NICE clinical guidelines:new challenges and how Cochrane

can help

Fergus Macbeth

NICE Clinical Guidelines

• Over 10 years NICE has published 129 guidelines

• 19 are updates

• Wide spectrum of topics covering most significant areas of clinical practice

• Developed by 4 National Collaborating Centres and an internal team (Short guidelines)

• Two year development following rigorous methodology

Implementation

• Support tools: audit tools, costing templates, slide sets• Field team: 6 people for all England!• System levers:

– An ´expectation’ by Inspectors that NICE guidelines are used

– Used by commissioners to specifiy services• Generally high profile • Disseminated and supported by professional bodies

and patient groups

New challenges

• Significant efficiency savings needed over 3 years

• Requirement to deliver c150 new quality standards based on NICE guidance over the next 4 years

• c60 new guidelines needed

• As well as updating existing output

When are guidelines out of date?

Proportion of clinical guidelines that need updating at x years following publication:

Age of guidelines

Percentage needing updating

95% Confidence interval

Year 1 0.90 0.13 - 6.20Year 2 4.09 1.55 - 10.57Year 3 14.53 8.48 - 24.29Year 4 33.15 23.15 - 45.98Year 5 50.40 37.98 - 64.27Year 6 61.42 47.75 - 75.28Year 7 61.42 47.75 - 75.28Year 8 83.47 59.01 - 97.35

How can Cochrane help?

Mapping of Cochrane use in NICE clinical guidelines

• Review of 116 clinical guidelines published by end February 2011

• Excluded 10 guideline updates

• Overall total =106 guidelines

• Searched text and appendices for citations of Cochrane reviews

Results

• 731 citations of Cochrane reviews– Range: 0 - 44 citations per guideline, mostly 1-10– Mean: 7 citations– Some Cochrane reviews >1 citation– Use as supporting information: 23 citations

Citation of Cochrane Reviews

Citations of Cochrane Reviews

No. of guidelines Percentage

0 20 191 to 5 45 42

6 to 10 19 1811 to 15 9 816 to 20 4 421 to 25 2 226 to 30 3 331 to 35 0 0.036 to 40 3 341 to 45 1 1

How were reviews used in guidelines?

• 1 guideline from each NCC published since 2009

• CG81, Breast cancer (advanced) - February 2009

• CG87, Type 2 diabetes: newer agents (a partial update of CG66) - June 2009

• CG90, Depression in adults (update) October 2009

• CG101, Chronic obstructive pulmonary disease (update) - June 2010

• CG 102, Bacterial meningitis and meningococcal septicaemia in children - June 2010 and Sept 2010

Summary

Total number of questions in guidelines

Cochrane review used unchanged

Cochrane review

updated or adapted

Cochrane review used

as supporting information

Cochrane review not

used

61 39 13 5 4

Cochrane review updated or changed

• Newly-published studies added to Cochrane review (6)

• Some studies excluded because did not meet inclusion criteria for question (2)

• Studies with a short follow up period excluded (1)

• Studies on specific treatments extracted (1)

• Studies on adults excluded for a guideline in children (1)

• Results from adults extrapolated for a guideline in children (1)

• Studies on a specific microorganism extracted (1)

Cochrane review not used

• Developers did not plan to update section but mentioned that further data was now available in the Cochrane review (1)

• Studies in Cochrane review investigated vaccines no longer used in clinical practice (1)

• Studies from Cochrane review assessed independently in guideline (2)

NICE and Cochrane working together

• Breast cancer (advanced)

• Type 2 diabetes: newer agents

• Depression in adults

Breast cancer (advanced)

• Guideline question: What is the choice of first line treatment for patients with metastatic breast cancer, endocrine therapy of chemotherapy?

• Cochrane review: Wilcken N, Hornbuckle J and Ghersi D (2006). Chemotherapy alone versus endocrine therapy alone for metastatic breast cancer

• Used unchanged but with some comments • Director of NCC was Cochrane Coordinating Editor,

review commissioned by NCC Cancer

Type 2 diabetes, newer agents

• Guideline question: Does the effectiveness differ between NPH insulin and a long-acting insulin analogue (insulin glargine, insulin detemir) when a basal insulin is indicated?

• Cochrane review: Horvath K, Jeitler K, Berghold A et al (2007). Long-acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus

• Used unchanged

Type 2 diabetes, newer agents

• Guideline question: 8 questions around DPP-4 inhibitors• Richter B, Bandeira-Echtler E, Bergerhoff K et al (2008).

Dipeptidyl peptidase-4 (DPP-4) inhibitors for type 2 diabetes mellitus

• Used unchanged• Populations of both Cochrane review and NICE

guideline matched• NICE review undertaken by Aberdeen HTA group who

also prepare Cochrane reviews on diabetes• One person was author of both Cochrane review and

review for NICE

Depression in adults

• Guideline question: What is the clinical effectiveness of pharmacological/physical interventions in the treatment of depression?

• Cochrane review: Geddes, J. R., Freemantle, N., Mason, J, et al (2002). Selective serotonin reuptake inhibitors (SSRIs) for depression

• Review did not cover escitalopram which achieved its UK licence in late 2001, a separate review undertaken. 72/126 studies in Cochrane review did not meet the inclusion criteria set by the GDG

• Cochrane authors made their data available to NCC

Conclusions

• Cochrane reviews widely used directly in NICE guidelines

• Can also provide useful supporting information

• Can be used unchanged when they address guideline question directly

• Can be updated or specific sections selected

• Cochrane authors/review groups have worked with guideline developers to update/adapt reviews

Meeting between NICE and Cochrane UK: Sept 2011

• Explored ways of making better links to :– Promote greater efficiency and appropriate

collaboration– Avoid duplication– Promote mutual feedback

Thank you

and to Phil Alderson, Toni Tan, Judith Thornton