immediate use in the entire licensed population. The Appraisal Committee accepted the comparison with psychosocial support in the form of BRENDA and believed that the most plausible cost per QALY was likely to be below £5100. Therefore, the Appraisal Committee concluded that nalmefene in conjunction with psychosocial support was a cost effective use of NHS resources compared with psychosocial support alone for treating people with alcohol dependence drinking at a high risk level, without physical withdrawal symptoms and not requiring immediate assisted withdrawal from alcohol.

Implementation of NICE Clinical Guideline 95 for assessment of stable chest pain in a rapid access chest pain clinic reduces the mean number of investigations and cost per patient

ObjectiveIn 2010, the National Institute for Health and Care Excellence (NICE) in the UK published Clinical Guideline 95 (CG95) advocating risk stratification of patients using ‘CADScore’ to guide appropriate cardiac...

Audit into the Appropriateness of CT Cervical Spine Scan Requesting in the Emergency Department

Introduction: The use of computed tomography (CT) imaging of the cervical spine (CS) is now the recommended primary screening modality for suspected CS injuries following trauma. The aim of this audit is to review the appropriate use of CS CT imaging in the emergency department (ED) and assess compliance with the National Institute for Health and Care Excellence (NICE) head injury clinical guidelines.Methods: Charts were reviewed for the last 50 trauma patients to receive a CS CT scan following a request from the ED at University Hospital Limerick between 10 July 2013 and 19 December 2013. The NICE clinical guideline 176 on head injury was used as the standard of care. These data were used to perform a retrospective audit to assess patients who satisfied NICE criteria to qualify for a CS CT scan.Results: 45 patients who had undergone a CS CT scan were identified, this group had a mean age of 42 years and 71% of them were male. At least one of the NICE guideline criteria was fulfilled in 100% of patients who had a CS CT, with 2.64 of the criteria fulfilled on average. Plain-film X-ray radiography (PF) was inadequate for diagnosis in 20 (44.4%) patients.Discussion: ED consultants appropriately refer patients for CS CT scans following CS trauma and adhere to NICE head injury clinical guidelines.Conclusion: Having guidelines in place in the ED and adopting CS CT imaging as an initial screening modality following CS injury may reduce time to definitive care and improve resource implications.

Informing the development of NICE (National Institute for Health and Care Excellence) quality standards through secondary analysis of qualitative narrative interviews on patients’ experiences

BackgroundWe set out to explore if, and how, an archive of qualitative, narrative interviews covering over 60 health issues could be used to inform the development of National Institute for Health and Care Excellence (NICE) quality standards. We also sought to identify which aspects of health care are important to people facing different health conditions and to test a set of ‘core components’ in focus groups with people who tend to be less well represented in interview research studies.Objectives(1) To conduct qualitative secondary analysis (of collections of narrative interviews) to identify common, core components of patients’ experiences of the NHS. (2) To test these candidate components with (i) further purposive sampling of the interview collections and (ii) a series of focus groups with users. (3) To embed the project alongside the development of NICE clinical guidelines and quality standards. (4) To inform the development of measurement tools on patients’ experiences. (5) To develop and share resources and skills for secondary analysis of qualitative health research.Methods and data sourcesWe used qualitative methods including qualitative secondary analysis, interviews with team members and focus groups. We also ran a workshop on secondary analysis practice and a dissemination seminar. The secondary analysis used narrative interviews from the archive held by the Health Experiences Research Group in Oxford. These interviews have been collected over a 12-year period, number over 3500 and are copyrighted to the University of Oxford for research publications and broadcasting. Other data were digital recordings of interviews and observations at meetings. We prepared reports intended to contribute to NICE clinical guidelines and quality standards development.ResultsWe identified eight consistently important aspects of care: involving the patient in decisions; a friendly and caring attitude; an understanding of how life is affected; seeing the same health professional; guiding through difficult conversations; taking time to explain; pointing towards further support; and efficiently sharing health information across services. Expectations varied but we found few differences in what is valued, even when we tested the reach of these ideas with groups who rarely take part in mainstream health research. The asthma report for NICE highlighted several issues, but only the importance of proper inhaler training contributed to a quality statement. Several barriers were identified to using (unpublished) tailor-made analyses in NICE product development.ConclusionsWe compared the perspectives about what is most valued in health care between people with different health conditions. They were in agreement, even though their experiences of health-care relationships varied enormously. With regard to the NICE clinical guideline and quality standard development process, the usual source of evidence is published qualitative or quantitative research. Unpublished secondary analysis of qualitative data did not fit the usual criteria for evidence. We suggest that targeted secondary analysis of qualitative data has more potential when the qualitative literature is sparse, unclear or contradictory. Further work might include further testing of the identified core components in other patient groups and health conditions, and collaboration with NICE technical teams to establish whether or not it is possible to identify areas of patient experience research where targeted secondary analyses have potential to add to a qualitative literature synthesis.FundingThe National Institute for Health Research Health Services and Delivery Research programme.