Are NICE guidelines too passive?

May 06, 2004

The effectiveness of the UK National Institute for Clinical Excellence (NICE) guidelines recommending changes in surgical procedures within the UK National Health Service is questioned by authors of a research letter in this week's issue of THE LANCET.

NICE issued its first guidance on procedures and technologies to the National Health Service In march 2000. James Ryan and colleagues assessed the effect of NICE guidance on NHS practice for two surgical procedures: extraction of impacted wisdom teeth and the selection of prostheses for total hip replacement. The guidance on these two procedures recommended the avoidance of routine wisdom-tooth extraction, and proposed that cement-based prostheses be used for total hip replacements.

Data on these procedures were available from 88 UK hospitals from 1997-2002, enabling comparisons before and after the NICE recommendations were made. Although a decrease in the removal of impacted wisdom teeth was observed from 1998 onwards, the investigators found that NICE guidelines had no significant effect on this downward trend. Similarly, there was no evidence from data available for 2000 and 2001 that the guidelines had any effect in prostheses used for hip replacements; counter to the recommendations, an increase in non-cement prostheses was reported after the guidelines were issued.

James Ryan comments: "Our findings could reflect the type of dissemination methods used by NICE. The usual form seems to be passive rather than active guidance, whereby in addition to publication of guidelines seen in passive guidance, adoption could also be promoted through regular training, monitoring, and review processes. In view of the ineffectiveness of passive strategies, use of more active dissemination methods could produce more effective uptake".

This week's editorial (p 1485) considers the challenge of implementing evidence-based guidance in the United States, where government agencies are adopting pharmaceutical industry techniques such as outreach visits to bring the message of rational prescribing to individual doctors. It concludes that investment in publicly funded education programmes are needed: 'What patients and doctors need are public programmes, not industry-sponsored initiatives that parade as education but are in fact thinly disguised marketing tools'.
Contact: Mr James Ryan, Mapi Values Ltd, Bollington SK10 5JB, Cheshire, UK; T) +44 (0)1625 577312 or +44 (0)1625 576815; E)

Lancet 2004; 363: 1485, 1525-26


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