Search

Objective: There are no existing validated search filters for the group of 37 Organisation for Economic Co-operation and Development (OECD) countries. This study describes how information specialists from the United Kingdom’s National Institute for Health and Care Excellence (NICE) developed and evaluated novel OECD countries’ geographic search filters for MEDLINE and Embase (Ovid) to improve literature search effectiveness for evidence about OECD countries. Methods : We created the draft filters using an alternative approach to standard filter construction. They are composed entirely of geographic subject headings and are designed to retain OECD country evidence by excluding non-OECD country evidence using the NOT Boolean operator. To evaluate the draft filters’ effectiveness, we used MEDLINE and Embase literature searches for three NICE guidelines that retrieved >5,000 search results. A 10% sample of the excluded references was screened to check that OECD country evidence was not inadvertently excluded. Results : The draft MEDLINE filter reduced results for each NICE guideline by 9.5% to 12.9%. In Embase, search results were reduced by 10.7% to 14%. Of the sample references, 7 of 910 (0.8%) were excluded inadvertently. These references were from a guideline about looked-after minors that concerns both OECD and non-OECD countries. Conclusion: The draft filters look promising—they reduced search result volumes while retaining most OECD country evidence from MEDLINE and Embase. However, we advise caution when using them in topics about both non-OECD and OECD countries. We have created final versions of the search filters and will validate them in a future study.

We read with interest the excellent editorial ‘Postnatal care: new NICE guideline for the “Cinderella service”’.1 GPs’ involvement in the care of women in the perinatal period has never been so important as currently, during the COVID-19 pandemic. Pregnant women affected by COVID-19 are at higher risk of developing serious complications,2 especially women of Black, Asian, and minority ethnic backgrounds, and those with underlying medical conditions.3 MBRRACE-UK reported that the maternal mortality rate due to COVID-19 …

Objective: We previously developed draft MEDLINE and Embase (Ovid) geographic search filters for Organisation for Economic Co-operation and Development (OECD) countries to assess their feasibility for finding evidence about the countries. Here, we describe the validation of these search filters. Methods: We identified OECD country references from thirty National Institute for Health and Care Excellence (NICE) guidelines to generate gold standard sets for MEDLINE (n=2,065) and Embase (n=2,023). We validated the filters by calculating their recall against these sets. We then applied the filters to existing search strategies for three OECD-focused NICE guideline reviews (NG103 on flu vaccination, NG140 on abortion care, and NG146 on workplace health) to calculate the filters’ impact on the number needed to read (NNR) of the searches. Results: The filters both achieved 99.95% recall against the gold standard sets. Both filters achieved 100% recall for the three NICE guideline reviews. The MEDLINE filter reduced NNR from 256 to 232 for the NG103 review, from 38 to 27 for the NG140 review, and from 631 to 591 for the NG146 review. The Embase filter reduced NNR from 373 to 341 for the NG103 review, from 101 to 76 for the NG140 review, and from 989 to 925 for the NG146 review. Conclusion: The NICE OECD countries’ search filters are the first validated filters for the countries. They can save time for research topics about OECD countries by finding the majority of evidence about OECD countries while reducing search result volumes in comparison to no filter use.

Editor’s Note The following is reproduced here, with permission of the UK Council for Psychotherapy and their collaborators, because it makes interesting and generally applicable points about research methodologies. The references are: UKCP (2019) https://www.psychotherapy.org.uk/wp-content/uploads/2019/07/NICE-Depression-coalition-position-statement.pdf accessed 16 October 2019 UKCP (2019) https://cdn.ymaws.com/www.psychotherapyresearch.org/resource/resmgr/docs/downloads/StakeholderPositionStatement.pdf accessed 16 October 2019

Chronic pain is debilitating and depressing. ‘Chronic primary pain has no clear underlying condition or the pain (or its impact) appears to be out of proportion to any observable injury or disease. ’1 In July 2014, Sir Simon Wessely stated in an article in The Times entitled, Pain may be in the mind , that: ‘Many of them [chronic pain patients] have mental health disorders — anxiety, depression, etc’, and that, ‘patients felt dismissed and denigrated when they were referred to mental health services … ’. 2 As patient safety campaigners, we are hearing from many people who are developing ‘unexplained’ chronic pain conditions after taking antidepressants (ADs), as prescribed, and sometimes over many years — and this has often led to polypharmacy with other drugs added ‘for symptoms’ along the way, most likely including ADs, benzodiazepines, Z-drugs, opioids, …

Objectives To evaluate the different policies to recognize child maltreatment in emergency departments (EDs) in Europe in order to define areas of improvement. Methods A survey was conducted on the recognition of child maltreatment in EDs in European countries with a focus on screening methods, parental risk factors, training and hospital policies. The survey was distributed through different key members from the EUSEM, REPEM and the EuSEN. A summary score based on the NICE guideline (4 questions on child characteristics, 4 questions on parental characteristics and 5 questions on hospital policy) was calculated. Results We analysed 185 completed surveys, representing 148 hospitals from 29 European countries. Of the respondents, 28.6% used a screening tool, and 31.8% had guidelines on parental risk factors. A total of 42.2% did not follow training based on child characteristics, and 57.6% did not follow training on parental characteristics. A total of 71.9% indicated that there was a need for training. 50.8% of the respondents reported a standardized policy for the detection of child maltreatment. Translating the survey results to NICE summary scores of the EDs in Europe, we found that 25.6% (34/133) met most, 22.6% (30/133) met some and 51.9% (69/133) met few of the NICE guideline recommendations. More specifically, with respect to hospital policies, 33.8% (45/133) met most, 15.0% (20/133) met some and 51.1% (68/133) met few of the NICE guideline recommendations. Conclusion There is high variability regarding policies for child maltreatment detection and only a quarter of the EDs met most of the NICE guideline recommendations for child maltreatment. There is a need for the use of screening tools, training of ED staff and implementation of local hospital policies.

The concept of patient insight, of a patient’s self-awareness of illness or impairment (and related issues), plays a significant role in clinical discourse and clinical practice. But what role does it play in the legal process, particularly when a patient’s decision-making capacity (or ‘mental capacity’) is in question? We report on a survey of 412 published judgments from the Court of Protection of England and Wales, published between 2007 and 2018. We found that the notion of patient insight played a role in 53 cases (13% of the total). We use a variety of techniques to provide a systematic profile of these ‘insight cases’. We provide a demographic profile of the patients whose insight is discussed (focusing on gender, age and diagnosis) and a professional profile of the expert witnesses who raise the issue of insight. We then deploy the technique of ‘logical geography’ to map the meaning of the term insight and the inferential patterns in which reports of patient insight are embedded. We point out that the published insight cases never explicitly define ‘insight,’ and that they include no reference to structured instruments or scales for the assessment of insight. We show that the concept of insight, as used in the Court of Protection, is not synonymous with the concept of agreement with a diagnosis of illness; this is at most one of a range of meanings that the concept carries. We show that, despite the fact that the presence or absence of insight is not itself a legal criterion for mental capacity, insightlessness does play a role, and sometimes a decisive role, in shaping findings as regards the presence or absence of mental capacity. Finally, we assess the extent to which expert testimony in the insight cases conforms to the insight-related recommendation of the recent NICE Guideline on Decision-Making and Mental Capacity.

The new NICE guidelines on thyroid disease and its management do not recommend the routine use of liothyronine, but do not completely rule it out either. Guidelines from the British and European Thyroid Associations are open to a “trial of liothyronine” on an individual basis.Some patients do not feel well on L-thyroxine despite a serum TSH in the reference range. Key issues to consider in such patients include establishing whether the patient had established hypothyroidism initially, and whether the L-thyroxine has been titrated carefully enough, possibly using small increments, to achieve a careful balance between symptoms and serum TSH concentrations. Patients should also be considered for other causes of the symptoms which may be wide-ranging.Meta-analyses of several, but small, randomised control trials show no advantage, or disadvantage of liothyronine over L-thyroxine. However, detailed sub-analysis identifies some tantalising results eg on preferential weight loss, patient preference, and possibly genetic markers. Although linked with plausible theoretical explanations, these results may be over-interpreted. The key questions are whether a short-term trial treatment is worthwhile and safe, and whether in the future sub-groups of patients can be identified who may benefit from liothyronine. These questions remain divisive but require additional focussed research.It could be argued that inflated costs of liothyronine in some countries have either distracted from or helped focus on the science. Costs need to be addressed. However better biomarkers of tissue level thyroid action, and a better understanding of the impact of genetic polymorphisms will help to make progress when choosing if there is a place for liothyronine in the future.(words: 262)

ObjectiveIn this retrospective cohort study we aimed to assess, in 202,247 people who started a statin therapy between 2007-2014, the factors that led to the initiation of the drug. To do this we explored CVD risk factors singularly and in combinations as recorded in electronic health records in the year before they receive their first prescription and we compared the risk scores with that suggested by the NICE guideline at that time.MethodsWe summarised demographic characteristics and proportions of people with a risk score below the threshold. Regression-based analyses are performed to evaluate the association between the missingness of the risk score and relevant risk score components.Results45,364 individuals (22.4%) were prescribed statins without a record of a risk score being available in the year prior to the prescription date. When the risk score was available, 68,174 out of 156,883 patients were prescribed statins even with a score below the 20% threshold. Smoking status was the most frequently recorded variable (74.9% of the instances), followed by systolic blood pressure (71.6%) and total cholesterol (70%), while HDL cholesterol was the least recorded (34.1%). Cholesterol levels are positively associated with the missingness of the risk score, while systolic blood pressure shows a negative association.ConclusionsGPs often start statins on people with no risk score recorded in their clinical records or in those with risk scores below the recommended threshold. Higher cholesterol values may result in a GP starting statin therapy without recording the other relevant components required to calculate a risk score.STRENGTHS AND LIMITATIONS OF THIS STUDYOur cohort contains a large number of individuals: the study provide a representative picture of initiation of statins in UK primary care.We specifically focus on which variables and factors GPs record in electronic databases in the year prior statin treatment initiation: this is the first study to directly tackle the issue of statins prescribing in the absence of all the information required by the NICE guidelineWe are not able to verify if GPs actually used the records of the individual health indicators, when these were available, to calculate the risk score.

To reassess if our hospital has improved its assessment of delirium diagnosis, prevention and management after raising awareness of delirium through education, training and dissemination of delirium care bundle throughout the trust. A prospective sample of patients admitted to a district general hospital between 1 April 2017 to 8 April 2017 with confusion or developed confusion during their hospital stay. A total of 28 patients were identified and their notes were reviewed. The National …

AimsTo evaluate if patients referred to Ealing Liaison Psychiatry Service (ELPS) with co-existing substance use are being appropriately identified as per NICE guidelines.Patients with co-existing substance misuse have greater morbidity and mortality and it is therefore important to identify these patients to optimise their management. NICE recommends that all patients are asked about their substance use.Anecdotally, our team felt we were doing a good job of identifying and managing such patients but we had no objective evidence of this.MethodCompleted a retrospective audit looking at a sample of patients referred to ELPS over two weeks in December 2019.A training session for ELPS was then held to highlight the initial audit results and NICE guideline recommendations.We then repeated the audit over two weeks in March 2020.ResultInitial audit (100 patients):Only 69% of patients asked about substance use. From those asked, 50-65.2% were using a substance, most commonly alcohol.None of the patients over the age of 80 were asked about substance use vs 79.5% of patients aged 20–40 years.55% of females vs 81% of males were asked about illicit substances.33.3% of ward referrals vs 74.2% of Emergency Department referrals asked about substance useRe-audit (53 patients):Significant improvement across all areas93% now asked about substance use60% of over 80s, 96% of females and 85% of ward referrals were now being correctly asked about substance useConclusionWe were surprised to find that we were initially not meeting NICE standards regarding asking patients about their substance use.Acknowledging this problem during our training session proved to be effective.This knowledge will help us develop our care pathways with our Acute colleagues and the Drug and Alcohol Liaison Service.

Background: Major orthopedic surgery, such as elective total hip replacement (eTHR) and elective total knee replacement (eTKR), are associated with a higher risk of venous thromboembolism (VTE) than other surgical procedures. Little is known, however, about the cost-effectiveness of VTE prophylaxis strategies in people undergoing these procedures. Aim: The aim of this work was to assess the cost-effectiveness of these strategies from the English National Health Service perspective to inform NICE guideline (NG89) recommendations. Materials and Methods: Cost-utility analysis, using decision modeling, was undertaken to compare 15 VTE prophylaxis strategies for eTHR and 12 for eTKR, in addition to “no prophylaxis” strategy. The analysis complied with the NICE Reference Case. Structure and assumptions were agreed with the guideline committee. Incremental net monetary benefit (INMB) was calculated, vs. the model comparator (LMWH+ antiembolism stockings), at a threshold of £20,000/quality-adjusted life-year (QALY) gained. The model was run probabilistically. Deterministic sensitivity analyses (SAs) were undertaken to assess the robustness of the results. Results: The most cost-effective strategies were LMWH for 10 days followed by aspirin for 28 days (INMB = £530 [95% CI: -£784 to £1,103], probability of being most cost-effective = 72%) for eTHR, and foot pump (INMB = £353 [95% CI: -£101 to £665]; probability of being most cost-effective = 18%) for eTKR. There was considerable uncertainty regarding the cost-effectiveness ranking in the eTKR analysis. The results were robust to change in all SAs. Conclusions: For eTHR, LMWH (standard dose) for 10 days followed by aspirin for 28 days is the most cost-effective VTE prophylaxis strategy. For eTKR, the results are highly uncertain but foot pump appeared to be the most cost-effective strategy, followed closely by aspirin (low dose). Future research should focus on assessing cost-effectiveness of VTE prophylaxis in the eTKR population.

Background Viral bronchiolitis is one of the most common causes of hospitalisation in young infants. It has previously been shown that many United Kingdom (UK) hospital Trusts were not compliant with many aspects of the National Institute for Health and Care Excellence (NICE) bronchiolitis guideline prior to its publication. Objectives This study aimed to investigate changes in the management of bronchiolitis by hospital Trusts between 2015 (before NICE guideline publication) and 2017, after publication. Study design We prospectively surveyed paediatricians at UK hospital Trusts on the management of bronchiolitis before (March to May 2015) and after (January to May 2017) the NICE bronchiolitis guideline publication in June 2015, using an electronic, structured questionnaire. Results In 2015 111 Trusts were represented and in 2017 100 Trusts. Significant improvements were seen in the use of nebulised bronchodilators and hypertonic saline and provision of parental written guidance. However, full compliance with the guideline did not change with 18% of Trusts compliant before publication of the guideline in 2015 and 19% fully compliant with the guideline in 2017. Conclusions Overall there were modest but important improvements in the reported management of bronchiolitis after the publication of the NICE guideline.

The British Thoracic Society (BTS) first produced a guideline on asthma and its management in 1990. The first collaborative guideline with the Scottish Intercollegiate Guideline Network (SIGN) using evidence-based medicine methodology was published in 2003.1 It has since become a mainstay of asthma management across the UK and beyond with updates published regularly every 18–24 months. The latest BTS/SIGN guideline for the management of asthma was published in 2016.2 Both BTS and SIGN are committed to continuing updates with the next update planned for publication in 2019. Following publication of National Institute for Health and Care Excellence (NICE) guidelines for diagnosis and monitoring, and for management of chronic asthma,3–5 there are now two if not three national guidelines, for England at least, with some (apparently) striking differences. This statement considers the similarities and differences to assist clinical colleagues in the care of people with asthma. The evidence base considered by the BTS/SIGN and NICE guideline development groups is broadly the same for each guideline, but the methodology used to produce recommendations is significantly different: These different processes have resulted in some discrepancies in recommendations made by BTS/SIGN and NICE. This article seeks to provide some context to these differences in key areas: The BTS/SIGN guideline also provides recommendations …

Multimorbidity is associated with a high treatment and care burden that may impact on the wellbeing of the patienthttp://ow.ly/D0xM307Ttoe

The Department of Health has defined hospital acquired venous thromboembolism (VTE) as any VTE event occurring within 90 days of hospital admission or surgery. 1 Hospital acquired thrombosis (HAT) is common during and after hospital admission and is considered a major patient safety issue. Current NICE guideline (CG 92) 2010, recommends that medical patients assessed at risk of VTE should have pharmacological prophylaxis commenced as soon as possible after risk assessment has been completed and continued until the patient is no longer at increased risk of VTE. 2 This quality improvement project was carried out in the medical assessment unit in Derriford Hospital, Plymouth. We aimed to increase appropriate VTE pharmacological prophylaxis to 100% prescribed in 6 hours by the end of May 2016 using the Plan-Do-Study-Act (PDSA) methodology. The primary outcome measure was whether or not enoxaparin was given within 6 hours of admission. Analysis showed that a major contributing factor to the prolonged time interval was lack of awareness of the Trust VTE guidelines which had recently been updated in accordance with NICE recommendations. Baseline measurement demonstrated that 29% of patients had first dose of enoxaparin within the 6-hour target, with a mean delay of 12 hours 22 minutes. With implementation of an education programme and development of a local VTE prevention care pathway to raise awareness of the new guidelines, a significant improvement was achieved with 71% of patients meeting the 6-hour target in PDSA cycle 1 and 83% of patients in PDSA cycle 2. The average time interval also reduced to 5 hours 52 minutes in PDSA cycle 1 and 5 hours 7 minutes in PDSA cycle 2. In conclusion, through utilization of simple change methodology, enoxaparin prescribing practice significantly improved. Potentially this may reduce morbidity (and mortality) associated with HAT together with cost implications of its management.

PE can be quite difficult to diagnose. It is relatively common and can be fatal without adequate treatment. As per NICE guideline on the management of patients with suspected PE, where patients are considered to be of lower risks for PE based on the Wells score, D-dimer can be used to stratify

Background:\ud This study explores the extent to which recommendations from the National Institute of Health and Care Excellence (NICE) 142 guidelines, section 9.2 (relating to identification, assessment and diagnosis) reflected existing routine clinical practice in Autism Spectrum Disorder (ASD) diagnosing services in Scotland; and whether there was a significant relation between routine practice which more closely reflected these recommendations and waiting times.\ud \ud Method:\ud A cross-sectional, retrospective case note analysis of recently diagnosed adults, in eight ASD services across Scotland.\ud \ud Results:\ud The study found that the existing practice of the participating services was consistent with 14 (maximum number) of the included recommendations in at least half of cases analysed (range 37–70 cases) and was not related to increased total waiting time for diagnosis.\ud \ud Conclusion:\ud The results, based only on the included recommendations, suggest that the section 9.2 recommendations can be integrated into clinical practice in Scotland with relative ease and that it is unlikely to have a negative impact on waiting times.

SummaryWhat is known and objective The tricyclic antidepressant dosulepin has been associated with an increased risk of toxicity in overdose compared with other antidepressants. In the UK, the MHRA and NICE have issued advice on the prescribing of dosulepin, and a National Prescribing Indicator (NPI) to monitor usage was introduced in Wales in 2011. The aim of this study was to assess whether trends in dosulepin usage in Wales and NE England changed following the two pieces of safety guidance and the introduction of the National Prescribing Indicator in Wales. Methods Primary care dosulepin usage in the 12 months prior to and following MHRA safety advice (in 2007), NICE guideline CG90 (in 2009) and the introduction of the NPI (in 2011) was obtained. Usage was measured using defined daily doses (DDDs) per 1000 prescribing units (PUs). The trends in the 12 months prior to and following the introduction of prescribing advice and the NPI were compared using an autoregressive integrated moving average (ARIMA) model. Results and discussion In Wales, the trend in dosulepin usage did not change significantly prior to and following the MHRA advice: −0·18 and −0·43 DDDs/1000PUs per month, respectively (P = 0·07), or prior to and following NICE CG90: −0·30 and −0·49 DDDs/1000PUs per month, respectively (P = 0·35). In the 12 months prior to and following the introduction of the NPI, the trend was −0·45 and −0·98 DDDs/1000PUs per month, respectively (P = 0·001). In NE England, the trend did not alter significantly following the NICE advice or the introduction of the NPI in Wales. What is new and conclusion The trend in dosulepin usage in Wales altered significantly following the introduction of the NPI, but not after the other prescribing advice. This association, coupled with the absence of a significant change in NE England over the same period, provided some evidence of the effectiveness of the NPI in prompting a change in prescribing behaviour in Wales.

The National Institute for Health and Care Excellence has published new guidance on the diagnosis and management of varicose veins in the legs.1 The guideline is short but is likely to mark a change in how varicose veins are managed in general practice, and makes recommendations on information for people with varicose veins, criteria for referral, and treatments and management in pregnancy. The guideline uses the Clinical Etiological Anatomical Pathophysiological (CEAP) classification of varicose veins (Box 1),2 which includes information on the clinical severity, aetiology, anatomical location, and pathophysiology of varicose veins and was originally intended for research purposes. Although accepted internationally and used in clinical practice it does have some limitations and is not used as the basis of referral criteria in the guideline. The Guideline Development Group agreed that it was more important for those referring to a vascular service to use clear, key clinical indicators and listen to the patient rather than trying to categorise people using CEAP. Box 1. ### CEAP classification

Objective. Palliative home care involves coordination of care between the professionals involved. The NICE guideline on supportive and palliative care (UK) recommends that teams, regardless of their base, should promote continuity for patients. This may involve nomination of a coordinating "key worker". This study aimed to explore who acts as key worker and who ought to take on this role in the views of patients, relatives, and primary care professionals. Furthermore, it aimed to explore the level of agreement on this issue between study participants. Design. Interview and questionnaire study. Setting. Former County of Aarhus, Denmark (2008-2009). Subjects. Ninety-six terminally ill cancer patients, their relatives, general practitioners (GPs), and community nurses (CNs). Main outcome measures. Actual key worker as valued by patients, relatives, and primary care professionals; ideal key worker as valued by patients and relatives. Results. Patients, relatives, GPs, and CNs most often saw themselves as having been the key worker. When asked about the ideal key worker, most patients (29%; 95%CI: 18;42) and relatives (32%; 95%CI: 22;45) pointed to the GP. Using patients' views as reference, we found very limited agreement with relatives (47.7%; k = 0.05), with GPs (30.4%; k = 0.01) and with CNs (25.0%; k = 0.04). Agreement between patients and relatives on the identity of the ideal key worker was of a similar dimension (29.6%; k = 0.11). Conclusion. Poor agreement between patients, relatives, and professionals on actual and ideal key worker emphasizes the need for matching expectations and clear communication about task distribution in palliative home care.

Obesity is a major public health issue and numerous clinical guidelines have been published to support management. One of the most comprehensive guidelines on obesity was published by the National Institute for Health and Clinical Excellence (NICE) in 2006 (NICE guideline 43) which aims to offer practical recommendations based on the available evidence and has a strong focus on primary care both in terms of prevention and clinical care. The current article summarises these guidelines in relation to primary care, reports on new evidence and developments since they were published, and critically appraises the usefulness of guidelines for management of obesity.

Background\ud The NICE guideline for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) emphasises the need for an early diagnosis in primary care with management tailored to patient needs. However, GPs can be reluctant to make a diagnosis and are unsure how to manage people with the condition.\ud \ud Methods\ud A meta synthesis of published qualitative studies was conducted, producing a multi-perspective description of barriers to the diagnosis and management of CFS/ME, and the ways that some health professionals have been able to overcome them. Analysis provided second-order interpretation of the original findings and developed third-order constructs to provide recommendations for the medical curriculum.\ud \ud Results\ud Twenty one qualitative studies were identified. The literature shows that for over 20 years health professionals have reported a limited understanding of CFS/ME. Working within the framework of the biomedical model has also led some GPs to be sceptical about the existence of the condition. GPs who provide a diagnosis tend to have a broader, multifactorial, model of the condition and more positive attitudes towards CFS/ME. These GPs collaborate with patients to reach agreement on symptom management, and use their therapeutic skills to promote self care.\ud \ud Conclusions\ud In order to address barriers to the diagnosis and management of CFS/ME in primary care, the limitations of the biomedical model needs to be recognised. A more flexible bio-psychosocial approach is recommended where medical school training aims to equip practitioners with the skills needed to understand, support and manage patients and provide a pathway to refer for specialist input.