National Institute For Health And Clinical Excellence Clinical Guideline Research Articles

Impact of sociodemographic patient factors on prescriber adherence to antihypertensive prescription guidelines: a cross-sectional study using data from The Irish Longitudinal Study on Ageing

Abstract Introduction Uncontrolled hypertension causes significant morbidity and mortality worldwide. Several international prescribing guidelines have been created to address this. However, prescriber adherence to these guidelines may be influenced by sociodemographic patient factors such as socio-economic status, gender and age. Aim To examine the effects of gender and other patient factors, including age, geographical location, educational attainment, duration of disease, socio-economic status, smoking status, and previous history of cardiovascular diseases on prescriber adherence to hypertension prescription guidelines. Achievement of blood pressure goals (<140/90 mmHg) with adherence to prescription guidelines was also assessed. Methods This study is a secondary analysis of cross-sectional data from the first wave (2009-2011) of The Irish Longitudinal Study on Ageing (TILDA), which included 8,175 Irish adults ≥50 years of age. Participants were included in the present study if they reported a previous doctor diagnosis of hypertension. Antihypertensive medication regimens were compared and categorised according to the 2011 National Institute for Health and Clinical Excellence (NICE)[1] prescription guidelines, which included the use of angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers, and thiazide diuretics in the treatment of hypertension. In this study, the antihypertensive medication regimens of participants were categorised based on age categories (<55, ≥55, and all age groups), and compared to the 2011 NICE Guidelines which differentiate treatment in those ≥55, and <55 years of age. The effects of patient sociodemographic factors on prescriber adherence to the guidelines, and the effects of guideline adherence on blood pressure control, (defined as blood pressure<140/90 mmHg), were determined using multinomial logistic regression models. The mlogit, RRR code in STATA 17 SE was used to report relative risks (RRs). Results A total of 2,992 participants were included, of whom 54.9% were women. The mean age of participants was 65.69 years (±9.23). Male gender, older age and lower socioeconomic status among participants were associated with increased prescriber guideline adherence. Prescribers were less likely to adhere to guidelines in female patients ≥55 years (RR 0.75 [0.62 to 0.91]), and female patients across all age groups (RR 0.80 [0.67 to 0.95]). Better blood pressure control was seen with medication regimens adherent to prescription guidelines with a mean of 140.38 (±18.98)/83.09 (±11.02) mmHg compared to a mean of 141.66 (±19.86)/84.77 (±11.71) mmHg in those non-adherent to guidelines. Conclusion This study highlights the effects of patient gender on prescriber adherence to antihypertensive prescription guidelines. A study strength is the use of a large, nationally representative cohort that used a standardised protocol of data collection within the Irish population. A potential limitation is the inclusion of self-reported data, including doctor diagnosis of hypertension. The results of this study may emphasise a larger issue of the systemic undertreatment of women within healthcare; however, these results should be interpreted in the context of 2011 guidelines, which have since been superseded by 2019 NICE guidelines. Further research may seek to determine possible reasons for such differences in hypertensive care. Reference 1. Linden B. NICE guidance on primary hypertension National Institute for Health and Clinical Excellence (2011) Hypertension: Clinical Management of Primary Hypertension in Adults. NICE Clinical Guideline 127. British journal of cardiac nursing. 2011;6:582-584.

NICE clinical guideline (CG152): the management of Crohn's disease in adults, children and young people

The guideline offers best practice advice on the care of adults, children and young people with Crohn's disease. To provide clinically effective and cost-effective evidence-based recommendations to guide clinical practice in a clinical guideline commissioned by the National Institute for Health and Clinical Excellence (NICE). A systematic review of the evidence including critical appraisal, meta-analysis and cost-effectiveness modelling. Thirty-one evidence-based recommendations covering induction and maintenance therapy are available. Five key priorities for implementation are identified together with nine future research recommendations. Three guideline versions are available: short (containing just the recommendations), full (containing the full evidence base) and an Understanding NICE guidance for patients and carers. Algorithms have been produced together with a NICE pathway and implementation tools. These are the first evidence-based clinical and cost-effectiveness guidelines for Crohn's disease in the United Kingdom.

Inconsistencies in Nice Guidance for Acupuncture: Reanalysis and Discussion

Acupuncture received a positive recommendation in the National Institute for Health and Clinical Excellence (NICE) clinical guideline for low back pain (LBP). However, no such recommendation was forthcoming in the NICE clinical guideline for osteoarthritis (OA). Importantly, the two guidelines adopted different treatment comparators in their economic analyses of acupuncture; in the LBP guideline 'usual care' was used (with no consideration of placebo/sham interventions), whereas 'sham acupuncture' was the comparator in the OA guideline. To analyse the implications of using different control group comparators when estimating the cost-effectiveness of acupuncture therapy. The NICE OA economic analysis for acupuncture was replicated using 'usual care' (ie, no placebo/sham component) as the treatment comparator. A 'transfer-to-utility' technique was used to transform Western Ontario and McMaster Osteoarthritis scores into EQ-5D utility scores to allow quality-adjusted life year (QALY) gains to be estimated. QALY estimates were combined with direct incremental cost estimates of acupuncture treatment to determine incremental cost-effectiveness ratios (ICERs). When 'usual care' was used as the treatment comparator, ICER point estimates were below £20 000 per QALY gained for each acupuncture trial analysed in the OA clinical guideline. In the original analysis, using placebo/sham acupuncture as the treatment comparator, ICERs were generally above £20 000 per QALY gained. The treatment comparator chosen in economic evaluations of acupuncture therapy is likely to be a strong determinant of the cost-effectiveness results. Different comparators used in the OA and LBP NICE guidelines may have led to the divergent recommendations in the guidelines.

NICE guideline and current practice of antibiotic prophylaxis for high risk cardiac patients (HRCP) among dental trainers and trainees in the United Kingdom (UK)

The National Institute for Health and Clinical Excellence (NICE) introduced the antibiotic prophylaxis guideline in 2008 for cardiac patients in the UK, which has led to a decrease in national prescription levels for antibiotic prophylaxis. Despite the introduction of the guideline there is still a discrepancy in levels of compliance among the dental community. The aims of this study were to determine the understanding of the NICE clinical guideline on antimicrobial prophylaxis against infective endocarditis (IE) and the difference in antibiotic prescription for high risk cardiac patients (HRCP) between dental trainers and trainees. A proforma was designed and distributed among dental trainers and trainees attending a conference at the London deanery. The trainers were GDPs responsible for training dental trainees allocated to them over a 12 month period based in a general dental practice. Dental trainees were recent graduates about to commence their vocational dental training. Eighty-five vocational dental trainees and 70 trainers completed the proforma on a voluntary basis. The results of the study confirm that most trainers (95.7%) and trainees (94.1%) are aware of this guideline but only 62% of trainers and 69.7% of trainees have read the guideline. Compliancy with the guideline was low among trainers (55.7%) and trainees (77.6%). Compliance was high among those who had read the guideline. Trainers were more likely to prescribe prophylaxis antibiotics for HRCP. The majority (74-76%) would prescribe antibiotics on a specialist's request. Some trainers (54.9%) and trainees (48.2%) would want antibiotics themselves if they were HRCP. This study concludes that much needs to be done to improve the understanding and practice of NICE guideline among the dental trainers and trainees.

Summary of: NICE guideline and current practice of antibiotic prophylaxis for high risk cardiac patients (HRCP) among dental trainers and trainees in the United Kingdom (UK)

Objective The National Institute for Health and Clinical Excellence (NICE) introduced the antibiotic prophylaxis guideline in 2008 for cardiac patients in the UK, which has led to a decrease in national prescription levels for antibiotic prophylaxis. Despite the introduction of the guideline there is still a discrepancy in levels of compliance among the dental community. The aims of this study were to determine the understanding of the NICE clinical guideline on antimicrobial prophylaxis against infective endocarditis (IE) and the difference in antibiotic prescription for high risk cardiac patients (HRCP) between dental trainers and trainees. Methods A proforma was designed and distributed among dental trainers and trainees attending a conference at the London deanery. The trainers were GDPs responsible for training dental trainees allocated to them over a 12 month period based in a general dental practice. Dental trainees were recent graduates about to commence their vocational dental training. Eighty-five vocational dental trainees and 70 trainers completed the proforma on a voluntary basis. Results The results of the study confirm that most trainers (95.7%) and trainees (94.1%) are aware of this guideline but only 62% of trainers and 69.7% of trainees have read the guideline. Compliancy with the guideline was low among trainers (55.7%) and trainees (77.6%). Compliance was high among those who had read the guideline. Trainers were more likely to prescribe prophylaxis antibiotics for HRCP. The majority (74-76%) would prescribe antibiotics on a specialist's request. Some trainers (54.9%) and trainees (48.2%) would want antibiotics themselves if they were HRCP. Conclusion This study concludes that much needs to be done to improve the understanding and practice of NICE guideline among the dental trainers and trainees.

Golimumab for the Treatment of Psoriatic Arthritis

The National Institute for Health and Clinical Excellence (NICE) invited the manufacturer of golimumab (Schering-Plough/Centocor) to submit evidence for the clinical and cost effectiveness of this drug for the treatment of active and progressive psoriatic arthritis (PsA) in patients who have responded inadequately to previous disease-modifying anti-rheumatic drugs (DMARDs). The Centre for Reviews and Dissemination and the Centre for Health Economics at the University of York were commissioned to act as the Evidence Review Group (ERG) to critically appraise the evidence presented by the manufacturer. This article provides a description of the company submission, the ERG review and the resulting NICE guidance. The ERG critically reviewed the evidence presented in the manufacturer's submission and identified areas requiring clarification, for which the manufacturer provided additional evidence. The main clinical effectiveness data were derived from a single phase III randomized controlled trial (GO-REVEAL) that compared golimumab with placebo for the treatment of active and progressive patients who were symptomatic despite the use of previous DMARDs or NSAIDs. The 14-week data showed that, compared with placebo, golimumab 50 mg significantly improved joint disease response as measured by American College of Rheumatology (ACR) 20 (relative risk [RR] 5.73, 95% CI 3.24, 10.56) and Psoriatic Arthritis Response Criteria (PsARC) [RR 3.45, 95% CI 2.49, 4.87], and significantly improved skin disease response as measured by Psoriasis Area and Severity Index (PASI) 75 (RR 15.95, 95% CI 4.62, 59.11). The 24-week absolute data showed that these treatment benefits were maintained. There was a significant improvement in patients' functional status as measured by Health Assessment Questionnaire change from baseline at 24 weeks (-0.33; p < 0.001). The open-label extension data showed that these beneficial effects were also maintained at 52 and 104 weeks. The ERG identified several issues relating to the clinical effectiveness results. Analyses of the 24-week data were less robust, failing to adjust for treatment contamination due to patient crossover at week 16. It was also unclear if these results were generalizable to clinical practice. No randomized controlled trial compared the effectiveness of different biologic therapies head-to-head. To compare the effectiveness of the biologics etanercept, infliximab, adalimumab and golimumab, the manufacturer conducted a network meta-analysis, including the comparator palliative care (usual care including use of NSAIDs or DMARDs). The ERG considered the assumption of exchangeability between the trials for the purpose of the network meta-analysis to be acceptable and the statistical approach to be reliable. The results indicated somewhat lower efficacy with golimumab than with comparator biologics. The ERG identified a number of issues relating to the cost-effectiveness results. The manufacturer calculated incremental cost-effectiveness ratios (ICERs) incorrectly by comparing golimumab with palliative care instead of the most cost-effective alternative (etanercept). Despite the manufacturer's claim that golimumab was a cost-effective treatment option, the manufacturer's own model showed that golimumab was unlikely to be cost effective, relative to currently accepted thresholds, when the ICERs were correctly calculated using an incremental analysis (i.e. comparing each treatment to the next best alternative). None of the sensitivity analyses carried out by the manufacturer or the ERG regarding uncertainty in the estimates of clinical effectiveness, the acquisition and administration cost of drugs, the cost of treating psoriasis and the utility functions estimated to generate health outcomes changed this conclusion. However, a key area in determining the cost effectiveness of biologics was whether they should be treated as a class. The ERG concluded that if all biologics were considered equally effective, then etanercept, adalimumab and golimumab had almost equal costs and equal QALYs, and all had an ICER of about £15 000 per QALY versus palliative care, whilst infliximab, with a higher acquisition cost, was dominated by the other biologics. The Appraisal Committee altered its position between the Appraisal Consultation Document and the Final Appraisal Determination. It ultimately recommended that golimumab be provided as an option for the treatment of active and progressive PsA in adults only if (i) it is used as described for other tumour necrosis factor inhibitor treatments in 'Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis' (NICE clinical guideline 199); and (ii) the manufacturer provides the 100 mg dose of golimumab at the same cost as the 50 mg dose.

Management of hypertension in adults in primary care: NICE guideline

Hypertension is common and is one of the leading causes of cardiovascular events such as stroke and ischaemic heart disease. It is responsible for approximately 12% of consultations in primary care. This is a summary of the key points in the 2011 National Institute for Health and Clinical Excellence (NICE) hypertension guideline.1 This is an update of NICE clinical guideline 18, which was first published in 2004 and was partially updated in 2006 (clinical guideline 34). The 2006 and 2011 updates were developed in collaboration with the British Hypertension Society (BHS). The areas included for updating were selected because of new evidence that might change existing recommendations. These included the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) in diagnosis; the place of new thresholds and targets for treatment; and a re-examination of the position of angiotensin-converting inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium-channel blockers (CCBs), and diuretics in the treatment algorithm. Consideration of differences in management for people of various ages and ethnicity, as well as how to treat resistant hypertension, were also included. The management of blood pressure in people with diabetes was not included in this guideline. ### Diagnosis The diagnosis of hypertension uses both clinic blood pressure monitoring (CBPM) and ABPM readings (Box 1). If blood pressure measured in the clinic is 140/90 mmHg or higher, a second measurement should be taken during the consultation. If the second measurement is substantially different from the first, take a third measurement. The lower of the last two measurements should be recorded as …

Diagnosis and assessment of food allergy in children and young people in primary care and community settings: NICE clinical guideline

Food allergy is recognised as a major paediatric health problem in western countries. The true prevalence is unknown but Europe and the US report ranges from 6% to 8% in children aged up to 3 years. The National Institute for Health and Clinical Excellence (NICE) has developed a guideline on the symptoms that should prompt consideration of food allergy when a child or young person presents in primary or community care.1 Food allergy is an adverse immune response to food allergens. Reactions can be classified into those that are immunoglobulin E (IgE) mediated or non-IgE mediated. Some children may have both IgE and non-IgE mediated reactions to food; in this guideline, these are referred to as mixed reactions. In both IgE and non-IgE reactions, there is a response by the immune system to a protein within food. IgE mediated reactions are immediate type 1 hypersensitivity reactions while non-IgE mediated reactions usually occur several hours after allergen exposure. The exact mechanism is not clearly understood but, in both reactions, elimination of the allergenic food protein is required to prevent symptoms. The correct diagnosis of food allergy should decrease the incidence of adverse food reactions that are a result of true food allergies; and help prevent the unnecessary exclusion of foods that are safe and that should be eaten as part of a normal, healthy diet. This guideline does not cover children and young people with food intolerances (such as intolerance to lactose), reactions to pharmacological agents (such as salicylates), or reactions to those substances that naturally occur in foods (such as benzoic acid). When to suspect food allergy Food allergy should be suspected when the following are present: persistent eczema, gastro-oesophageal reflux disease and bowel symptoms, including constipation, that do not respond to normal …

A systematic review of the effectiveness of weight management interventions in adults with learning disabilities

Background: The increased prevalence of overweight and obesity in adults with a learning disability (LD) was highlighted by the Disability Rights Commission report (DRC 2006) as causing significant health risk and major health problems. The report called urgently for the development of evidence-based guidelines of effective weight loss methods for this target group, NICE (2006) guidelines similarly require clinicians working in weight management to promote interventions that are effective and evidence-based. Despite one review no systematic reviews in this area existed, thus the aim of this research was to systematically review current literature on weight management interventions for adults with LD to identify effective interventions. Method: A comprehensive, systematic search of the literature was conducted (via Academic Search Complete, AMED, CINAHL, Cochrane, Medline, PsycINFO and SCOPUS's electronic bibliographic databases) using key terms, and supplemented with hand searching of key journals, references and citations. Inclusion and exclusion criteria were applied to studies identified. Studies were included if they examined one or more weight management interventions recommended by NICE (2006): diet, physical activity, behavioural interventions, anti-obesity medication or bariatric surgery, in adults with a LD. Exclusion criteria were a mixed population, weight loss not reported and diagnosis of Prader-Willi Syndrome. The literature was assessed for quality using the validated Critical Appraisal Skills Programme tools (Public Health Resource Unit 2006) and the data synthesised for evaluation. Results: A total of 11 studies were identified: six quasi-experimental trials and five pre-experimental studies, no studies of anti-obesity medication or bariatric surgery were found. Weight loss was modest across all types of interventions; only one study showed clinically significant weight loss of 5–10% but had poor external validity and thus was not able to be generalised to the wider LD population; one study provided low level evidence for weight maintenance however did not demonstrate clinically significant weight loss. The overall quality of evidence reviewed was judged to be poor. Discussion: With the exception of one study, findings indicated modest, clinically insignificant weight loss which falls short of weight loss achieved by the general population using the same interventions, suggesting further adaptation to the programmes may be needed. However, the research reviewed has major methodological flaws relating to the research design, absence of randomisation, limited use of control groups, studies which are underpowered and insufficient long-term follow-up. Future research should take account of these flaws and also give greater consideration to the heterogeneity of this population with regards to inclusion criteria and analysis in order to draw out more useful conclusions for practice. Conclusion: There was insufficient evidence to support the effectiveness of currently recommended interventions for weight loss and weight maintenance in adults with LD and a need for further high quality research to inform clinical practice and decision-making in this area, thereby improving the long term health and well-being of this population.

Nocturnal enuresis in children and young people: NICE clinical guideline

Nocturnal enuresis, or bedwetting, is a common problem in children. It is a source of stress for them, as well as for their families, who may also incur significant financial costs. The Avon Longitudinal Study of Parents and Children found that the prevalence of bedwetting <2 nights per week is 30% at 4.5 years and 8% at 9.5 years, and the prevalence of bedwetting <2 nights per week is 8% at 4.5 years and 1.5% at 9.5 years.1 Treatment has not usually been offered until children are 7 years old. The National Institute for Health and Clinical Excellence (NICE) has published a guideline on the assessment and treatment of children who have nocturnal enuresis;2 this makes recommendations for those aged under 7 years and also provides some advice for parents of children who are under 5 years old. Assessment, general advice, and advice on the use of rewards is similar for all children aged over 5 years. The guideline does not suggest that children aged 5–7 years should be given interventions such as alarms or drugs, but acknowledges that some of these children will benefit from them — as such, they should not be excluded from these interventions on the basis of age alone. ### Assessment of child and family Table 1 gives some possible interpretations of a child's bedwetting history. View this table: Table 1 Bedwetting history and possible interpretationsa

NICE clinical guideline: chest pain of recent onset

Chest pain is a common presentation in general practice: in the UK, up to 1% of visits to a GP are due to chest pain.1 Chest pain matters: the risk of death is doubled in the year following a new presentation with chest pain in general practice.1 The recently published guideline from the National Institute for Health and Clinical Excellence (NICE), Chest Pain of Recent Onset: Assessment and Diagnosis of Recent Onset Chest Pain or Discomfort of Suspected Cardiac Origin ,2 addresses the assessment and diagnosis of patients with recent-onset chest pain (or discomfort) that may be of cardiac origin. It does not make recommendations for the management of the condition once the diagnosis is made. The NICE unstable angina and non-ST elevation myocardial infarction (NSTEMI) clinical guideline3 was published at the same time as the chest pain guideline; local protocols are recommended for management of STEMI, and a NICE clinical guideline for the management of stable angina is currently being prepared.4 The chest pain guideline has two separate diagnostic pathways. The first is for patients with acute chest pain who may have an acute coronary syndrome (ACS), and the second for those with intermittent stable chest pain who may have stable angina. The need to provide information to patients (and, where appropriate, their family or carer/advocate) and to involve them in decisions is emphasised throughout. The recommendations around acute and ‘acute but not current’ (that is, recent pain but currently pain free) chest pain are summarised in Boxes 1 and 2. For chronic stable chest pain, a key aspect of the guideline of particular relevance to primary care is the recommendation that formal risk stratification of the likelihood of coronary artery disease (CAD) be undertaken, based on aspects of the history (Box 3 …

Newer agents for blood glucose control in type 2 diabetes: systematic review and economic evaluation

Exenatide, the gliptins and detemir were all clinically effective. The long-acting insulin analogues glargine and detemir appeared to have only slight clinical advantages over NPH, but had much higher costs and did not appear to be cost-effective as first-line insulins for type 2 diabetes. Neither did exenatide appear to be cost-effective compared with NPH but, when used as third drug after failure of dual oral combination therapy, exenatide appeared cost-effective relative to glargine in this analysis. The gliptins are similar to the glitazones in glycaemic control and costs, and appeared to have fewer long-term side effects. Therefore, it appears, as supported by recent NICE guidelines, that NPH should be the preferred first-line insulin for the treatment of type 2 diabetes. More economic analysis is required to establish when it becomes cost-effective to switch from NPH to a long-acting analogue. Also, long-term follow-up studies of exenatide and the gliptins, and data on combined insulin and exenatide treatment, would be useful.

NICE guidance on reducing the risk of venous thromboembolism in patients admitted to hospital

NICE guidance on reducing the risk of venous thromboembolism in patients admitted to hospital

Actual cost of providing long-acting reversible contraception: a study of Implanon® cost

BackgroundThe National Institute for Health and Clinical Excellence (NICE) has judged Implanon® to be the most cost effective of the long-acting reversible contraception (LARC) methods, and its cost effectiveness is...

Correction: surgery for obesity in adults

Our review on Surgery for obesity in adults (DTB 2008; 46: 41–5) incorrectly suggested that, in relation to advice from the National Institute for Health and Clinical Excellence (NICE), “PCTs...

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