National Institute For Health And Clinical Excellence Guidelines 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.

Clinical decision rules in predicting computed tomography scan findings and need for neurosurgical intervention in mild traumatic brain injury: a prospective observational study.

In this study, we will compare the diagnostic values of head CT decision rules in predicting the findings of CT scans in a prospective multicenter study in university emergency departments in Iran. The primary outcome was any traumatic lesion findings in brain CT scans, and the secondary outcomes were death, the need for mechanical ventilation, and neurosurgical intervention. Decision rules including the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), National Institute for Health and Clinical Excellence (NICE), National Emergency X-Radiography Utilization Study (NEXUS), and Neurotraumatology Committee of the World Federation of Neurosurgical Societies (NCWFNS) were compared for the main outcomes. In total, 434 mild TBI patients were enrolled in the study. The NCWFNS had the highest sensitivity (91.14%) and the lowest specificity (39.42%) for predicting abnormal finding in CT scan compared to other models. While the NICE obtained the lowest sensitivity (79.75%), it was associated with the highest specificity (66.67%). All model performances were improved when administered to predict neurosurgical intervention among patients with GCS 13-15. NEXUS (AUC 0.862, 95% CI 0.799-0.924) and NCWFNS (AUC 0.813, 95% CI 0.723-0.903) had the best performance among all evaluated models. The NCWFNS and the NEXUS decision rules performed better than the CCHR and NICE guidelines for predicting any lesion in the CT imaging and neurosurgical intervention among patients with mTBI with GCS 13-15. For a subset of mTBI patients with GCS 15, the NOC criteria havehigher sensitivity for abnormal CT imaging, but lower specificity and more requested CTs.

#3790 BASELINE BLOOD PRESSURE CONTROL IN THE NURTURE CKD COHORT STUDY

Abstract Background and Aims Blood pressure (BP) control is one of the most important therapeutic interventions in chronic kidney disease (CKD) and reduces cardiovascular morbidity, mortality and progression to end stage kidney disease. The optimal BP target for patients with CKD is debated, with several guidelines making different recommendations. This analysis of the UK multicentre NURTuRE CKD cohort study assessed achievement of BP targets and investigated associations with achieved BP. Method 2996 participants with CKD stages G3-4 or G1-2 plus albuminuria >30 mg/mmol were enrolled from 16 nephrology centres in the UK from 2017 to 2019. Medical history, demographic, biometric and laboratory samples were collected at baseline. BP was measured according to a standard operating procedure. Three measurements differing by <10% were recorded and the mean value used for analysis. BP control was assessed against the following guidelines: National Institute for Health and Clinical Excellence (NICE), Kidney Disease Improving Global Outcomes (KDIGO) 2012 and 2021 guidelines. Results 2992 participants had a baseline BP measurement and of these 59% were male, 53% were ≥65 years, 87% were of white ethnicity and 31% had diabetes. Median eGFR was 33.8 (24.0 to 46.6) ml/min/1.73m2. The mean systolic BP for the cohort was 139 ± 20 and diastolic 80 ± 12 mmHg. The characteristics of patients with a higher mean systolic BP included: ≥65 years, male sex, black ethnicity, diabetic, body mass index >30 kg/m2, a history of atherosclerotic cardiovascular disease, lower eGFR values and higher albuminuria category. Conversely, mean systolic BP was not associated with index of multiple deprivation quintiles, health literacy by the single-literacy item screener and smoking status. Achievement of BP targets is shown in Table 1. Of 2723 with centrally calculated urine albumin creatinine ratio (ACR) and BP data available, only 1036 participants (38.0%) met the NICE guideline recommended BP. For the KDIGO 2012 guideline, 794 participants (29.2%) achieved recommended BP control. For KDIGO 2021, only 420 participants (15.4%) met the standard of systolic BP <120mmHg. For those in the highest risk albuminuria category (A3) only 143 (18.6%) and 96 (12.5%) of participants met the KDIGO BP recommendations for 2012 and 2021, respectively. Conclusion BP control in the NUTuRE-CKD cohort at baseline was suboptimal when compared to all three major guidelines. Subgroups at highest risk of adverse outcomes demonstrated poorer BP control. Given the importance of BP control in people with CKD, further research into BP management approaches and barriers to achieving optimal control is required. Priority should be given to developing a patient-centred approach to reduce BP more effectively.

Real World Management of Anaphylaxis Versus the National Institute for Health and Clinical Excellence (NICE) Guidelines.

Objectives Anaphylaxis is an acute, life-threatening immediate allergic reaction caused by the sudden systemic release of mediators from mast cells. This study aims to assess the current practice of emergency management of children and adults diagnosed with anaphylaxis at the Royal Hospital, Muscat, Oman, in line with the National Institute for Health and Clinical Excellence (NICE) guidelines. MethodsThis is an observational retrospective study of all anaphylaxis cases seen at the emergency department (ED) from January 2013 to January 2018 and compared with the management of anaphylaxis in the ED as per the NICE guidelines. Inclusion criteria were all patients, children (age 16 and below), and adults diagnosed with anaphylaxis based on the World Allergy Organization (WAO) criteria. Exclusion criteria are all cases labeled as anaphylaxis that did not match the WAO criteria for anaphylaxis.ResultsOf 100 patients with a preliminary diagnosis of anaphylaxis, 49 patients (49%) were true-anaphylaxis cases based on the WAO definition 16 were children (age 16 years and below), and 33 were adults ( age 16 years and above). The other 51 patients (51%) with misdiagnosed anaphylaxis were later diagnosed with spontaneous urticaria, septic shock, vocal cord dysfunction, severe asthma, and anxiety attack. All 49 patients with true-anaphylaxis appropriately received adrenaline intramuscularly at the ED. All 16 children were admitted, seen by an allergist, and received an adrenaline auto-injector when indicated. Only 5 of the 33 adults were admitted and seen by an allergist, and 4 of those required an adrenaline auto-injector upon discharge. The remaining 28 adults were discharged from the ED, and only 3 of these were referred to the allergist. None received an adrenaline auto-injector upon discharge from the ED, and no mention in the ED notes on patient education regarding allergen avoidance.ConclusionThird of the patients who presented to ED were children (<16 years), and two third were adults. Insect venom was the main reason for anaphylaxis in both age groups. There was an underutilization of adrenaline auto-injector prescriptions for adult patients. This could be very well improved by disseminating policies and guidelines to adult physicians.

WE2.8 Improving Management for Acute Cholecystitis and Biliary Pancreatitis – the ‘Hot Gallbladder Pathway’

Abstract Aim There is a wide variation between National Health Service (NHS) hospitals in the management of patients with acute cholecystitis and biliary pancreatitis. 20–33% of patients will make repeat visits to hospital with gallstone-related symptoms before any surgical intervention performed. We established a ‘Hot Gallbladder Pathway’ with the aim for improving outcome and decreasing complications of these patients. The aim of this quality improvement project was to assess if a district general hospital (DGH) could provide a safe and effective ‘hot gallbladder’ service with a clear pathway. Method Quality improvement methods were used to integrate the ‘hot gallbladder pathway’ to manage patients with acute calculous cholecystitis and biliary pancreatitis. A prospective observational study with strict inclusion/ exclusion criteria and secure online data was conducted during a 13-month period. The data were then compared against existing National Institute for Health and Clinical Excellence (NICE) guidelines and further changes were recommended. Results We achieved almost 70% of the patients undergoing emergency laparoscopic cholecystectomy in both group of patients who met the pathway criteria within the expected time frame, compared with the pre-implementation result of 23% and national average of only 16% in England. None of the patients suffered from intraoperative complications or 30-day mortality. Conclusion A clear ‘hot gall bladder pathway’ is effective at improving care for patients requiring emergency laparoscopic cholecystectomy and potentially useful for other acute Trusts which their standard is below the NICE guideline.

Diseases of the Respiratory Tract: Asthma and Chronic Obstructive Pulmonary Disease

Short acting beta2-agonists (SABAs) such as salbutamol and terbutaline are commonly used in the treatment of asthma and chronic obstructive pulmonary disease (COPD). According to the guideline produced by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN), SABAs are considered to be the first line of treatment in asthma management. The National Institute for Health and Clinical Excellence (NICE) guidelines also recommend the use of SABA as the first line of treatment for managing patients with COPD. The recommendations in NICE guidelines state that in COPD patients, breathlessness and exercise limitation should be first medicated with short-acting bronchodilators (including beta2-agonists or anticholinergics) when it is required. Both salbutamol and terbutaline have been widely used for asthma and COPD, and they have been found to be extremely beneficial in the two pathologic conditions.

8 Improving Management for Acute Cholecystitis and Biliary Pancreatitis – the ‘Hot Gallbladder Pathway’

Abstract Aim There is a wide variation between National Health Service (NHS) hospitals in the management of patients with acute cholecystitis and biliary pancreatitis. 20–33% of patients will make repeat visits to hospital with gallstone-related symptoms before any surgical intervention performed. We established a ‘Hot Gallbladder Pathway’ with the aim for improving outcome and decreasing complications of these patients. The aim of this quality improvement project was to assess if a district general hospital (DGH) could provide a safe and effective ‘hot gallbladder’ service with a clear pathway. Method Quality improvement methods were used to integrate the ‘hot gallbladder pathway’ to manage patients with acute calculous cholecystitis and biliary pancreatitis. A prospective observational study with strict inclusion/ exclusion criteria and secure online data was conducted during a 13-month period. The data were then compared against existing National Institute for Health and Clinical Excellence (NICE) guidelines and further changes were recommended. Results We achieved almost 70% of the patients undergoing emergency laparoscopic cholecystectomy in both group of patients who met the pathway criteria within the expected time frame, compared with the pre-implementation result of 23% and national average of only 16% in England. None of the patients suffered from intraoperative complications or 30-day mortality. Conclusions A clear ‘hot gall bladder pathway’ is effective at improving care for patients requiring emergency laparoscopic cholecystectomy and potentially useful for other acute Trusts which their standard is below the NICE guideline.

Letter to the Editor: Rethinking The Cost Of Antipsychotic Treatment: The Average Cost Of The Drugs Used In Turkey In 2020.

Letter to the Editor: Rethinking The Cost Of Antipsychotic Treatment: The Average Cost Of The Drugs Used In Turkey In 2020.

Impact of the national sarcoma guidelines on the prevalence and outcome of inadvertent excisions of soft tissue sarcomas: An observational study from a UK tertiary referral centre

ObjectivesThis study aims to investigate the impact of the national guideline on the prevalence and outcome in patients with soft-tissue sarcoma (STS) who had undergone inadvertent excisions. MethodsA total of 2336 patients were referred to a tertiary sarcoma centre from six regions (North East, North West, East Midlands, West Midlands, Wales, and South West) in the United Kingdom with a diagnosis of STS between 1996 and 2016, of whom 561 patients (24.0%) had undergone inadvertent excisions. Patients were categorised into two groups of 10-year periods pre and post the National Institute for Health and Clinical Excellence (NICE) guideline implementation in 2006. ResultsThe proportion of inadvertent excisions decreased after the NICE guideline implementation: 27.2% (pre-NICE) versus 19.8% (post-NICE) (p = 0.001). A substantial regional variation (17.4%–34.5%) in the proportion of inadvertent excisions in the pre-NICE era was reduced in the post-NICE era (14.3%–22.4%). The 5-year disease-specific survival was 77.7% (pre-NICE) versus 75.6% (post-NICE) (p = 0.961) and there was a trend toward lower incidence of local recurrence in the post-NICE era; 13.5% (pre-NICE) versus 10.5% (post-NICE) (p = 0.522). Multivariate analyses revealed that residual tumours in re-resection specimens were independently associated with an increased risk of disease-specific mortality (HR, 3.35; p < 0.001) and local recurrence (HR, 1.99; p = 0.017), which was significantly reduced after the NICE guideline implementation (53.2% versus 42.0%; p = 0.022). ConclusionsThe NICE guideline implementation reduced the proportion of patients with STS who had undergone inadvertent excisions and residual tumour in re-resection specimens, indicating an improved pre-referral management of STSs.

Impact of implementation of the national institute for health and clinical excellence (NICE) head injury guideline in a tertiary care center emergency department: A pre and post-intervention study.

Head injury, a common presentation to the emergency department (ED), is a substantial problem in developing countries like Nepal. The current national institute for health and clinical excellence (NICE) guideline revised in January 2014 focuses on effective clinical assessment and early management of head injuries according to their severity in all age groups. This study assessed the impact of implementing this guideline on the proportions of computed tomography (CT) head scans, guideline adherence, and confidence level of the attending physicians. We consecutively recruited 139 traumatic head injury (THI) patients in this prospective pre-post interventional study conducted in the ED of a tertiary care center. We implemented the NICE guideline into routine practice using multimodal intervention through physicians' education sessions, information sheets and guideline-dissemination. The pre and post-implementation CT head scan rates were compared. The post-implementation guideline adherence was assessed. Online Google form-questionnaires including 12 validated case scenarios were distributed to the attending physicians at the end of both phases to assess their confidence levels. The implementation resulted in a statistically significant decrease in the proportion of CT head scan rates from 92.0% to 70.0% (p-value = 0.005). Following educational interventions, improved guideline adherence of 20.3 percentage points (p-value = 0.001) was observed. Nine ED attending physicians were enrolled in the study who showed statistically significant improvement in their confidence level following the intervention. The NICE guideline showed a sensitivity and specificity of 93.6% and 76.4% with 82.6% accuracy compared to that of clinical judgment (100%, 34.6%, and 58.1% respectively) in detecting intracranial lesions. The implementation was successful in satisfying the aim of the NICE guideline by decreasing the proportion of CT head scans, improving guideline adherence and increasing the confidence of the attending physicians.

Evaluation of a specialist service model for treating body dysmorphic disorder (BDD): application of National Institute for Health and Clinical Excellence Guidelines for BDD (NICE, 2006)

AimsBody dysmorphic disorder (BDD) is still poorly recognised with a dearth of research into treatment. The OCD/BDD Service (South West London St. George's Mental Health NHS Trust) is a specialist service offering treatment for BDD using the National Institute for Health and Clinical Excellence (NICE) stepped care model for BDD as a basis for service provision.This is the only known study to date to evaluate the implementation of the NICE guidelines recommended treatment for BDD in clinical practice. Furthermore, a sample of patients and clinicians were interviewed to elicit their evaluation of treatment.MethodA total of 48 patients with a primary diagnosis of BDD who were offered treatment between 2006 and 2018 were identified. Questionnaires routinely completed at time of assessment were Yale Brown Obsessive Compulsive Scale for BDD (YBOCS-BDD); Montgomery-Asberg Depression Rating Scale (MADRS); Beck Depression Inventory (BDI) and Sheehan Disability Scale (SDS). Assessments were conducted by clinicians with expertise in BDD. Clinical data including risks and sociodemographic information were collated and analysed. Data were examined with intention to treat analysis. Thematic Analysis (TA) was used to analyse data from semi-structured interviews conducted with ten clinical staff and seven patients regarding their experiences of treatment. Qualitative data were coded and themes identified.ResultClinical data at assessment indicated impaired functioning plus high risks and substance misuse. There was a higher percentage of females (58%); average duration of BDD was 19.23 years. Clinical outcomes indicated significant improvements in the total sample from baseline on measures of BDD, depression and functioning (p = 0.001). Patients described their progress in terms of living skills, social interactions and quality of life. The main themes identified included the significance of the therapeutic relationship expressed by both patients and clinicians; the lack of early intervention and knowledge of BDD in healthcare.ConclusionCurrent recommendations for treating BDD were found to be beneficial overall. However, there are patients who are non-responders and including experiences of patients’ and clinicians’ perspectives provided valuable insights into other options for treatment which are lacking and could enhance current recommendations where CBT and medication have not enabled progress. The young onset age with long duration, highlights the need for developing awareness of BDD so that it is not a hidden disorder.

Standards for lithium monitoring. “Are we good at adhering to these standards in Lanarkshire”?

AimsThe National Institute for Health and Clinical Excellence (NICE) recommend that renal and thyroid function must be checked before lithium is prescribed and for all patients who are prescribed lithium should have their renal and thyroid function checked every six months, and their serum lithium checked every three months. The aim of this audit is to ascertain whether or not routine blood monitoring for bipolar disorder patients, taking lithium is in keeping with the guidelines.BackgroundLithium has been a mainstay in the management of bipolar disorder since the 1970's; indeed, lithium carbonate was first used in the early 1880's for the treatment of mania. Despite its usefulness however, the drawback of lithium treatment remains its very narrow therapeutic index, toxic side effects and as such its need for close therapeutic monitoring.MethodA list of patients with a diagnosis of bipolar disorder being treated with lithium was collated from an electronic database of psychiatry patients in Cumbernauld Community and inpatients at Glencairn unit Coathill Hospital and Cleland Hospital. A retrospective analysis using Clinical Portal was conducted looking at blood results; Lithium levels checked 3 times a year and Kidney functions and Thyroid function checked twice a year, over the previous year. Our results were then compared to the NICE Guidelines for lithium monitoring to see if they complied with the expected routine monitoring schedule. We may have missed patients open to Community Psychiatric Nurses (CPN) but not open to Consultant psychiatrists. Other group that might have been missed could be open to General Practitioners but not to secondary care. We attempted to contact them but this was unsuccessful.ResultTotal of 690 patients were studied. Of 690 patients 51 patients had the diagnosis of Bipolar Affective Disorder. 49 percent of them were prescribed Lithium. 48percent had their Lithium bloods checked and 60 percent had their Kidney function and thyroid functions checked according to the guidelines. There were no data available for around 7 percent of patients but their Lithium levels were indicated only in Clinical notes.ConclusionThis audit has demonstrated that Lithium monitoring falls short of conforming to accepted standards. Data obtained by this audit have prompted an electronic alert system for patients on Lithium endorsing primary care, mental health and laboratory staff to work together to ensure supporting recommended Lithium monitoring.

Using clinical guidelines to assess the potential value of laboratory medicine in clinical decision-making.

IntroductionIt is often quoted that 70% of clinical decisions are based on laboratory results, but the evidence to substantiate this claim is lacking. Since clinical guidelines aim to document best-practice decision making for specific disease conditions, inclusion of any laboratory test means that the best available evidence is recommending clinicians use it. Cardiovascular disease (CVD) is the world’s most common cause of mortality, so this study reviewed all CVD guidelines published by five national/international authorities to determine what proportion of them recommended laboratory testing.Materials and methodsFive leading CVD guidelines were examined, namely the European Society of Cardiology (ESC), the UK National Institute for Health and Clinical Excellence (NICE), the American College of Cardiology (ACC), the Australian Heart Foundation (AHF) and the Cardiac Society of Australia and New Zealand (CSANZ).ResultsA total of 101 guidelines were reviewed. Of the 33 individual ESC guidelines relating to CVD, 24/33 made a direct reference to the use of clinical laboratory tests in either diagnosis or follow-up treatment. The same applied to 15/20 of NICE guidelines, 24/32 from the ACC and 15/16 from the AHF/CSANZ. Renal function and blood count testing were the most recommended (39 and 26 times), with lipid, troponin and natriuretic peptide measurement advocated 25, 19 and 19 times respectively.ConclusionsThis study has shown that laboratory testing is advocated by between 73% and 94% of individual CVD guideline recommendations from five national/international authorities. This provides an index to assess the potential value of laboratory medicine to healthcare.

Suicide in England in the COVID-19 Pandemic: Early Figures from Real Time Surveillance

Background: There are concerns that the COVID-19 pandemic may lead to an increase in suicide. The coronial system in England is not suitable for close monitoring of suicide because of the frequent gap of several months before inquests are held. Methods: We used data from established systems of "real time surveillance" (RTS) of suspected suicides, in areas covering a total population of around 13 million, to examine for any increase after the first national lockdown in England. Outcomes: The average monthly number of suicides in the months before lockdown, January-March 2020, was 125·7, compared to 121·3 in April-October 2020 (-4%; 95% CI -19% to 13%, p=0·59). Incidence rate ratios did not rise significantly in individual months after lockdown began and were not raised during the 2-month lockdown period April-May 2020 or the 5-month period after the easing of lockdown, June-October 2020 (IRR: 1·00 [0·8-1·25] and 0·94 [0·81-1·08]). Comparison of the suicide rates after lockdown in 2020 for the same months in selected areas in 2019 showed no difference. Interpretation: We did not find a rise in suicide in England in the months after the first national lockdown began in 2020, despite evidence of greater distress. However, a number of caveats should be noted. These are early figures and may change. Any effect of the pandemic may vary by population group or geographical area. The use of RTS in this way is new and further development is needed before it can provide full national data. Funding: The study was carried out as part of the role of the National Confidential Inquiry into Suicide and Safety in Mental Health in supporting suicide prevention in England, funded by NHS England/NHS Improvement.Declaration of Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: LA chairs the National Suicide Prevention Strategy Advisory Group (NSPSAG) at the Department of Health and Social Care in England; NK is a member of the Group, chaired the guideline development group for the 2012 National Institute for Health and Clinical Excellence (NICE) guidelines on the longer-term management of self-harm, currently chairs the guideline development group for the NICE depression in adults’ guidelines, is currently the topic advisor on the new NICE guideline on self-harm, and reports grants from the Department of Health and Social Care, National Institute of Health Research and NICE. All authors work with NHS England on the National Quality Improvement initiatives for suicide and self-harm. LA, NK, and PT report grants from the Health Quality Improvement Partnership.

Refeeding hypophosphataemia in patients on parenteral nutrition: Prevalence, risk factors and predicting its occurrence

Rationale: Patients on parenteral nutrition (PN) may develop refeeding hypophosphataemia (RH) and manifest clinical complications. To assess RH, several diagnostic criteria are used which may account to the highly variable prevalence in the literature (15–62%)1. To identify at-risk patients, the National Institute for Health and Clinical Excellence (NICE) guidelines is used widely but lacks validation. We aim to: 1) determine if the prevalence of RH is influenced by different diagnostic criteria; 2) validate the prognostic accuracy of the NICE guidelines in predicting RH; and 3) identify important risk factors for a new model to better predict RH.

Impact of the updated NICE referral pathway for patients with suspected brain cancer on a neuroscience service

Introduction The National Institute for Health and Clinical Excellence (NICE) publish guidelines to facilitate the referral of patients with suspected malignancies, including CNS tumours, from primary care to the appropriate hospital services. We aimed to assess the impact and utility of the most recently revised guidelines, published in 2015, on our neurosurgical service. Materials & methods We performed a retrospective analysis of the 2-week wait (2WW) referrals received by the neurosurgery department at our institution over a 3 and a half year period between 2015 and 2019. Details pertaining to the patient’s clinical condition and ultimate diagnosis were collected from their medical records and assessed to determine whether the referral criteria were fulfilled. Results Referrals for 101 patients were received over the study period (mean 29/year). Of these, 82 patients (81.2%) were referred based on symptoms, whilst 19 patients (18.8%) were referred with an abnormal brain scan. Seventy-five referrals (74%) were deemed compliant with the guideline criteria. The sensitivity and specificity of the updated guidelines was 90% (73–98%, 95% CI) and 32.4% (22–45%, 95% CI) respectively. The commonest reason for a non-compliant referral, in 21 cases (81%), was headache disorder without neurological deficit. Overall, 30 patients (30%) referred via the 2WW rule were found to have a brain tumour. With guideline adherence, the brain tumour detection rate was 3-fold higher (36.0% vs 11.5%, p = 0.02). Conclusions An update to the NICE guidelines has coincided with an increase in the number of 2WW referrals received by our department, an increase in guideline compliant referrals and an improved rate of tumour detection, though a significant proportion of patients referred via this route ultimately do not require the services of a neurosurgeon. Greater provision of urgent imaging for general practitioners, in accordance with the current NICE guidelines, may reduce unnecessary neurosurgery consultations.

Refeeding Hypophosphatemia in Patients Receiving Parenteral Nutrition: Prevalence, Risk Factors, and Predicting Its Occurrence.

Patients receiving parenteral nutrition (PN) support may develop refeeding hypophosphatemia (RH), and its prevalence is highly variable in the literature. Identifying at-risk patients is crucial to minimize clinical complications. The National Institute for Health and Clinical Excellence (NICE) guidelines are used widely to assess the risk of RH, but they lack validation. We aim to (1) identify the prevalence of RH by multiple diagnostic criteria; (2) assess the predictive ability of the NICE guidelines for RH; and (3) identify important risk factors for RH and evaluate their predictive abilities for RH in a new model. This is a single-center retrospective study on adult patients with PN ≥48 hours. Prevalence of RH was determined by 4 established diagnostic criteria. Prognostic accuracy of the NICE guidelines were assessed by the area under the receiver operating characteristic (ROC) curve. Multivariable logistic regressions were performed to develop a new risk-assessment model. Of 149 enrolled patients, 23%-48% (35 to 72 of 149 patients) developed RH (depending on the diagnostic criteria used). The NICE guidelines demonstrated poor discrimination across all diagnostic criteria (ROC, 0.43-0.53). Critical illness, the use of diuretics, and hypomagnesemia prior to PN were independently associated with RH. These risk factors formed the new model for predicting RH and had good discrimination (ROC 0.74; 95% confidence interval, 0.66-0.82). Prevalence of RH varied according to established diagnostic criteria. The current NICE guidelines poorly predict the occurrence of RH, and modification is likely beneficial. A new risk-assessment model was developed; nevertheless, further validation is required.

Analysis of a pancreatic cancer diagnostic pathway in the UK compared to national NICE guidelines: A single institution experience

Purpose: Diagnostic workup of patients with pancreatic cancer is complex. The National Institute for Health and Clinical Excellence (NICE) updated guidelines in 2018 to ensure patients receive consistent and timely diagnosis and management. Moreover, the impending Faster Diagnosis Standard requires complete work-up within 28 days.

Understanding the contribution of UK public health research to clinical guidelines: a bibliometric analysis

Background: There is an increasing need to understand the wider impacts of research on society and the economy. For health research, a key focus is understanding the impact of research on practice and ultimately on patient outcomes. This can be challenging to measure, but one useful proxy for changes in practice is impact on guidelines. Methods: The aim of this study is to map the contribution of UK research and UK research funders to the National Institute for Health and Clinical Excellence (NICE) public health guidelines, understanding areas of strengths and weakness and the level of collaboration and coordination across countries and between funders. The work consisted of two main elements: analysis of the references cited on NICE guidelines and interviews with experts in public health. Results: Across the papers cited on 62 NICE public health guidelines, we find that 28% of the papers matched include at least one UK affiliation, which is relatively high when compared to other health fields. In total, 165 unique funders were identified with more than three acknowledgements, based in 20 countries. 68% of papers which acknowledge funding cite at least one UK funder, and NIHR is the most highly cited funder in the sample. Conclusions: The UK makes an important contribution to public health research cited on NICE PH guidelines, although the research does not appear to be bibliometrically distinct from other research sectors, other than having a relatively low level of international collaboration. However, the extent to which NICE public health guidelines reflect practice at the local authority level is less clear. More research is needed to understand the sources of evidence to support public health decision making at the local level and how NICE guidance can be made more applicable, timely and accessible in this new context.

Understanding the contribution of UK public health research to clinical guidelines: a bibliometric analysis.

Background:There is an increasing need to understand the wider impacts of research on society and the economy. For health research, a key focus is understanding the impact of research on practice and ultimately on patient outcomes. This can be challenging to measure, but one useful proxy for changes in practice is impact on guidelines. Methods:The aim of this study is to map the contribution of UK research and UK research funders to the National Institute for Health and Clinical Excellence (NICE) public health guidelines, understanding areas of strengths and weakness and the level of collaboration and coordination across countries and between funders. The work consisted of two main elements: analysis of the references cited on NICE guidelines and interviews with experts in public health. Results:Across the papers cited on 62 NICE public health guidelines, we find that 28% of the papers matched include at least one UK affiliation, which is relatively high when compared to other health fields. In total, 165 unique funders were identified with more than three acknowledgements, based in 20 countries. 68% of papers which acknowledge funding cite at least one UK funder, and NIHR is the most highly cited funder in the sample. Conclusions:The UK makes an important contribution to public health research cited on NICE PH guidelines, although the research does not appear to be bibliometrically distinct from other research sectors, other than having a relatively low level of international collaboration. However, the extent to which NICE public health guidelines reflect practice at the local authority level is less clear. More research is needed to understand the sources of evidence to support public health decision making at the local level and how NICE guidance can be made more applicable, timely and accessible in this new context.