A Review of NICE Methods and Processes Across Health Technology Assessment Programmes: Why the Differences and What is the Impact?

BACKGROUND

Decisions made by the National Institute for Health and Care Excellence (NICE) exert an influence on the allocation of resources within 'fixed' National Health Service budgets. Yet guidance for different types of health interventions is handled via different 'programmes' within NICE, which follow different methods and processes.

OBJECTIVE

The objective of this research was to identify differences in the processes and methods of NICE health technology assessment programmes and to explore how these could impact on allocative efficiency within the National Health Service.

METHODS

Data were extracted from the NICE technology appraisal programme, medical technologies guidance, diagnostic assessment programme, highly specialised technologies programme, and clinical guidelines process and methods manuals to undertake a systematic comparison. Five qualitative interviews were carried out with NICE members of staff and committee members to explore the reasons for the differences found.

RESULTS

The main differences identified were in the required evidence review period, or lack thereof, mandatory funding status, the provision of a reference case for economic evaluation, the requirement for and the type of economic analysis undertaken, and the decision making criteria used for appraisal.

CONCLUSION

Many of the differences found can be justified on grounds of practicality and relevance to the health technologies under assessment. Nevertheless, from a strict utilitarian view, there are several potential areas of inefficiency that could lead to the misallocation of resources within the National Health Service, although some of these might be eliminated or reduced if an egalitarian view is taken. The challenge is determining where society is willing to trade health gains between different people.

Does a biomedical research centre affect patient care in local hospitals?

BACKGROUND

Biomedical research can have impacts on patient care at research-active hospitals. We qualitatively evaluated the impact of the Oxford Biomedical Research Centre (Oxford BRC), a university-hospital partnership, on the effectiveness and efficiency of healthcare in local hospitals. Effectiveness and efficiency are conceptualised in terms of impacts perceived by clinicians on the quality, quantity and costs of patient care they deliver.

METHODS

First, we reviewed documentation from Oxford BRC and literature on the impact of research activity on patient care. Second, we interviewed leaders of the Oxford BRC's research to identify the direct and indirect impacts they expected their activity would have on local hospitals. Third, this information was used to inform interviews with senior clinicians responsible for patient care at Oxford's acute hospitals to discover what impacts they observed from research generally and from Oxford BRC's research work specifically. We compared and contrasted the results from the two sets of interviews using a qualitative approach. Finally, we identified themes emerging from the senior clinicians' responses, and compared them with an existing taxonomy of mechanisms through which quality of healthcare may be affected in research-active settings.

RESULTS

We were able to interview 17 research leaders at the Oxford BRC and 19 senior clinicians at Oxford's acute hospitals. The research leaders identified a wide range of beneficial impacts that they expected might be felt at local hospitals as a result of their research activity. They expected the impact of their research activity on patient care to be generally positive. The senior clinicians responsible for patient care at those hospitals presented a more mixed picture, identifying many positive impacts, but also a smaller number of negative impacts, from research activity, including that of the Oxford BRC. We found the existing taxonomy of benefit types to be helpful in organising the findings, and propose modifications to further improve its usefulness.

CONCLUSIONS

Impacts from research activity on the effectiveness and efficiency of patient care at the local acute hospitals, as perceived by senior clinicians, were more often beneficial than harmful. The Oxford BRC contributed to those impacts.

Detection of B-mode polarization in the cosmic microwave background with data from the South Pole Telescope

Gravitational lensing of the cosmic microwave background generates a curl pattern in the observed polarization. This "B-mode" signal provides a measure of the projected mass distribution over the entire observable Universe and also acts as a contaminant for the measurement of primordial gravity-wave signals. In this Letter we present the first detection of gravitational lensing B modes, using first-season data from the polarization-sensitive receiver on the South Pole Telescope (SPTpol). We construct a template for the lensing B-mode signal by combining E-mode polarization measured by SPTpol with estimates of the lensing potential from a Herschel-SPIRE map of the cosmic infrared background. We compare this template to the B modes measured directly by SPTpol, finding a nonzero correlation at 7.7σ significance. The correlation has an amplitude and scale dependence consistent with theoretical expectations, is robust with respect to analysis choices, and constitutes the first measurement of a powerful cosmological observable.

Cost-effectiveness analysis: role and implications

Background:

Cost-effectiveness analysis (CEA) is often misperceived to be a cost-cutting exercise. The intention of CEA is not to identify and implement cheap technologies, but rather those which offer maximum health gain, subject to available funds. Such analysis is crucial for decision making in health care, as tight budget constraints mean spending in one area of healthcare displaces spending elsewhere. Therefore in order to achieve the greatest health gain for the overall population, treatments must be selected which provide the greatest health gain within the available funds.

Summary:

The relevance of CEA in health care systems is explained, using varicose vein treatment in the UK NHS as an example. Treatment for varicose veins is often not commissioned to at a local level, most likely because it is misperceived to be a cosmetic problem. However, this view does not take into account the impact of quality of life. CEA balances costs against a quantitative measure of health related quality of life, and could therefore be used to determine whether it is cost-effective to provide varicose vein treatment. The current literature on the cost-effectiveness of varicose vein treatment is reviewed, and an overview of cost-effectiveness principles is provided. Concepts such as economic modelling, incremental cost-effectiveness ratios (ICERs), net monetary benefit (NMB) and sensitivity analysis are explained, using examples relevant to varicose veins where appropriate.

Conclusion:

This article explains how, far from cutting costs and sacrificing patient health, CEA provides a useful tool to maximise the health of the population in the face of ever tightening budget constraints. CEA could be used to compare the cost-effectiveness of the various treatment options for varicose veins, and efficiencies realised.

Effects of alcohol and caffeine on maritime navigational skills

Twelve experienced navigators participated in an experiment to determine the effects of alcohol, caffeine, and an alcohol+caffeine mixture on performance during the following tasks: visual search, the search and location of items on a navigational chart (chartsearch) and the solving of maritime navigational problems. Alcohol (75 ml) produced impairment in performance on visual search (p<0.05) and navigational problem-solving (p<0.01). Caffeine was found to enhance performance on visual search (p<0.05) but not on the chartsearch, although a significant correlation was found between performance on the two tests (p<0.05). Caffeine was not found to improve the accuracy of navigational problem-solving (p>0.05). Neither alcohol nor caffeine had any significant effect on the speed of problem-solving (p>0.05).

Marketing public health services

Marketing techniques that have proved their worth in the private sector can be applied successfully to public and non-profit agencies. This paper explores the applicability of marketing practices to public health departments. Many health departments are now facing pressures to re-examine and update roles in light of changes in morbidity and mortality and changes in consumer wants and needs. Marketing techniques can be helpful in evaluating services systematically in regard to consumer needs and preferences, planning and improving services to meet those needs and increasing agency visibility and credibility. One health department's experience in using marketing techniques is shared. Problems faced, solutions developed and recommendations for future activities are discussed.

Children's understanding of their emotionally disturbed peers: a replication

Despite increasing recognition of the early importance of peer relations, virtually no systematic information exists on the way in which normal children view their emotionally disturbed peers. This paper reports a replication of recent findings on children's use of the concept of emotional disturbance. Ss were 40 fourth and sixth graders. Five vignettes that described one normal and four emotionally disturbed boys were read to individual Ss; who were interviewed about their understanding of the central figures (CFs). Interviews were coded to a 5-point scale of degree of perceived emotional disturbance. Earlier findings were replicated to a remarkable degree. Ss differentiated among the CFs in a manner congruent with clinician judges' ratings. Grade differences indicate the differential attention to and valuing of specific behaviors, rather than global differences in perception of emotional disturbance.

Children's understanding of their emotionally disturbed peers. II. Etiological factors

In a previous study, we (Marsden and Kalter, 1976) found that fourth- and sixth-grade children not only made distinctions between normal and emotionally disturbed behavior, but also were able to discriminate degrees of childhood psychopathology in a manner strikingly congruent with clinician-judges. Having assessed children's perceptions of emotional disturbance, we turned our attention to how the children might account for the development of such childhood disorders. We are aware of no previous study which has examined children's views of the etiology of emotionally disturbed behavior of their peers. Such information could shed further light on children's understanding of childhood psychopathology and might implicitly indicate what children believe are the necessary ingredients for healthy emotional development. This knowledge would be useful to mental health professionals, teachers, and parents seeking both to understand the emotionally disturbed child's place in his peer group and to convey an understanding of emotional illness to normal children.

Children's understanding of their emotionally disturbed peers. I. The concept of emotional disturbance

Study of the interpersonal relations of emotionally disturbed children has focused largely on relationships within the family. Theories of childhood psychopathology focus almost exclusively on the parent-child triad as the etiological core of childhood emotional disturbance (Frank, 1965). Far less attention has been paid to the role of extra-familial attitudes and relationships in childhood psychopathology. In a general way, the increasing importance of the peer group during childhood has been recognized, but researchers have hardly begun to consider whether and how the manifold aspects of relationships between the emotionally disturbed and their normal peers might bear on the course of the disturbance or its refractoriness to treatment (e.g., Solomon and Wahler, 1973). Nor have they considered peer group influences on the development of the emotionally disturbed child's perception of the world and his place within it. Despite increasing recognition of the early importance of peer relations, virtually no systematic information exists on the ways in which normal children view their emotionally disturbed peers. Our purpose in this paper is to report the first of several analyses of data from an initial investigation of children's understanding of their emotionally disturbed peers. Specifically, we wish to examine whether there is evidence that normal children do, in fact, perceive as emotionally disturbed the symptomatic and distressing behavior of peers that mental health professionals would recognize as indicative of psychopathology. Further, we wish to study these issues with respect to grade and sex differences.