Neonatal outcomes according to different glucose threshold values in gestational diabetes: a register-based study

BACKGROUND

Mild hyperglycaemia is associated with increased birth weight but association with other neonatal outcomes is controversial. We aimed to study neonatal outcomes in untreated mild hyperglycaemia using different oral glucose tolerance test (OGTT) thresholds.

METHODS

This register-based study included all (n = 4,939) singleton pregnant women participating a 75 g 2-h OGTT in six delivery hospitals in Finland in 2009. Finnish diagnostic cut-offs for GDM were fasting ≥ 5.3, 1 h ≥ 10.0 or 2-h glucose ≥ 8.6 mmol/L. Women who did not meet these criteria but met the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria (fasting 5.1-5.2 mmol/L and/or 2-h glucose 8.5 mmol/L, n = 509) or the National Institute for Health and Clinical Excellence (NICE) criteria (2-h glucose 7.8-8.5 mmol/L, n = 166) were considered as mild untreated hyperglycaemia. Women who met both the Finnish criteria and the IADPSG or the NICE criteria were considered as treated GDM groups (n = 1292 and n = 612, respectively). Controls were normoglycaemic according to all criteria (fasting glucose < 5.1 mmol/L, 1-h glucose < 10.0 mmol/L and 2-h glucose < 8.5 mmol/L, n = 3031). Untreated mild hyperglycemia groups were compared to controls and treated GDM groups. The primary outcome - a composite of adverse neonatal outcomes, including neonatal hypoglycaemia, hyperbilirubinaemia, birth trauma or perinatal mortality - was analysed using multivariate logistic regression.

RESULTS

The risk for the adverse neonatal outcome in untreated mild hyperglycemia was not increased compared to controls (adjusted odds ratio [aOR]: 1.01, 95% confidence interval [CI]: 0.71-1.44, using the IADPSG criteria; aOR: 1.05, 95% CI: 0.60-1.85, using the NICE criteria). The risk was lower compared to the treated IADPSG (aOR 0.38, 95% CI 0.27-0.53) or the treated NICE group (aOR 0.32, 95% CI 0.18-0.57).

DISCUSSION

The risk of adverse neonatal outcomes was not increased in mild untreated hyperglycaemia compared to normoglycaemic controls and was lower than in the treated GDM groups. The OGTT cut-offs of 5.3 mmol/L at fasting and 8.6 mmol/L at 2 h seem to sufficiently identify clinically relevant GDM, without excluding neonates with a risk of adverse outcomes.

Understanding the National Institute for Health and Care Excellence Severity Premium: Exploring Its Implementation and the Implications for Decision Making and Patient Access

OBJECTIVES

This study aimed to evaluate the impact of the National Institute for Health and Care Excellence's (NICE) new severity modifier, which has replaced the end-of-life (EoL) premium, on future NICE recommendations, considering past decision-making patterns.

METHODS

NICE technology appraisals (TAs) published between January 2020 and December 2022 were reviewed. Summary statistics were generated to assess how the new severity modifier might affect hypothetical decision making in historical TAs.

RESULTS

A total of 138 data points were identified from 132 TAs. Although the EoL premium was applied in 46 appraisals (33%), 57 (39%) qualify for a severity-based quality-adjusted life-year (QALY) multiplier. Only 19 appraisals (14.6%) not receiving an EoL premium met the severity criteria, the majority (17) qualifying for a 1.2× multiplier. In appraisals predicted to meet the severity criteria, 45 (79%) were in oncology, making them 4.04 times (95% CI 1.91-9.02) more likely to qualify for a severity modifier than nononcology indications. Among historically EoL indications, 42 (91%) were predicted to meet the severity criteria, making them 14.8 times (95% CI 6.37-37.6) more likely to qualify for a severity modifier.

CONCLUSIONS

The new severity modifier will predominantly benefit oncology indications, continuing their previous explicit prioritization under the EoL decision modifier. However, the new severity modifier is harder to achieve and less generous; only a fraction of appraisals qualify for the highest effective £51 000 per QALY threshold. The vast majority of indications previously approved at £50 000 per QALY would now need to meet a cost-effectiveness threshold of <£36 000. This may necessitate greater pricing flexibility from manufacturers and increase the likelihood of negative recommendations.

Ovarian cancer symptoms in pre-clinical invasive epithelial ovarian cancer - An exploratory analysis nested within the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

OBJECTIVE

UKCTOCS provides an opportunity to explore symptoms in preclinical invasive epithelial ovarian cancer (iEOC). We report on symptoms in women with pre-clinical (screen-detected) cancers (PC) compared to clinically diagnosed (CD) cancers.

METHODS

In UKCTOCS, 202638 postmenopausal women, aged 50-74 were randomly allocated (April 17, 2001-September 29, 2005) 2:1:1 to no screening or annual screening till Dec 31,2011, using a multimodal or ultrasound strategy. Follow-up was through national registries. An outcomes committee adjudicated on OC diagnosis, histotype, stage. Eligible women were those diagnosed with iEOC at primary censorship (Dec 31, 2014). Symptom details were extracted from trial clinical-assessment forms and medical records. Descriptive statistics were used to compare symptoms in PC versus CD women with early (I/II) and advanced (III/IV/unable to stage) stage high-grade-serous (HGSC) cancer. ISRCTN-22488978; ClinicalTrials.gov-NCT00058032.

RESULTS

1133 (286PC; 847CD) women developed iEOC. Median age (years) at diagnosis was earlier in PC compared to CD (66.8PC, 68.7CD, p = 0.0001) group. In the PC group, 48% (112/234; 90%, 660/730CD) reported symptoms when questioned. Half PC (50%, 13/26PC; 36%, 29/80CD; p = 0.213) women with symptomatic HGSC had >1symptom, with abdominal symptoms most common, both in early (62%, 16/26, PC; 53% 42/80, CD; p = 0.421) and advanced (57%, 49/86, PC; 74%, 431/580, CD; p = 0.001) stages. In symptomatic early-stage HGSC, compared to CD, PC women reported more gastrointestinal (change in bowel habits and dyspepsia) (35%, 9/26PC; 9%, 7/80CD; p = 0.001) and systemic (mostly lethargy/tiredness) (27%, 7/26PC; 9%, 7/80CD; p = 0.017) symptoms.

CONCLUSIONS

Our findings, add to the growing evidence, that we should reconsider what constitutes alert symptoms for early tubo-ovarian cancer. We need a more nuanced complex of key symptoms which is then evaluated and refined in a prospective trial.

New guidance for self-harm: an opportunity not to be missed

In this editorial we, as members of the 2022 NICE Guideline Committee, highlight and discuss what, in our view, are the key guideline recommendations (generated through evidence synthesis and consensus) for mental health professionals when caring for people after self-harm, and we consider some of the implementation challenges.

Flexibility in assessment of rare disease technologies via NICE's single technology appraisal route: a thematic analysis

Aim: NICE's highly specialized technology (HST) evaluations are highly restrictive in terms of entry criteria and as a consequence, the vast majority of rare disease medicines are assessed through NICE's standard, single technology appraisal (STA) route. We explored whether NICE shows flexibility and pragmatism when evaluating treatments for rare diseases through its STA process. Materials & methods: We matched a sample of recent, randomly selected STAs for rare diseases to STAs for non-rare diseases and conducted a thematic analysis to identify patterns in NICE's decision-making, with a specific focus on the application of NICE's published methods and the handling of uncertainty. Results: Three themes emerged where some flexibility was shown: 'handling of uncertainty and discretion', 'application of NICE methods' and 'commercial arrangements'. Rare disease technologies were generally subject to longer appraisal times than those for non-rare diseases. Conclusion: Although NICE shows a degree of flexibility and pragmatism toward uncertainties in the evidence base for rare disease medicines, this is often off-set by a lengthy appraisal process, which can lead to delays in patients receiving vital treatment.

A cost-utility analysis of two Clostridioides difficile infection guideline treatment pathways

OBJECTIVES

Treatment guidelines are key drivers of prescribing practice in the management of Clostridioides difficile infection (CDI), but recommendations on best practice can vary. We conducted a cost-utility analysis to compare the treatment pathway recommended by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guideline with the pathway proposed by the National Institute for Health and Care Excellence (NICE) guideline, from the perspective of the UK National Health Service.

METHODS

A decision tree modelling approach was adopted to reflect the treatment pathway for CDI as outlined in ESCMID and NICE guidelines. Patients experiencing a CDI infection received up to three treatments per infection to achieve a response and could subsequently experience up to two recurrences. Data on patient demographics, treatment response, recurrence, utilities, CDI-related mortality, and costs were taken from published literature.

RESULTS

The ESCMID treatment pathway was cost-effective versus the NICE treatment pathway at a threshold of £20 000 per quality-adjusted life year gained, with an incremental cost-effectiveness ratio of £4931. Cost-effectiveness was driven by differences in index infection recommendations (ESCMID recommends fidaxomicin as first-line treatment whereas NICE recommends vancomycin). The model results were robust to variations in inputs investigated in scenarios and sensitivity analyses, and probabilistic sensitivity analysis demonstrated that the ESCMID guideline treatment strategy had a 100% likelihood of being cost-effective versus the NICE treatment strategy.

DISCUSSION

Compared with the NICE guideline, the ESCMID guideline recommendations for treating an index CDI represent the most cost-effective use of healthcare resources from the perspective of the UK National Health Service.

Use of National Institute for Health and Care Excellence head injury guidelines among patients with delayed presentation after head trauma can lead to missed traumatic brain injury: a 5-year institutional review

Introduction

In 2014, traumatic brain injury (TBI) caused 3 million ER visits, hospitalizations, and deaths in the US. The National Institute for Health and Care Excellence (NICE) guidelines, initially generated using data from patients presenting within 24 h of head trauma, are used to determine the need for head computed tomography (CT) scan in patients after 24 h. The authors wanted to determine the proportion of CT scans for head trauma performed at our center in late presenters (>24 h after head trauma), the incidence of intracranial pathology in early (24 h) versus late (>24 h) presenters, and the sensitivity of the NICE guidelines for TBI in these two subpopulations.

Methods

A retrospective chart review was conducted at a tertiary care center in Karachi. All people (>16) who had a head CT for head trauma from 2010 to 2015 were included. Age, sex, primary diagnosis, comorbid disorders, mechanism-of-injury, duration (in hours) from head trauma to presentation, site, and extent of injury (injury severity scale), hospital stay, number and details of surgical procedures, CT scan findings, other injuries, and mortality were recorded. Means were compared using the Independent Sample t-test, while categorical variables were compared using χ2. Multivariate logistic regression analyses were used to identify TBI predictors.

Results

The authors found 2009 eligible patients; seven were excluded due to incomplete medical records. The final statistical analysis comprised 2002 head trauma patients. Overall, 52% of early and late presenters had severe injuries, and 2.3% died. 32.2% of patients with head trauma had CT after 24 h. Early presenters were 46.7% traumatized, while late presenters were 63%. The NICE guidelines were 93% sensitive for early presenters and 83% for late presenters with traumatic intracranial injury.

Conclusion

Patients coming to the emergency department after 24 h of head trauma are a large proportion of the overall head trauma population. The NICE guidelines for late-presenting head injuries are less sensitive and may overlook intracranial injuries if imaging is not performed.

Transitioning from child to adult cleft lip and palate services in the United Kingdom: Are the NICE Guidelines reflected in young adults' experiences?

Cleft lip and/or palate (CL/P) is one of the most common congenital conditions worldwide. Individuals born with CL/P will embark on a long-term treatment pathway throughout childhood and often into adulthood. As they grow older, young people become more involved in medical decisions. The National Institute for Clinical Excellence (NICE) has published guidance for health professionals on how transitions of responsibility should be managed in health services. The aim of the current study was to examine the extent to which the NICE recommendations are currently being implemented in UK CL/P services according to young adults' first-hand accounts. Semi-structured interviews were carried out with 15 young adults with CL/P aged 16-25 years. Interview questions were designed to map onto the NICE guidance. Data were analysed to assess whether each guideline was met, partially met, or not met for each individual participant. Overall, findings suggest that further consideration is needed as to how best to implement the recommendations effectively. The introduction of assigned transition workers in CL/P services to co-ordinate transition to adult care offers one possible solution. Focusing on the provision of holistic, patient-centred care, this aspect of the CL/P service could include giving patients access to medical history documentation, liaison with key health professionals including GPs and dental practitioners, and the development of age-appropriate resources to facilitate the transition process.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 12

In this latest update we highlight the final results from the RCT-DUPLICATE initiative, the publication of guidance from Haute Autorité de Santé (HAS), the joint viewpoint from the Institute for Quality and Efficiency in HealthCare (IQWIG) and the Belgian HealthCare Knowledge Center, and a position from the European Organization for Research and Treatment of Cancer (EORTC). Finally, we discuss how the NICE RWE framework has been implemented to allow consideration of RWE external control arms.

Exploring uncertainty and use of real-world data in the National Institute for Health and Care Excellence single technology appraisals of targeted cancer therapy

OBJECTIVES

Dealing with uncertainty is one of the critical topics in health technology assessment. The greater decision uncertainty in appraisals, the less clear the clinical- and cost-effectiveness of the health technology. Although the development of targeted cancer therapies (TCTs) has improved patient health care, additional complexity has been introduced in drug appraisals due to targeting more specific populations. Real-world data (RWD) are expected to provide helpful information to fill the evidence gaps in appraisals. This study compared appraisals of TCTs with those of non-targeted cancer therapies (non-TCTs) regarding sources of uncertainty and reviewed how RWD have been used to supplement the information in these appraisals.

METHODS

This study reviews single technology appraisals (STAs) of oncology medicines performed by the National Institute for Health and Care Excellence (NICE) over 11 years up to December 2021. Three key sources of uncertainty were identified for comparison (generalisability of clinical trials, availability of direct treatment comparison, maturity of survival data in clinical trials). To measure the intensity of use of RWD in appraisals, three components were identified (overall survival, volume of treatment, and choice of comparators).

RESULTS

TCTs received more recommendations for provision through the Cancer Drugs Fund (27.7, 23.6% for non-TCT), whereas similar proportions were recommended for routine commissioning. With respect to sources of uncertainty, the external validity of clinical trials was greater in TCT appraisals (p = 0.026), whereas mature survival data were available in fewer TCT appraisals (p = 0.027). Both groups showed similar patterns of use of RWD. There was no clear evidence that RWD have been used more intensively in appraisals of TCT.

CONCLUSIONS

Some differences in uncertainty were found between TCT and non-TCT appraisals. The appraisal of TCT is generally challenging, but these challenges are neither new nor distinctive. The same sources of uncertainty were often found in the non-TCT appraisals. The uncertainty when appraising TCT stems from insufficient data rather than the characteristics of the drugs. Although RWD might be expected to play a more active role in appraisals of TCT, the use of RWD has generally been limited.

Penicillin Allergy label - the unmet needs - causes and potential solutions

Summary

Background. Penicillin allergy is the most prevalent drug allergy. Its overdiagnosis has been associated with inappropriate antibiotic prescribing, increased antimicrobial resistance, worse clinical outcomes, and increased healthcare costs. Methods. 403 inpatients were audited against National Institute of Clinical Excellence (NICE) Clinical Guidance 183 (CG183) on diagnosis, investigations, documentation, and management of penicillin allergy. 50 junior doctors were surveyed to explore barriers to best practice, investigating their knowledge of, and confidence using the NICE CG183 guidelines. Their views on potential solutions were also explored. Results. The audit identified: 13% (54/403) of patients labelled penicillin allergic; 24% (13/54) fulfilled criteria for referral but none were referred to specialists. With regards to documentation: 33% (18/54) documented exact drug name; 72% (39/54) documented signs and symptoms; 20% (11/54) documented reaction severity; 2% (1/54) documented indication for the drug taken; 4% (2/54) documented number of doses taken or days before onset of the reaction and 0% documented route of administration. The survey revealed barriers including: 1- lack of awareness and confidence in applying the NICE CG183 on diagnosis and management; 2- tendency to err on the side of caution when de-labelling patients. All agreed that decision support tools would address barriers to best practice and appropriate penicillin allergy de-labelling Conclusions.The current practice of diagnosing, documenting, and managing penicillin allergies does not meet NICE CG183. A lack of awareness and confidence using NICE CG183 are the main contributing barriers to best practice. Decision support tools, including a drug allergy app, would help overcome these barriers.

Professionals' attitudes towards people with intellectual disabilities who self-harm: A literature review

BACKGROUND

National Institute for Health and Care Excellence (NICE, 2013) Guidance on Self-Harm states that professionals supporting people who self-harm should demonstrate compassion, respect and dignity. This literature review examines the evidence for professionals' attitudes towards people with intellectual disabilities who self-harm.

METHOD

Four databases (PsychInfo, IBSS, CINAHL and Medline) were systematically searched to find relevant research since 2000.

RESULTS

Four studies met the criteria. Attitudes of professionals supporting people with intellectual disabilities are contrasted with those of professionals in settings focused on supporting people without intellectual disabilities. Professionals supporting people with intellectual disabilities tended to display attitudes and attributions reflective of biobehavioural and psychosocial theories of self-harm, with a greater emphasis on relationships.

CONCLUSION

Much more research is needed which examines the attitudes of professionals supporting people with intellectual disabilities who self-harm.

Appraisals by Health Technology Assessment Agencies of Economic Evaluations Submitted as Part of Reimbursement Dossiers for Oncology Treatments: Evidence from Canada, the UK, and Australia

Publicly funded healthcare systems, including those in Canada, the United Kingdom (UK), and Australia, often use health technology assessment (HTA) to inform drug reimbursement decision-making, based on dossiers submitted by manufacturers, and HTA agencies issue publicly available reports to support funding recommendations. However, the level of information reported by HTA agencies in these reports may vary. To provide insights on this issue, we describe and assess the reporting of economic methods in recent oncology HTA recommendations from the Canadian Agency for Drugs and Technologies in Health (CADTH), National Institute for Health and Care Excellence (NICE), and Pharmaceutical Benefits Advisory Committee (PBAC). Publicly available HTA recommendations and reports for oncology drugs issued by CADTH over a 2-year period, 2019-2020, were identified and compared with the corresponding HTA documents from NICE and the PBAC. Reporting of key model characteristics and attributes, survival analysis methods, methodological criticisms, and re-assessment of the economic results were characterized using descriptive statistics. Dichotomous differences in the methodological criticisms observed between the three agencies were assessed using Cochran's Q tests and substantiated using pairwise McNemar tests. Chi-squared tests were used to assess the dichotomous differences in the reporting of methods and explore the potential relationships between categorical variables, where appropriate. HTAs published by CADTH, NICE, and the PBAC consistently reported a broad spectrum of descriptive information on the economic models submitted by manufacturers. While common economic evaluation attributes were well-reported across the three HTA agencies, significant differences in the reporting of survival analysis methods and methodological criticisms were observed. NICE consistently reported more comprehensive information, compared to either CADTH or PBAC. Despite these differences, broadly similar recommendation rates were observed between CADTH and NICE. The PBAC was found to be more restrictive. Based on our 2-year sample of oncology, the HTAs published by CADTH matched with the corresponding HTAs from NICE and PBAC; we observed important variations in the reporting of economic evidence, especially technical aspects, such as survival analysis, across the three agencies. In addition to guidelines for HTA submissions by manufacturers, the community of HTA agencies should also have common standards for reporting the results of their assessments, though the information and opinions reported may differ.

Using 5 consecutive years of NICE guidance to describe the characteristics and influencing factors on the economic evaluation of orphan oncology drugs

Objective

Orphan oncology drugs used in this article were defined by the type of disease treated by drugs, as drugs used to treat rare diseases with a prevalence of ≤ 500 per million people per year. In this article, our concern was to explore focus on the economic evaluation of the National Institute for Health and Care Excellence (NICE), when orphan oncology drugs were appraised for reimbursement, and provide advice and suggestions to decision-makers.

Methods

A retrospective study was used in this study. Thirty guidance were gathered as our subject by NICE from 2016 to 2020, excluded drugs were not identified as orphan by European Medicines Agency (EMA) and orphan drugs were not used for cancer, and orphan oncology drugs were terminated at the time of data collection at NICE. Qualitative analysis, descriptive statistics, and Fisher's exact test were conducted.

Results

Of all guidance, the partitioned survival model was used most to appraise orphan oncology drugs, and every drug had a kind of commercial arrangement such as patient access scheme (PAS), managed access arrangements (MAAs), and commercial access agreement (CAAs). End of life is an important indicator that had been defined by NICE in the methods of technology appraisal in 2013, and drugs that met the criterion would be given a higher threshold of ICER. In addition, we found that potential health benefits were increasingly concerned such as drug delivery.

Conclusion

In the setting of uncertain clinical and cost efficacy, orphan oncology drugs are comprehensively evaluated in multiple additional dimensions, which include life-extending benefits, and innovation. NICE uses a combination of special considerations for incomplete data, appropriate economic models, and appropriate health technology assessment (HTA) methods during the assessment process, besides, orphan oncology drugs with insufficiency evidence were recommended Cancer Drugs fund (CDF) to afford for patients, which would obtain more availability and accessibility, based on which, high-quality drugs for treating rare cancers can fall within the scope of affordable healthcare provided by the English medical insurance fund.

A call to action to harmonize patient-reported outcomes evidence requirements across key European HTA bodies in oncology

Patient-reported outcome (PRO) data are increasingly being included in Health Technology Assessment (HTA) submissions for oncology drugs. This study aims to provide differences in PRO evidence requirements in oncology across key HTA bodies and calls for its harmonization. Method guidance provided by HTA bodies in Germany, France, and the UK, and analysis of HTA reports of 20 oncology case studies were evaluated in this review. Differences exist between HTA bodies regarding guidance on how PRO data should be collected, reported and analyzed as well as how the data are reviewed and considered in oncology HTAs. HTA bodies can play a key role to harmonize PRO method guidance in collaboration with regulators and sponsors.

Evaluation of the impact and acceptability of Cognitive Behavioural Analysis System of Psychotherapy (CBASP) for chronic depression

BACKGROUND

Cognitive Behavioural Analysis System of Psychotherapy (CBASP) is an evidenced based treatment model for chronically depressed patients.

AIMS

The main aim of this service evaluation was to assess the acceptability and clinical impact of CBASP for chronic depression within an Improving Access to Psychological Therapies (IAPT) service.

METHOD

Routinely collected data were analysed for all patients that received CBASP treatment focussing on the recovery rates of these patients in terms of depression, anxiety and social functioning. Interviews were conducted with patients who had recently been discharged from CBASP therapist within one month of the follow-up date, explore their experiences of therapy.

RESULTS

Outcome data for 27 patients suggested substantial reduction in scoring on measures of depression and anxiety following CBASP treatment. Across all interviews it was clear that patients developed an insight and understanding of how their behaviours affect the outcome of interpersonal situations.

CONCLUSIONS

Results from this service evaluation suggest that CBASP is acceptable to service users and has a positive clinical impact in terms of IAPT recovery targets for anxiety, depression and social functioning.

Real-Time Artificial Intelligence-Based Histologic Classifications of Colorectal Polyps Using Narrow-Band Imaging

Background and Aims

With the development of artificial intelligence (AI), we have become capable of applying real-time computer-aided detection (CAD) in clinical practice. Our aim is to develop an AI-based CAD-N and optimize its diagnostic performance with narrow-band imaging (NBI) images.

Methods

We developed the CAD-N model with ResNeSt using NBI images for real-time assessment of the histopathology of colorectal polyps (type 1, hyperplastic or inflammatory polyps; type 2, adenomatous polyps, intramucosal cancer, or superficial submucosal invasive cancer; type 3, deep submucosal invasive cancer; and type 4, normal mucosa). We also collected 116 consecutive polyp videos to validate the accuracy of the CAD-N.

Results

A total of 10,573 images (7,032 images from 650 polyps and 3,541 normal mucous membrane images) from 478 patients were finally chosen for analysis. The sensitivity, specificity, PPV, NPV, and accuracy for each type of the CAD-N in the test set were 89.86%, 97.88%, 93.13%, 96.79%, and 95.93% for type 1; 93.91%, 95.49%, 91.80%, 96.69%, and 94.94% for type 2; 90.21%, 99.29%, 90.21%, 99.29%, and 98.68% for type 3; and 94.86%, 97.28%, 94.73%, 97.35%, and 96.45% for type 4, respectively. The overall accuracy was 93%. We also built models for polyps ≤5 mm, and the sensitivity, specificity, PPV, NPV, and accuracy for them were 96.81%, 94.08%, 95%, 95.97%, and 95.59%, respectively. Video validation results showed that the sensitivity, specificity, and accuracy of the CAD-N were 84.62%, 86.27%, and 85.34%, respectively.

Conclusions

We have developed real-time AI-based histologic classifications of colorectal polyps using NBI images with good accuracy, which may help in clinical management and documentation of optical histology results.

Non-ischemic cerebral enhancing lesions after thrombectomy: a multicentric retrospective French national registry

To report the occurrence of non-ischemic cerebral enhancing (NICE) lesions following mechanical thrombectomy (MT) through the retrospective French nationwide registry of NICE lesions. All thrombectomy capable stroke centers (TSC) in France were invited to fill out a questionnaire disseminated through a trainee-led research network (JENI-RC: Jeunes en Neuroradiologie Interventionnelle-Research Collaborative). NICE lesions were defined according to previous literature as delayed onset punctate, nodular, or annular foci enhancements with peri-lesion edema and vascular distribution in the territory of the MT with no other confounding disease. All 43 TSC French centers responded. Three patients were reported by 3 different centers over a total of 34,824 MT (2015-2020). Patient no. 1 developed symptomatic NICE lesions 8 weeks after MT with combination of aspiration and stentriever for a right middle cerebral artery occlusion. Patient no. 2 developed asymptomatic NICE lesions 5 weeks after MT with direct thromboaspiration for a right middle cerebral artery occlusion. Patient no. 3 developed symptomatic NICE lesions 6 weeks after MT with direct thromboaspiration, and combination of aspiration and stentriever for a basilar artery occlusion. This study provides evidence that NICE lesions following MT are a possible rare complication with a similar presentation as previously described following endovascular aneurysm treatment. Both radiologists and neurologists should be aware of this adverse event and make use of MRI contrast agents in case of unexplained symptoms/images during follow-up after MT.

How accurate are the longer-term projections of overall survival for cancer immunotherapy for standard versus more flexible parametric extrapolation methods?

AIMS

To assess the accuracy of standard parametric survival models, spline models, and mixture cure models (MCMs) fitted to overall survival (OS) data available at the time of submission in the NICE HTA process compared with data subsequently made available.

METHODS

Standard parametric distributions, spline models, and MCMs were fitted to OS data presented in single technology appraisals (TAs) for immune-checkpoint inhibitors (ICIs) in cancer. For each TA, the estimated survival from the fitted models was compared with Kaplan-Meier (KM) data that were made available following the HTA submission using differences between point estimates and restricted area under the curve (AUC) at both the midpoint and the end of additional follow-up. Differences in interval AUC values (calculated for each 6-month period) were also assessed.

RESULTS

Standard parametric survival models and spline models were more likely to underestimate longer-term survival, irrespective of the measure used to assess model accuracy. MCMs were more likely to overestimate survival; however, this was improved in some cases by applying an additional hazard of mortality for "statistically cured" patients.

LIMITATIONS

The accuracy of the models was assessed based on much shorter OS data than the period for which extrapolation is needed, which may impact conclusions regarding the most accurate models. The most recent TAs for ICIs have not been captured.

CONCLUSIONS

There are no definitive findings that unquestionably support the use of one specific extrapolation technique. Rather, each has the potential to provide accurate or inaccurate extrapolation to longer-term data in certain circumstances, but the added flexibility of more complex models can be justified for treatments, like ICIs, that have extended survival for patients across disease areas. The use of mortality adjustments for "statistically cured" patients allows decision-makers to explore more conservative scenarios in the face of high decision uncertainty.

NICE atrial fibrillation guideline snubs wearable technology: a missed opportunity?

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a growing public health epidemic. In the UK, over 1.3 million people have a diagnosis of AF and an estimated 400,000 remain undiagnosed. AF-related strokes account for a quarter of all strokes and, as AF episodes are often asymptomatic, are still often the first manifestation of AF. Early diagnosis and initiation of oral anticoagulation, where appropriate, may prevent some of these thromboembolic strokes. Public Health England is committed to decrease the incidence of AF-related strokes and has sponsored initiatives aimed at improving AF detection by promoting the uptake of wearable technologies. However, the National Institute for Health and Care Excellence (NICE) has not recommended wearable technology in their recent AF diagnosis and management guidelines (NG196). Diagnostic accuracy of single-lead electrocardiography (ECG) generated by the latest iteration of wearable devices is excellent and, in many cases, superior to general practitioner interpretation of the 12-lead ECG. High-quality ECG from wearable devices that unequivocally shows AF can expedite AF detection. Otherwise, there is a real risk of delaying AF diagnosis with the potential of devastating consequences for patients and their families.

UK clinicians' views on the use of formulations for the management of BPSD: a multidisciplinary survey

BACKGROUND AND OBJECTIVES

The process of formulating in the area of dementia care is at an early stage of development. A review published in 2016, identified 14 different types of formulation-based approaches for the management of Behavioural and Psychological Symptoms of Dementia (BPSD). The present study examines professionals' views about the use of systematic formulations for choosing first-line non-pharmacological interventions for BPSD.

METHODS

A 34-item online survey, with six items about formulation-based interventions for the management of BPSD, was circulated to multi-disciplinary UK dementia networks. Quantitative data were examined for the use of formulation-based frameworks in practice. Thematic analyses provided insight into the practicalities of using formulations.

RESULTS

The majority of the 355 participants responding to the questions stated they used formulation-led models to inform interventions, but 24% stated they did not. Thirty-two types of formulation frameworks were named, and there was a diverse spread across the UK. The Newcastle model was the most frequently used framework, with fifty percent of the participants who formulated reporting using this framework. Four themes regarding the use of formulation emerged, relating to function, process, reported outcomes and obstacles.

CONCLUSION

Formulation-based approaches to targeting intervention are becoming popular in dementia care in the UK. More types of formulation frameworks are used in practice compared with the 2016 review. The use of formulations are seen as key to offering an alternative to pharmacological treatments. Understanding both the value of formulation-led approaches and the obstacles to their use are important to implementing NICE 2018 recommendations.

NICE diagnostic heart failure pathway: screening referrals identifies patients better served by community-based management

AIMS

Evaluate whether UK National Institute for Health & Care Excellence (NICE) chronic heart failure (HF) guidelines can be safely and effectively refined through specialist referral management.

METHODS AND RESULTS

All referrals to a UK centre 1/3/2019-30/5/2019 and 1/6/2020-31/7/2020 were reviewed by HF specialists. Patients were triaged to specialist assessment in HF clinic, according to the NICE HF diagnostic pathway [urgency based on N-terminal pro brain natriuretic peptide (NTproBNP) levels], or the referrer given remote Advice & Guidance (A&G), to aid primary care management. Standardized triage criteria for recommending primary care management were (i) presentation inconsistent with HF, (ii) competing comorbidity/frailty meant specialist assessment in clinic not in patient's best interests, (iii) recent assessment for same condition, or (iv) patient had known HF. Following triage patients managed in the primary care were categorized as low or high risk of adverse outcomes. Outcome measures were 90 day all-cause and HF hospital admission and mortality rates. Four hundred and eighty-six patients had the median age of 80 (74-86) years, and 253 (52%) were male. Two hundred and six (42%) had NTproBNP > 2000 pg/mL. Primary care management was recommended for 128 patients (26%): 105 (22%) A&G alone and 23 input from community HF nurse specialists. Primary care management was recommended due to the following: presentation inconsistent with HF 53 (42%), more important competing comorbidity/frailty 35 (27%), recent assessment 17 (13%), and known HF 23 (18%). Patients managed in primary care had higher rates of all-cause hospitalization (30% vs. 19%; P = 0.018) and death (7% vs. 2%; P = 0.0054) than those seen in HF clinic. Of those managed in primary care, 50 (39%) were determined to be at low risk and 78 (61%) at high risk. High-risk patients were older (87 vs. 80 years; P = 0.0026), had much higher NTproBNP (2666 vs. 697 pg/mL; P < 0.0001), and were managed in the primary care due to severe comorbidity (45%) or known HF (31%). They had extremely high rates of adverse outcomes: 35 all-cause hospitalization (45%), 12 HF hospitalization (15%), and 9 deaths (12%). Low-risk patients were usually felt not to have HF (86%) and confirmed to have low rates of adverse outcomes: three all-cause hospitalizations (6%; P < 0.0001 compared with high risk) and zero HF hospitalization (P = 0.0033) or death (P = <0.012).

CONCLUSIONS

Incorporating specialist referral management into NICE HF diagnostic pathway reduces the demand on HF clinics and may improve the patient experience by facilitating community care. However, many of the patients identified for primary care management are at very high risk of adverse outcomes in the short term and are frequently hospitalized. Urgent implementation of alternative pathways and community-based care packages in parallel for these high-risk patients is extremely important.

The management of suspected scaphoid fractures in the UK: a national cross-sectional study

AIMS

Current National Institute for Health and Clinical Excellence (NICE) guidance advises that MRI direct from the emergency department (ED) should be considered for suspected scaphoid fractures. This study reports the current management of suspected scaphoid fractures in the UK and assesses adherence with NICE guidance.

METHODS

This national cross-sectional study was carried out at 87 NHS centres in the UK involving 122 EDs and 184 minor injuries units (MIUs). The primary outcome was availability of MRI imaging direct from the ED. We also report the specifics of patient management pathways for suspected scaphoid fractures in EDs, MIUs, and orthopaedic services. Overall, 62 of 87 centres (71%) had a guideline for the management of suspected scaphoid fractures.

RESULTS

A total of 11 of 87 centres (13%) had MRI directly available from the ED. Overall, 14 centres (17%) used cross-sectional imaging direct from the ED: MRI in 11 (13%), CT in three (3%), and a mixture of MRI/CT in one (1%). Four centres (6%) used cross-sectional imaging direct from the MIU: MRI in three (4%) and CT in two (2%). Of 87 centres' orthopaedic specialist services, 74 (85%) obtained repeat radiographs, while the most common form of definitive imaging used was MRI in 55 (63%), CT in 16 (19%), mixture of MRI/CT in three (3%), and radiographs in 11 (13%).

CONCLUSION

Only a small minority of centres currently offer MRI directly from the ED for patients with a suspected scaphoid fracture. Further research is needed to investigate the facilitators and barriers to the implementation of NICE guidance. Cite this article: Bone Jt Open 2021;2(11):997-1003.

Mobile Safety Alarms Based on GPS Technology in the Care of Older Adults: Systematic Review of Evidence Based on a General Evidence Framework for Digital Health Technologies

Background

GPS alarms aim to support users in independent activities. Previous systematic reviews have reported a lack of clear evidence of the effectiveness of GPS alarms for the health and welfare of users and their families and for social care provision. As GPS devices are currently being implemented in social care, it is important to investigate whether the evidence of their clinical effectiveness remains insufficient. Standardized evidence frameworks have been developed to ensure that new technologies are clinically effective and offer economic value. The frameworks for analyzing existing evidence of the clinical effectiveness of GPS devices can be used to identify the risks associated with their implementation and demonstrate key aspects of successful piloting or implementation.

Objective

The principal aim of this study is to provide an up-to-date systematic review of evidence based on existing studies of the effects of GPS alarms on health, welfare, and social provision in the care of older adults compared with non–GPS-based standard care. In addition, the study findings were assessed by using the evidence standards framework for digital health technologies (DHTs) established by the National Institute for Health and Care Excellence (NICE) in the United Kingdom.

Methods

This review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Primary studies published in peer-reviewed journals and gray literature from January 2005 to August 2020 were identified through searches in 13 databases and several sources of gray literature. Included studies had individuals (aged ≥50 years) who were receiving social care for older adults or for persons with dementia; used GPS devices as an intervention; were performed in Canada, the United States, European Union, Singapore, Australia, New Zealand, Hong Kong, South Korea, or Japan; and addressed quantitative outcomes related to health, welfare, and social care. The study findings were analyzed by using the NICE framework requirements for active monitoring DHTs.

Results

Of the screened records, 1.6% (16/986) were included. Following the standards of the NICE framework, practice evidence was identified for the tier 1 categories Relevance to current pathways in health/social care system and Acceptability with users, and minimum evidence was identified for the tier 1 category Credibility with health, social care professionals. However, several evidence categories for tiers 1 and 2 could not be assessed, and no clear evidence demonstrating effectiveness could be identified. Thus, the evidence required for using DHTs to track patient location according to the NICE framework was insufficient.

Conclusions

Evidence of the beneficial effects of GPS alarms on the health and welfare of older adults and social care provision remains insufficient. This review illustrated the application of the NICE framework in analyses of evidence, demonstrated successful piloting and acceptability with users of GPS devices, and identified implications for future research.

Health technology assessment (HTA) in England, France and Germany: what do matched drug pairs tell us about recommendations by national HTA agencies?

Aims: To explore health technology assessment (HTA) outcomes of matched drug pairs by national agencies in Germany (Gemeinsamer Bundesausschuss, GBA), France (Haute Autorité de Santé, HAS) and England and Wales (NICE). Methods: We considered published GBA decisions, HAS reports and NICE guidance from January 2011 to June 2018. HTAs of matched pairs were compared overall, and for non-cancer and cancer drugs separately. We further analyzed the role of additional attributes related to cancer therapies. Results: Matched pairs show higher concordance for GBA/HAS than for GBA/NICE and HAS/NICE. Overall, NICE evaluated technologies more favorably than GBA and HAS. GBA appraisals of cancer drugs, however, tended to be more positive than cancer-related recommendations by NICE and HAS. Conclusion: The findings indicate substantial variations in HTAs, although cancer-related outcomes seem to diverge less than non-cancer results.

Development and Validation of a Mobile Clinical Decision Support Tool for the Diagnosis of Drug Allergy in Adults: The Drug Allergy App

BACKGROUND

Penicillin allergy overdiagnosis has been associated with inappropriate antibiotic prescribing, increased antimicrobial resistance, worse clinical outcomes, and increased health care costs.

OBJECTIVE

To develop and validate a questionnaire-based algorithm built in a mobile application to support clinicians in collecting accurate history of previous reactions and diagnosing drug allergy appropriately.

METHODS

A survey was completed by 164 medical and nonmedical prescribers to understand barriers to best practice. Based on the survey recommendations, we created a 10-item questionnaire-based algorithm to allow classification of drug allergy history in line with the National Institute for Health and Care Excellence guidelines on drug allergy. The algorithm was incorporated into a mobile application and retrospectively validated using anonymized clinical databases at regional immunology and dermatology centers in Manchester, United Kingdom.

RESULTS

A total of 55.2% of prescribers (95% confidence interval, 47% to 63.4%) thought it impossible to draw a firm conclusion based on history alone and 59.4% (95% CI, 51.4% to 67.5%) believed that regardless of the details of the penicillin allergy history, they would avoid all β-lactams. A drug allergy mobile application was developed and retrospectively validated, which revealed a low risk for misclassification of outcomes compared with reference standard drug allergy investigations in the allergy and dermatology clinics.

CONCLUSIONS

Perceived lack of time and preparedness to collect an accurate drug allergy history appear to be important barriers to appropriate antimicrobial prescribing. The Drug Allergy App may represent a useful clinical decision support tool to diagnose drug allergy correctly and support appropriate antibiotic prescribing.

NICE shared decision making guidelines and mental health: challenges for research, practice and implementation

The National Institute for Health and Care Excellence (NICE) initiated an ambitious effort to develop the first shared decision making guidelines. The purpose of this commentary is to identify three main concerns pertaining to the new published guidelines for shared decision making research, practice, implementation and cultural differences in mental health.

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

The authors evaluated the impact of genetic screening for familial hypercholesterolaemia (FH) in a lipid clinic cohort of patients with definite and possible FH as defined by the Simon Broome Register (SBR) criteria.

METHODS

Patients with a lipid clinic diagnosis of definite and possible FH based on the SBR criteria were referred to a nurse-led regional service for FH genetic testing.

FINDINGS

140 patients were referred for genetic testing. Six had SBR-definite FH due to the presence of tendon xanthomata and 134 had SBR-possible FH. A monogenic FH mutation was detected in all six patients (100%) with SBR-definite FH and in 34 (25%) of patients with possible FH.

CONCLUSION

The appropriate use of molecular genetics in a lipid clinic will greatly facilitate the management of hyperlipidaemia and cardiovascular risk since the management of FH patients (National Institute for Health and Care Excellence (NICE) Clinical Guideline 71) is different from non-FH patients (NICE Clinical Guideline 181).

Accounting for Heterogeneity in Resource Allocation Decisions: Methods and Practice in UK Cancer Technology Appraisals

OBJECTIVES

The availability of novel, more efficacious and expensive cancer therapies is increasing, resulting in significant treatment effect heterogeneity and complicated treatment and disease pathways. The aim of this study is to review the extent to which UK cancer technology appraisals (TAs) consider the impact of patient and treatment effect heterogeneity.

METHODS

A systematic search of National Institute for Health and Care Excellence TAs of colorectal, lung and ovarian cancer was undertaken for the period up to April 2020. For each TA, the pivotal clinical studies and economic evaluations were reviewed for considerations of patient and treatment effect heterogeneity. The study critically reviews the use of subgroup analysis and real-world translation in economic evaluations, alongside specific attributes of the economic modeling framework.

RESULTS

The search identified 49 TAs including 49 economic models. In total, 804 subgroup analyses were reported across 69 clinical studies. The most common stratification factors were age, gender, and Eastern Cooperative Oncology Group performance score, with 15% (119 of 804) of analyses demonstrating significantly different clinical outcomes to the main population; economic subgroup analyses were undertaken in only 17 TAs. All economic models were cohort-level with the majority described as partitioned survival models (39) or Markov/semi-Markov models. The impact of real-world heterogeneity on disease progression estimates was only explored in 2 models.

CONCLUSION

The ability of current modeling approaches to capture patient and treatment effect heterogeneity is constrained by their limited flexibility and simplistic nature. This study highlights a need for the use of more sophisticated modeling methods that enable greater consideration of real-world heterogeneity.

Wound healing: what is the NICE guidance from the UK?

Alteration of wound healing increases the risk of a patient's morbidity and mortality. This can lead to scarring, infection, malignant transformation and a reduction in quality of life. Management of wounds costs the UK an estimated £5.3 billion annually which is paid for by the state, with further financial burden due to health related productivity loss. Wound care is managed by a broad spectrum of different health professionals leading to different standards of care. For example, only 16% of lower leg wounds have either an ankle-brachial pressure index measurement or Doppler scan. Due to this variation in wound care, we have summarised all available NICE guidelines and guidance up to February 2021 on the topic of wound healing listed in the National Institute for Health and Care Excellence (NICE) archives. The goal is to provide an easy to access summary of wound care interventions. Our search provided us with 18 technology appraisals related to wound healing which have been summarised.

Accounting for inflation within NICE cost-effectiveness thresholds

BACKGROUND

The National Institute for Health and Care Excellence (NICE) makes recommendations on the reimbursement of new drugs utilizing an Incremental Cost-Effectiveness Ratio (ICER) threshold range that has been in use since 2004 and has remained unchanged.

RESEARCH DESIGN AND METHODS

To model how the NICE cost-effectiveness thresholds would vary if inflation was accounted for and their potential effects on appraisal outcomes, all single technology appraisal (STA) recommendations published in 2019 were identified. The outcome and most plausible ICERs were then evaluated against thresholds, after taking inflation into account.

RESULTS

41 STAs with base-case ICERs were identified. For general STAs, 46% of ICERs were ≤£20,000/QALY, 27% were £20,000-£30,000/QALY and 27% >£30,000/QALY. Cumulatively, there was a 43% decrease in the purchasing power of the pound from 2004 to 2019 due to inflation. To compensate, the NICE ICER threshold would have to increase to £28,584-£42,876/QALY. Using inflation-adjusted thresholds led to an absolute increase of 18% and 12% of STAs whose ICERs fell below the lower and upper bounds of this threshold range, respectively.

CONCLUSION

By not adjusting for inflation, the NICE ICER thresholds have declined in real terms. Whether ICER thresholds should be dynamic to reflect factors like inflation requires further research.

Computed tomography coronary angiography: Diagnostic yield and downstream testing

BACKGROUND

The UK National Institute for Health and Care Excellence (NICE) updated its guidelines on stable chest pain in 2016 and recommended computed tomography coronary angiography (CTCA) as first line investigation for all patients with new onset symptoms. We implemented the guideline and audited downstream testing.

METHODS

We undertook a retrospective search of the local radiology database from January 2017 to May 2018.

RESULTS

Six-hundred and fifty-two patients underwent CTCA (mean age of 55 years, 330 were male). Thirty-four patients were found to have severe coronary artery disease (CAD), with 30 undergoing invasive coronary angiography (ICA) which confirmed severe CAD in 22, a yield of 73%.Fifty-eight patients were found to have moderate CAD on CTCA with 36 referred for ICA, of which, 33 attended and 18 were found to have severe CAD. Eighteen were referred for imaging stress tests and one was positive. The total yield of severe CAD at ICA was 55%. The majority of patients had normal coronary arteries.

CONCLUSIONS

CTCA was an effective rule-out test for most patients. In patients that went on to have ICA, the overall yield of severe CAD was relatively high. This compares well with our previous audit applying the NICE 2010 guidelines which recommended ICA for all high probability patients wherein the yield of severe CAD was 30%.

The impact of rarity in NICE's health technology appraisals

BACKGROUND

In the absence of a framework designed to evaluate medicines for rare diseases in the UK, most orphan medicines are appraised by the National Institute for Health and Care Excellence (NICE) through the Single Technology Appraisal (STA) process.

RESULTS

An analysis of STA appraisals of orphan and non-orphan medicines revealed that orphan medicines were subject to a significantly longer mean time in the NICE process than non-orphan medicines [370 days (n = 44) vs. 277 days (n = 118), p =  < 0.0001]. A higher proportion of orphan STAs required more than one Appraisal Committee Meeting (ACM) versus non-orphan STAs, and orphan STAs were disadvantaged by worse outcomes with respect to positive recommendations than those orphan medicines assessed by Highly Specialised Technology evaluation (HST).

CONCLUSIONS

The uncertainties inherent to developing orphan medicines may contribute to these disadvantages. Improved understanding of the challenges in drug development for orphan medicines and clearer guidance for decision makers on navigating uncertainty in the HTA process may promote greater equity in access to medicines across rare and common conditions.

10 Years of End-of-Life Criteria in the United Kingdom

OBJECTIVES

In January 2009, the National Institute for Health and Care Excellence introduced supplementary guidance for end-of-life (EoL) treatments, which allowed treatments with an incremental cost-effectiveness ratio over the regular threshold (£20 000-£30 000) to be recommended, if they satisfied the EoL criteria. The aims of this study were (1) to systematically review 10 years of EoL supplementary guidance implementation and explore how it could be improved, and (2) to create a framework for incorporating the uncertainty relating to EoL criteria satisfaction into model-based cost-effectiveness analyses for decision making.

METHODS

All appraisals between January 2009 and 2019 were screened for EoL discussions. Data were extracted on the EoL criteria and cost-effectiveness assessment details. Additionally, a quantitative method was developed to include the EoL criteria satisfaction uncertainty into model-based cost-effectiveness analyses. A stylized example was created to provide a case study for the inclusion of EoL criteria satisfaction uncertainty.

RESULTS

An EoL discussion was identified in 35% of appraisals, 57% of which led to a positive EoL decision. Only 5.7% of technologies with positive EoL decisions were not recommended, versus 43.8% of technologies with negative EoL decisions. EoL criteria assessment was often reported insufficiently and evaluated inconsistently and nontransparently. A total of 54.9% of EoL decisions were made while at least 1 criterion was surrounded by considerable uncertainty. By applying the proposed quantitative method, this EoL criteria satisfaction uncertainty was accounted for in decision making. The stylized example demonstrated that the impact of EoL criteria satisfaction uncertainty can be substantial enough to reverse the reimbursement decision.

CONCLUSIONS

To improve consistency/transparency and correct reimbursement decisions' likelihood, new guidelines on the implementation of the EoL criteria are needed.

Impact of NICE guidelines on the survival of patients with soft-tissue sarcomas

AIMS

Urgent referral to a specialist centre for patients with a soft-tissue sarcoma (STS) has been recommended by the National Institute for Health and Care Excellence (NICE) in the UK since 2006. However, the impact of this recommendation on the prognosis for these patients remains unclear. We aimed to determine the impact of the NICE guidelines on the disease-specific survival (DSS) of patients with an STS.

METHODS

A total of 2,427 patients with an STS referred to a supraregional centre in the ten-year periods before (n = 1,386) and after (n = 1,041) the issue of the NICE guidelines were evaluated.

RESULTS

The mean size of the tumour was significantly smaller at the time of diagnosis (10.3 cm (SD 6.5) vs 9.1 cm (SD 6.2); p < 0.001) and the number of patients who had undergone an inadvertent excision significantly decreased (28% (n = 389) vs 20% (n = 204); p < 0.001) following the introduction of the NICE guidelines. The five-year DSS was 63% in the pre-NICE and 71% in post-NICE groups (p < 0.001). The improved survival was more significant for those with a high-grade tumour (pre-NICE, 48%; post-NICE, 68%; p < 0.001). In those with a high-grade tumour, the mean size of the tumour (11.6 cm (SD 6.2) vs 9.6 cm (SD 5.8); p < 0.001) and the number of patients with metastasis at the time of diagnosis (15% (n = 124 vs 10% (n = 80); p = 0.007) significantly decreased in the post-NICE group.

CONCLUSION

An improvement in survival was seen after the introduction of the NICE guidelines, especially in patients with a high-grade STS. More patients were referred at an earlier stage, indicating a clearer pathway after the issue of national policy for the management of STSs in the UK. Cite this article: Bone Joint J 2021;103-B(3):569-577.

Does NICE influence the adoption and uptake of generics in the UK?

The aim of this paper is to examine generic competition in the UK, with a special focus on the role of Health Technology Assessment (HTA) on generic market entry and diffusion. In the UK, where no direct price regulation on pharmaceuticals exists, HTA has a leading role for recommending the use of medicines providing a non-regulatory aspect that may influence the dynamics in the generic market. The paper focuses on the role of Technology Appraisals issued by the National Institute for Health and Care Excellence (NICE). We follow a two-step approach. First, we examine the probability of generic entry. Second, conditional on generic entry, we examine the determinants of generic market share. We use data from IQVIA British Pharmaceutical Index (BPI) for the primary care market for 60 products that lost patent between 2003 and 2012. Our results suggest that market size remains one of the main drivers of generic entry. After controlling for market size, intermolecular substitution and difficulty of manufacturing increase the likelihood of generic entry. After generic entry, our estimates suggest that generic market share is highly state dependent. Our findings also suggest that while NICE recommendations do influence generic uptake, there is only marginal evidence they affect generic entry.

The ethics of grandfather clauses in healthcare resource allocation

A grandfather clause is a provision whereby an old rule continues to apply to some existing situation while a new rule applies to all future cases. This paper focuses on the use of grandfather clauses in health technology appraisals (HTAs) issued by the National Institute for Health and Care Excellence (NICE) in the United Kingdom. NICE provides evidence-based guidance on healthcare technologies and public health interventions that influence resource allocation decisions in the National Health Service (NHS) and the broader public sector in England and Wales. In this context, a grandfather clause is included when NICE does not recommend treatment with a given technology. The grandfather clause provides an exemption from the general recommendation for patients who have already started treatment with the technology in question, before the publication of the NICE guidance. In this paper we first lay out the contexts in which grandfather clauses occur in NICE guidance, and then consider ethical arguments against and in support of grandfather clauses and the continuation of treatment. We argue that NICE's current practice of automatic inclusion of a grandfather clause is ethically problematic and unfair. While the inclusion of a grandfather clause may be appropriate and justified in specific cases, we argue that inclusion of such a clause should be considered as part and parcel of the decision making process on a case by case basis, rather than adopted as the default.

Real-World Study Analysing Progression and Survival of Patients with Idiopathic Pulmonary Fibrosis with Preserved Lung Function on Antifibrotic Treatment

INTRODUCTION

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive and irreversible lung disease. Licensed treatment options for IPF are pirfenidone and nintedanib. The aim of this study was to assess the impact of antifibrotic therapy in patients with IPF with preserved lung function based upon a forced vital capacity (FVC) above 80%.

METHOD

This is a retrospective single-centre cohort study, performed as part of a service evaluation, between January 2007 and September 2018. Patient demographic, treatment and lung function profiles were collected using electronic patient records. A linear mixed model and Kaplan-Meier estimator were utilised to assess changes in FVC and survival over 36 months.

RESULTS

A total of 161 patients were included in this study. Mean age was 72 ± 4. Twenty-four (14.9%) received pirfenidone, 86 (53.4%) received nintedanib and 18 (11.2%) received both antifibrotics provided by a compassionate use program (CUP), as the National Institute of Heath and Clinical excellence (NICE) criteria for antifibrotics in the UK is restricted to an FVC 50-80%. Thirty-three (20.5%) patients did not receive treatment. Patients without antifibrotic therapy had a statistically higher baseline FVC compared to other groups: 3.55 l (100%) vs 2.85 l (89.7%) pirfenidone (p = 0.012), vs 2.99 l (93.5%) nintedanib (p = 0.04) and 3.10 l (92.7%) (p = 0.07) for both antifibrotics. FVC decline over 1 year was similar in groups receiving pirfenidone, nintedanib or no treatment [3.72% (158.1 ml) untreated vs 2.77% (139 ml) pirfenidone vs 2.96% (131 ml) nintedanib]; however, it was significantly greater in patients who received both antifibrotics [6.36% (233 ml), p = 0.01]. Use of antifibrotics was associated with a higher median survival post diagnosis; 3.5, 3 and 3.75 years respectively in pirfenidone, nintedanib and both antifibrotic cohorts, compared to the untreated cohort (2.5 years).

CONCLUSION

One in five untreated patients with an average FVC of 100% die within a median of 2.5 years. Antifibrotic therapy was associated with a higher median survival of 3-3.75 years despite treatment groups having lower baseline lung function.

Ocrelizumab not recommended in France for patients with primary progressive multiple sclerosis while recommended in England: a review comparing the assessment by HAS and NICE

INTRODUCTION

Ocrelizumab is the first approved drug for primary progressive multiple sclerosis. Following appraisal by health technology assessment (HTA) bodies, this medicine has not been widely covered across European countries. We have compared the HTA process in England and France.

AREA COVERED

We undertook an analysis of relevant documents that were published by the two HTA bodies. We analyzed patients' availability of Ocrelizumab at the different stages of the process.

EXPERT OPINION

We identified differences in the assessment, one being the use of a different population of the pivotal trial, which has resulted in the consideration of distinct clinical effectiveness estimates. Ocrelizumab became available earlier in France as part of an early access program. However, rapid access was discontinued for newly eligible patients following an opinion concluding that Ocrelizumab yielded no additional benefit over placebo. This opinion was not compatible with the criteria allowing reimbursement in France.In England, there was no early access program and following an appraisal that included cost-effectiveness evaluation combined with pricing agreements, medicine was finally recommended. In conclusion, differences in the HTA process may result in appreciable differences in timing and outcome from marketing authorization to the adoption of newly licensed drugs.

Fractured Neck of Femur Management at a District General Hospital: Adherence to NICE guidelines CG124 for total hip replacement

Introduction: The National Institute for Health and Care Excellence (NICE) in 2011 declared standards in the management of fracture neck of femur (NOF) patients suggesting a total hip replacement (THR) if necessary criteria were met. The Best Practice Tariff (BPT) states all NOF fracture patients should be operated on within 36 h of presentation to Accident & Emergency. We conducted this retrospective study for the years 2016–2018 to evaluate the adherence to these guidelines by Basildon and Thurrock University Hospital and compared the results with national standards. Methods: Data for the period from 2016 to 2018 was collected from the National Hip Fracture Database (NHFD) retrospectively. The data was analysed to calculate various procedures performed for fracture NOF fixations, the number of THR’s for displaced intracapsular fracture NOF, and percentage of patients operated within 36 h and evaluated reasons for the delay. Results: Over the 3 years, the number of THR eligible displaced intracapsular neck of femur fracture patients that underwent THR was above the national average. Across all 3 years, the number of patients who underwent surgery within 36 h was less than the national average. Administrative/logistic reasons for the delay were the major cause for delayed surgery in all 3 years. Conclusion: Compliance with the NICE guidelines and achievement of national standards in NOF fracture care is achievable by most district general hospitals. Awareness and implementation of NICE guidelines for THRs need to be enhanced. A sustained, continual team effort and strict vigilance are necessary to prevent delayed surgery.

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.

Inclusion of Carer Health-Related Quality of Life in National Institute for Health and Care Excellence Appraisals

OBJECTIVES

Health interventions for patients can have effects on their carers too. For consistency, decision makers may wish to specify whether carer outcomes should be included. One example is the National Institute for Health and Care Excellence (NICE), whose reference case specifies that economic evaluations should include direct health effects for patients and carers where relevant. We aimed to review the methods used in including carer health-related quality of life (HRQL) in NICE appraisals.

METHODS

We reviewed all published technology appraisals (TAs) and highly specialized technologies (HSTs) to identify those that included carer HRQL and discussed the methods and data sources.

RESULTS

Twelve of 414 TAs (3%) and 4 of 8 HSTs (50%) included carer HRQL in cost-utility analyses. Eight were for multiple sclerosis, the remainder were each in a unique disease area. Twelve of the 16 appraisals modeled carer HRQL as a function of the patient's health state, 3 modeled carer HRQL as a function of the patient's treatment, and 1 included family quality-adjusted life year (QALY) loss. They used 5 source studies: 2 compared carer EQ-5D scores with controls, 2 measured carer utility only (1 health utilities index and 1 EQ-5D), and 1 estimated family QALY loss from a child's death. Two used disutility estimates not from the literature. Including carer HRQL increased the incremental QALYs and decreased incremental cost-effectiveness ratios in all cases.

CONCLUSIONS

The inclusion of carer HRQL in NICE appraisals is relatively uncommon and has been limited by data availability.

Clinical guidelines for burosumab in the treatment of XLH in children and adolescents: British paediatric and adolescent bone group recommendations

X-linked hypophosphataemia (XLH) is caused by a pathogenic variant in the PHEX gene, which leads to elevated circulating FGF23. High FGF23 causes hypophosphataemia, reduced active vitamin D concentration and clinically manifests as rickets in children and osteomalacia in children and adults. Conventional therapy for XLH includes oral phosphate and active vitamin D analogues but does not specifically treat the underlying pathophysiology of elevated FGF23-induced hypophosphataemia. In addition, adherence to conventional therapy is limited by frequent daily dosing and side effects such as gastrointestinal symptoms, secondary hyperparathyroidism and nephrocalcinosis. Burosumab, a recombinant human IgG1 MAB that binds to and inhibits the activity of FGF23, is administered subcutaneously every 2 weeks. In clinical trials (phase 2 and 3) burosumab was shown to improve phosphate homeostasis that consequently resolves the skeletal/non-skeletal manifestations of XLH. Burosumab was licensed in Europe (February 2018) with the National Institute for Health and Care Excellence, UK approving use within its marketing authorisation in October 2018. In this publication, the British Paediatric and Adolescent Bone Group (BPABG) reviewed current evidence and provide expert recommendations for care pathway and management of XLH with burosumab.

People Living with Multiple Long-Term Conditions: Meeting the Challenges of Personalized Decision Making

As with any diagnosis, the underlying purpose of a 'multimorbidity' one is to identify and establish the impact of a person's health conditions on their lives and to facilitate personalized decisions regarding proposed interventions. Clinicians routinely make decisions about the use of interventions for people with multiple long-term conditions. This is challenging because evidence to support this process currently relies on guidance on single health conditions for people without multimorbidity, typically taking fewer medications. Establishing the person's preferences over relevant criteria is central to a person-centered decision-making process, and it is particularly challenging, given the complexities of the person's multiple conditions. The final challenge is in combining the clinician's best estimates of the benefits and harms of possible interventions with the person's preferences. A review of these challenges, drawing on the NICE guidelines, leads to a proposal for using a Multi-Criteria Decision Analysis-based support tool for personalized shared decision making for multiple long-term conditions.

Cured Today, Ill Tomorrow: A Method for Including Future Unrelated Medical Costs in Economic Evaluation in England and Wales

OBJECTIVES

In many countries, future unrelated medical costs occurring during life-years gained are excluded from economic evaluation, and benefits of unrelated medical care are implicitly included, leading to life-extending interventions being disproportionately favored over quality of life-improving interventions. This article provides a standardized framework for the inclusion of future unrelated medical costs and demonstrates how this framework can be applied in England and Wales.

METHODS

Data sources are combined to construct estimates of per-capita National Health Service spending by age, sex, and time to death, and a framework is developed for adjusting these estimates for costs of related diseases. Using survival curves from 3 empirical examples illustrates how our estimates for unrelated National Health Service spending can be used to include unrelated medical costs in cost-effectiveness analysis and the impact depending on age, life-years gained, and baseline costs of the target group.

RESULTS

Our results show that including future unrelated medical costs is feasible and standardizable. Empirical examples show that this inclusion leads to an increase in the ICER of between 7% and 13%.

CONCLUSIONS

This article contributes to the methodology debate over unrelated costs and how to systematically include them in economic evaluation. Results show that it is both important and possible to include future unrelated medical costs.

Leveraging DICE (Discretely-Integrated Condition Event) Simulation to Simplify the Design and Implementation of Hybrid Models

OBJECTIVES

Using an example of an existing model constructed by the National Institute for Health and Care Excellence (NICE) to inform a real health technology assessment, this study seeks to demonstrate how a discretely integrated condition event (DICE) simulation can improve the implementation of Markov models.

METHODS

Using the technical report and spreadsheet, the original model was translated to a standard DICE simulation without making any changes to the design. All original analyses were repeated and the results were compared. Aspects that could have improved the original design were then considered.

RESULTS

The original model consisted of 32 copies (8 risk strata × 4 treatments) of the Markov structure, containing more than 6000 Microsoft Excel® formulas (18 MB files). Three aspects (nonadherence, scheduled treatment stop, and end of fracture risk) were handled by incorporating weighted averages into the cycle-specific calculations. The DICE implementation used 3 conditions to represent the states and a single transition event to apply the probabilities; 3 additional events processed the special aspects, and profiles handled the 8 strata (0.12 MB file). One replication took 16 seconds. The original results were reproduced but extensive additional sensitivity analyses, including structural analyses, were enabled.

CONCLUSION

Implementing a real Markov model using DICE simulation both preserves the advantages of the approach and expands the available tools, improving transparency and ease of use and review.

Ovarian cancer symptoms, routes to diagnosis and survival - Population cohort study in the 'no screen' arm of the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

OBJECTIVE

There are widespread efforts to increase symptom awareness of 'pelvic/abdominal pain, increased abdominal size/bloating, difficulty eating/feeling full and urinary frequency/urgency' in an attempt to diagnose ovarian cancer earlier. Long-term survival of women with these symptoms adjusted for known prognostic factors is yet to be determined. This study explored the association of symptoms, routes and interval to diagnosis and long-term survival in a population-based cohort of postmenopausal women diagnosed with invasive epithelial tubo-ovarian cancer (iEOC) in the 'no screen' (control) UKCTOCS arm.

METHODS

Of 101,299 women in the control arm, 574 were confirmed on outcome review to have iEOC between randomisation (2001-2005) and 31 December 2014. Data was extracted from medical notes and electronic records. A multivariable model was fitted for individual symptoms, time interval from symptom onset to diagnosis, route to diagnosis, speciality, morphological Type, age at diagnosis, year of diagnosis (period effect), stage, primary treatment, and residual disease.

RESULTS

Women presenting with symptoms listed in the NICE guidelines (HR1.48, 95%CI1.16-1.89, p = 0.001) or the modified Goff Index (HR1·68, 95%CI1·32-2.13, p < 0.0001) had significantly worse survival than those who did not. Each additional presenting symptom decreased survival (HR1·20, 95%CI1·12-1·28, p < 0.0001). In multivariable analysis, in addition to advanced stage, increasing residual disease and inadequate primary treatment, abdominal pain and loss of appetite/feeling full were significantly associated with increased mortality.

CONCLUSIONS

The ovarian cancer symptom indices identify postmenopausal women with a poorer prognosis. This study however cannot exclude the possibility of better outcomes in those who are aware and act on their symptoms.