National Institute Of Health And Clinical Excellence Research Articles

Hypertension guidelines: thresholds, targets, and teratogenicity

The current British Hypertension Society (BHS) Guidelines for the management of Hypertension run to an impressive 46 pages.1 The Quick Reference Guide on management of hypertension in adults in primary care published by the National Institute of Health and Clinical Excellence (NICE) in June 2006 is shorter at 11 pages.2 Both documents give essentially the same message about thresholds, treatments, and targets for hypertensive patients with the NICE guide providing easy to follow, colourful flow diagrams. By definition clinical guidelines need to be clear and user-friendly but I worry that important and subtle messages may be lost completely in the process. A case in point is the management of hypertension in young women of childbearing age. In the NICE Quick Reference Guide only one line mentions this group saying that beta blockers should be avoided in women of childbearing age. There is no mention of why and no reference to the potential dangers of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) should these women become pregnant. Research emerging in the early 1990s indicated a causative association between the use of ACE inhibitors during pregnancy and the development of severe fetal abnormalities. A significantly increased incidence of oligohydramnios, neonatal renal failure, pulmonary hypoplasia, calvarial hypoplasia, and fetal death were reported. These effects are thought to be the result of hypoperfusion of the fetal kidneys during development.3 The increased risk of fetal abnormalities was initially thought to be limited to women receiving ACE inhibitor therapy in the second and third trimesters of pregnancy. However, a more recent study has suggested a significantly increased risk (>2.7) of major congenital malformations in women receiving ACE inhibitor therapy in the first trimester of pregnancy.4 A higher incidence of fetal abnormalities in the offspring of women taking ARBs during pregnancy has also been noted.5 Current BHS guidelines recommend ACE inhibitors as first-line agents for younger, non-black patients but advise that these agents should be avoided in women who wish to become pregnant. The recommendations also state that ACE inhibitors and ARBs should be discontinued immediately if a woman were to become pregnant while receiving treatment with either agent. The Quick Reference NICE guidelines suggest beta blockers may have a role in younger women but do not specify why.2 Despite their known adverse effects, recent US data shows that 4.4% of women of childbearing age (15–44 years) take ACE inhibitors, reflecting an 83% increase in use from 1995–2002.6 In addition, a UK poll suggests that 40% of pregnancies are unplanned, with over half of these due to lack of contraception.7 At the Hypertension Clinic, University Hospital Birmingham we recently investigated the number of women of childbearing age (16–45 years), who had been prescribed ACE inhibitors or ARBs in primary care before referral.8 In addition, contraceptive use by these women was evaluated to assess whether adequate precautions were being taken to prevent pregnancy in these at-risk patients. A cohort of female patients aged 16–45 years was identified from approximately 1500 new referrals from January 2004 to October 2006, excluding those not taking antihypertensive medication. Contraceptive status was established where possible. Forty-seven of 101 (47%) women aged 16–45 years were taking an ACE inhibitor (n = 35) an ARB (n = 11) or both (n = 1) of whom 26 (55%) were aged 16–40 years. In this younger group, eight were using no contraception and three were using barrier methods only. In other words, one-quarter of women in the study were taking these agents and were aged 40 years or less; of these, many were not using reliable contraception. The study identifies a worrying trend to use ACE inhibitors or ARBs in younger women who are at risk of poor perinatal outcomes if they become pregnant. On the basis of this small study and my own clinical experience I feel that the BHS and NICE guidelines may put younger women at risk if doctors are unaware of potential fetotoxic and teratogenic consequences of prescribing ACE inhibitors and ARBs. When I give talks to GPs and hospital doctors, several colleagues confirm that they were previously unaware of such an association. A final point that the study highlighted was the surprising number of young women who were taking antihypertensives in the first place. This brings me on to thresholds for intervention, white coat hypertension, and appropriateness of treatment in this very low-risk group: important subjects for another Viewpoint, perhaps.

Dementia: symptoms, diagnosis and management

This article provides an overview of dementia. It looks at the incidence of dementia, the three main types of this condition and the suggested clinical management guidelines for Alzheimer's disease dementia, with specific focus on the main pharmacological approach to this condition. The management is discussed with specific reference to the National Institute of Health and Clinical Excellence (NICE) guidelines released in 2006 with regards to Alzheimer's disease dementia.

Welfarism, extra-welfarism and capability: The spread of ideas in health economics

This paper explores the spread of ideas within health economics, in relation to the impact of the capability approach to date and the extent to which it might impact in the future. The paper uses UK decision making to illustrate this spread of ideas. Within health economics, Culyer used the capability approach in developing the extra-welfarist perspective (where health status directly influences which social state is preferred). It is not a direct application of capability as the evaluation's focus remains narrow; the concern is with functioning, and maximisation is retained. Culyer's work provided a theoretical basis for using quality-adjusted life-years in decision making and this perspective is accepted as the basis for evaluation by the UK National Institute of Health and Clinical Excellence (NICE). To the extent that extra-welfarism represents a capability approach, capabilities influence NICE's decision making and hence UK health care provision. This paper explores the extent to which extra-welfarism draws on the capability approach; the spread of extra-welfarist ideas; and recent interest in more direct applications of the capability approach.

Economic evaluation of healthcare technologies using primary research

Clinicians and policy makers are often required to make difficult decisions regarding which health technologies they use. Increasingly, government bodies, such as the National Institute of Health and Clinical Excellence...

Back to basics – getting involved in public education

Being a doctor nowadays is not a role which automatically raises one's status and brings one respect. Our treatment plans and advice are no longer accepted without discussion and/or often compromise. Our patients are now familiar with technical jargon and often come to appointments armed with the ‘latest research’ or up-to-date National Institute of Health and Clinical Excellence (NICE) guidance, which can make such consultations feel more like flashbacks to the Part 2 clinical exam. With an increasingly informed and sometimes critical public regarding all aspects of health and medicine, it is imperative that we, as psychiatrists, are at the forefront of providing information about the illnesses and conditions we treat. Essentially, such information for the public must be easy to understand, accurate and unbiased.

New guidelines for osteoarthritis.

Patients should no longer be told that 'osteoarthritis is a natural part of getting old,' says Neil Betteridge, chief executive of Arthritis Care. Now, thanks to new guidelines published by the National Institute of Health and Clinical Excellence (NICE), they should never again hear that 'nothing can be done'.

Probable idiopathic intracranial hypertension in pre-pubertal children

We welcome the recommendation to discontinue routine antibiotic prophylaxis in paediatric urinary tract infection, as mentioned in a review of the National Institute of Health and Clinical Excellence (NICE) guidance...

A personal viewpoint against the motion that breast cancer patient advocacy groups unfairly distort the cancer budget

A personal viewpoint against the motion that breast cancer patient advocacy groups unfairly distort the cancer budget

Not a NICE CT protocol for the acutely head injured child

To assess the impact of the introduction of the Birmingham Children's Hospital (BCH) head injury computed tomography (CT) guidelines, when compared with the National Institute of Health and Clinical Excellence (NICE) guidelines, on the number of children with head injuries referred from the Emergency Department (ED) undergoing a CT examination of the head. All children attending BCH ED over a 6-month period with any severity of head injury were included in the study. ED case notes were reviewed and data were collected on a specifically designed proforma. Indications for a CT examination according to both NICE and BCH head injury guidelines and whether or not CT examinations were performed were recorded. A total of 1428 children attended the BCH ED following a head injury in the 6-month period. The median age was 4 years (range 6 days to 15 years) and 65% were boys. Four percent of children were referred for a CT using BCH guidelines and were appropriately examined. If the NICE guidelines had been strictly adhered to a further 8% of children would have undergone a CT examination of the head. All of these children were discharged without complication. The remaining 88% had no indication for CT examination by either BCH or NICE and appropriately did not undergo CT. Adherence to the NICE head injury guidelines would have resulted in a three-fold increase in the total number of CT examinations of the head. The BCH head injury guidelines are both safe and appropriate in the setting of a large children's hospital experienced in the management of children with head injuries.

Turning evidence into recommendations: Protocol of a study guideline development groups

BackgroundHealth care practice based on research evidence requires that evidence is synthesised, and that recommendations based on this evidence are implemented. It also requires an intermediate step: translating synthesised evidence into practice recommendations. There is considerable literature on evidence synthesis and implementation, but little on how guideline development groups (GDGs) produce recommendations. This is a complex process, with many influences on communication and decision-making, e.g., the quality of evidence, methods of presentation, practical/resource constraints, individual values, professional and scientific interests, social and psychological processes. To make this process more transparent and potentially effective, we need to understand these influences. Psychological theories of decision-making and social influence provide a framework for this understanding.ObjectivesThis study aims to investigate the processes by which GDGs formulate recommendations, drawing on psychological theories of decision-making and social influence. The findings will potentially inform the further evolution of GDG methods, such as choice of members and procedures for presenting evidence, conducting discussion and formulating recommendations.MethodsLongitudinal observation of the meetings of three National Institute of Health and Clinical Excellence (NICE) GDGs, one from each of acute, mental health and public health, will be tape recorded and transcribed. Interviews with a sample of GDG members at the beginning, middle, and end of the GDG's work will be recorded and transcribed. Site documents including relevant e-mail interchanges, GDG meeting minutes, and stakeholders' responses to the drafts of the recommendations will be collected. Data will be selected for analysis if they refer to either evidence or recommendations; the focus is on "hot spots", e.g., dilemmas, conflicts, and uncertainty. Data will be analysed thematically and by content analysis, drawing on psychological theories of decision-making and social influence.

Improving the quality of mental health care in primary care settings: a view from the United Kingdom

In the forty years since 'general practice' became a focus for research in psychiatry the UK there have been considerable developments in policy, practice and research. The aim of this paper is to review recent research and policy developments concerned with improving quality of mental health in primary care settings. Methods: Narrative review of the literature. Results: Disappointing results from large scales trials in the last decade have led to a move towards more exploratory studies and attempts to understand more about contextual factors. Policy initiatives such as the NICE (National Institute of Health and Clinical Excellence) guidelines have set clear standards for the delivery of care, but considerable variation in quality of care persists in primary care settings. The Medical Research Council of the UK has suggested a sequential model for future randomised trials of complex interventions. Conclusion: Major outstanding challenges are the difficulties in recruiting GPs (General Practitioners) into research studies who are not particularly interested in mental health and linking research and policy such that the findings of such studies are effectively implemented in everyday practice.

The role of NICE technology appraisal in NHS rationing

This article examines the role of National Institute of Health and Clinical Excellence (NICE) technology appraisal in detail, focussing on the process itself and the methods used to establish cost-effective practices for the National Health Service (NHS). Approaches to identifying both effective and cost-effective practices have become central to rationing decisions in the NHS. The establishment of the NICE, which produces guidance on what treatments should be provided by the NHS, represents the most visible approach to introducing economic considerations into these decisions. The decisions over which activities will be displaced by NICE approved treatments are made at a local level, while the cost-effectiveness threshold used to evaluate technologies is set nationally. This may result in treatments being displaced which are more cost-effective than those being introduced. AREAS TO DEVELOP RESEARCH: The introduction of programmes looking at disinvestment opportunities to help aid local decision makers is a key step in improving the allocation of NHS resources and removing geographical inequalities.

Hot and cold technologies for tissue ablation in urology

Increasingly, technology plays an important role in urology, and with this greater use comes the expected increase in regulation. Authors from the UK present a review of the physical properties of ablative technologies, evaluating efficacy and safety, and summarising guidance issued by the National Institute of Health and Clinical Excellence (NICE) where available. There are also reviews from the UK on haematuria, and on the pathology of bladder cancer from an international group of European authors.

Understanding multiple sclerosis

Multiple sclerosis generally starts in early adult life and affects more women than men. National Institute of Health and Clinical Excellence (NICE) (2003) estimates that ‘between three and seven people per 100,000 population are diagnosed with MS each year’. The Multiple Sclerosis Society (2005) describes it as ‘The most common neurological disorder among young adults, and affects around 2.5million people in the world, and 85 000 people in the UK. Every week around 50 people in the UK are diagnosed with MS. Diagnosis is usually between 20 and 40 years of age – rarely under 12 or over 55 years of age.’

The sour taste of cherry-picking

No one could have missed the news this week that β-blockers are to be phased out in the treatment of hypertension. The update of Hypertension: Management of Hypertension in Adults in Primary Care (National Institute of Health and Clinical Excellence (NICE), 2006) comes just two years after the original guidelines were published, and signify major changes in the treatment of high blood pressure.

Is ECT Cost-effective? A Critique of the National Institute of Health and Clinical Excellence's Report on the Economic Analysis of ECT

The report of the National Institute of Health and Clinical Excellence (NICE) on the economic analysis of electroconvulsive therapy (ECT) concludes that ECT and pharmacotherapy are "likely to be equally cost-effective" in the treatment of major depression. However, this economic analysis is acknowledged by the NICE report to be "crude and based on a number of uncertain assumptions." An evaluation by the Health Technology Assessment Committee of the National Coordinating Centre for Health Technology Assessment, commissioned and funded on behalf of NICE, provides a detailed cost comparison of ECT and pharmacotherapy in the treatment of major depression [Greenhalgh, Health Technol Assess, 9 (9) (2005) 1-156]. The Health Technology Assessment Committee analyzed data from separate studies of the efficacy of antidepressants and ECT. However, these data included few randomized controlled trials directly comparing the cost-effectiveness of ECT and medication in treatment-resistant depression. In the limited number of trials included in the report, there was a bias in favor of medication. For example, compared with the antidepressant trials, the ECT trials included more patients who had comorbid psychosis and treatment-resistant depression and would therefore have a more difficult treatment of depression. The Committee also evaluated data to determine that the relapse rate after pharmacological treatment is approximately 3 times the relapse rate after ECT. Although the report provides a format for analyzing the cost-effectiveness of ECT and recommends future directions for research, the conclusions reached by the Committee are relatively limited and should not be used as a template for future public policy.

Public health guidance and the role of new NICE

This paper describes the operating and methods for the newly established centre for Public Health Excellence in the National Institute of Health and Clinical Excellence (NICE). The origins of the establishment of this organisation are described and the types of public health guidance which will be produced are outlined. The Advisory Committee Structure for the new organisation is also presented. The importance of the application of evidence based guidance in public health is considered