How guidance on the use of interventional procedures is produced in different countries: An international survey

NICE guidance on interventional procedures: the perspectives of a new Clinical Advisor

A commitment to delivering the very best care to patients is central to the work of all clinicians. The introduction of new interventional procedures to clinical practice is essential to improve patient care. Yet, history tells us that when interventional procedures are introduced without due regard to their efficacy and safety there can be significant adverse consequences for the patient (DH 2001). Nearly three decades ago the concept of Clinical Governance was introduced to the NHS to address these concerns. The aim was to allow continuous improvement in the quality of services while safeguarding patient safety and ensuring high standards of care (Scally and Donaldson 1998).

Public consultation changes guidance on the use of health-care interventions. An observational study

Objectives

To investigate the responses to public consultation on draft guidance on interventional procedures (IP) for the UK National Health Services, and the changes made as a result of consultation.

Design

Retrospective review of responses received during public consultation for 183 pieces of draft guidance, and subsequent changes made.

Setting

The National Institute for Health and Care Excellence in the UK. Guidance produced December 2009–December 2014.

Main outcome measures

Numbers (%) of public consultations receiving responses, and resulting changes made to draft guidance.

Results

Responses were received during 159 (86.9%) periods of public consultation, from a total of 853 people or organizations (median number per consultation 3; range 0–82; interquartile range 1–5). Changes were made to draft guidance following 136 (74.3%) consultations. These changes were to the category (2.7%) or wording (8.7%) of the main recommendation; to other recommendations (about consent, patient selection, training and future research) (31.1%); and to other sections of guidance (description of the procedure and of the evidence on its efficacy and safety) (70.5%). Additional published evidence was proffered for 22.4%. Health‐care professionals or their specialist societies were the most frequent responders to consultation (68.8%), patients or patient organizations accounted for 22.4% and medical device companies accounted for 8.8%.

Conclusions

This study shows substantial engagement with public consultation and frequent changes made to draft guidance as a result. These findings are likely to be relevant to other areas of health‐care and national policymaking that seek to be responsive to their stakeholders.

IDENTIFYING AND SELECTING NEW PROCEDURES FOR HEALTH TECHNOLOGY ASSESSMENT: A DECADE OF NICE EXPERIENCE IN THE UNITED KINGDOM

Objectives: The aim of this study was to analyze the experience of the National Institute for Health and Care Excellence (NICE) in identifying new procedures entering the United Kingdom (UK) healthcare system, for assessment and publication of recommendations on their use. This system is designed to provide guidance in an area where regulation is lacking worldwide.

Methods: Retrospective analysis of all procedures notified to the Interventional Procedures Programme (NICE) between 2002 and 2012. Notifications were analyzed year by year for their source (who notified them), clinical specialties involved, and whether guidance was subsequently published.

Results: A total of 1,094 procedures were notified by clinicians (51 percent), and by others, including hospitals (6 percent), horizon scanners (5 percent), patients (4 percent), private health insurers (4 percent), and medical device manufacturers (3 percent). Guidance was published on 44 percent of procedures notified to the program. There was a decrease in the numbers of procedures notified during 2003–2012 (p = .049). There were notifications across all specialties, with the largest numbers in general surgery (125), urology (104), orthopedics (99), interventional radiology (93), cardiology (82), and obstetrics and gynecology (82).

Conclusions: The “open” NICE Web portal allows anyone to notify new procedures, aiming to maximize the opportunity of identifying all those procedures entering clinical practice. This has resulted in identification of large numbers of procedures from across the whole range of medical specialties. The fact that similar proportions of procedures notified from diverse sources have been selected for assessment and publication of practice recommendations suggests that this inclusive approach is worthwhile.

Strategies to improve clinical research in surgery through international collaboration

More than 235 million patients undergo surgery every year worldwide, but less than 1% are enrolled in surgical clinical trials--few of which are international collaborations. Several levels of action are needed to improve this situation. International research collaborations in surgery between developed and developing countries could encourage capacity building and quality improvement, and mutually enhance care for patients with surgical disorders. Low-income and middle-income countries increasingly report much the same range of surgical diseases as do high-income countries (eg, cancer, cardiovascular disease, and the surgical sequelae of metabolic syndrome); collaboration is therefore of mutual interest. Large multinational trials that cross cultures and levels of socioeconomic development might have faster results and wider applicability than do single-country trials. Surgeons educated in research methods, and aided by research networks and trial centres, are needed to foster these international collaborations. Barriers to collaboration could be overcome by adoption of global strategies for regulation, health insurance, ethical approval, and indemnity coverage for doctors.

Regulation and safe adoption of new medical devices and procedures

BACKGROUND

Recent problems with medical devices have highlighted the need for improved surveillance. New procedures are largely unregulated.

SOURCES OF DATA

Information from regulators. Guidance produced by the National Institute for Health and Care Excellence Interventional Procedures and Medical Technologies Advisory Committees and the evidence used in their evaluations.

AREAS OF AGREEMENT

More and better evidence is required for new medical devices and procedures when they are introduced into practice. Routine collection of observational data on outcomes should be improved.

AREAS OF CONTROVERSY

How best to protect patients from harm while allowing rapid access to potentially beneficial interventions.

GROWING POINTS

Establishing systems for good data collection on the use of devices and procedures.

AREAS TIMELY FOR DEVELOPING RESEARCH

How to accrue more and better evidence about devices and procedures through clinical trials and various avenues of observational data collection.

Comparison of the assessment of five new interventional procedures in different countries

Objectives: The aim of this study was to identify and compare health technology assessments of the same new interventional procedures produced in different countries.

Methods: We selected five new interventional procedures and studied related assessments produced in different countries.

Results: There were twenty assessments (range, 3–5 per procedure) from nine countries—fourteen from Australia, Canada, and United Kingdom. The number of primary RCTs cited by the assessments ranged from 0 to 13. In the assessment reports, “headline” statements about the strength of evidence for efficacy (73 percent) were made more frequently than for safety (53 percent). These statements were scored for their apparent judgment of the strength of the evidence—1 (poor) to 5 (strong)—and received scores of 3 or less in all but four cases. Recommendations about additional research were included in 55 percent of the assessments. Statements in assessments about other aspects of use of the procedures were included more infrequently—in 35 percent for patient selection, in 20 percent for consent issues, and in 15 percent for types of clinical teams. Recommendations about appropriate healthcare settings, or about operator training, were included only in assessments produced by a single organization.

Conclusion: There was a only small number of assessments world-wide, for a range of new procedures with potentially high impact. Where available, assessments were produced on a relatively poor evidence base. International collaboration in evidence appraisal and review, and in the gathering of new data through research or registers, could improve the advice available to healthcare systems worldwide about the adoption of new interventional procedures.

Evaluation and stages of surgical innovations

Surgical innovation is an important part of surgical practice. Its assessment is complex because of idiosyncrasies related to surgical practice, but necessary so that introduction and adoption of surgical innovations can derive from evidence-based principles rather than trial and error. A regulatory framework is also desirable to protect patients against the potential harms of any novel procedure. In this first of three Series papers on surgical innovation and evaluation, we propose a five-stage paradigm to describe the development of innovative surgical procedures.

Challenges in evaluating surgical innovation

Research on surgical interventions is associated with several methodological and practical challenges of which few, if any, apply only to surgery. However, surgical evaluation is especially demanding because many of these challenges coincide. In this report, the second of three on surgical innovation and evaluation, we discuss obstacles related to the study design of randomised controlled trials and non-randomised studies assessing surgical interventions. We also describe the issues related to the nature of surgical procedures-for example, their complexity, surgeon-related factors, and the range of outcomes. Although difficult, surgical evaluation is achievable and necessary. Solutions tailored to surgical research and a framework for generating evidence on which to base surgical practice are essential.