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BACKGROUND: In the UK, NHS hospitals receive large amounts of evidence-based recommendations for care delivery from the National Institute for Health and Care Excellence (NICE) and other organisations. Little is known about how NHS organisations implement such guidance and best practice for doing so. This study was therefore designed to examine the dissemination, decision-making, and monitoring processes for NICE interventional procedures (IP) guidance and to investigate the barriers and enablers to the implementation of such guidance.
METHODS: A cross-sectional survey questionnaire was developed and distributed to individuals responsible for managing the processes around NICE guidance in all 181 acute NHS hospitals in England, Scotland, Wales and Northern Ireland. A review of acute NHS hospital policies for implementing NICE guidance was also undertaken using information available in the public domain and from organisations' websites.
RESULTS: The response rate to the survey was 75 % with 135 completed surveys received. Additionally, policies from 25 % of acute NHS hospitals were identified and analysed. NHS acute hospitals typically had detailed processes in place to implement NICE guidance, although organisations recognised barriers to implementation including organisational process barriers, clinical engagement and poor targeting with a large number of guidance issued. Examples of enablers to, and good practice for, implementation of guidance were found, most notably the value of shared learning experiences between NHS hospitals. Implications for NICE were also identified. These included making improvements to the layout of guidance, signposting on the website and making better use of their shared learning platform.
CONCLUSIONS: Most organisations have robust processes in place to deal with implementing guidance. However, resource limitations and the scope of guidance received by organisations create barriers relating to organisational processes, clinician engagement and financing of new procedures. Guidance implementation can be facilitated through encouragement of shared learning by organisations such as NICE and open knowledge transfer between organisations.
VibraTip™ was selected by the Medical Technologies Advisory Committee (MTAC) to undergo evaluation through the National Institute for Health and Care Excellence (NICE). VibraTip™ provides a vibratory stimulus for the purpose of detecting diabetic peripheral neuropathy (DPN) in patients with type 1 or 2 diabetes mellitus, and is intended to replace the current practice of using the 128 Hz tuning fork or 10 g monofilament (comparators). The sponsor (McCallan Medical) provided clinical and economic submissions which were evaluated by an External Assessment Centre (EAC). Of six diagnostic studies identified, the EAC considered that only one was directly relevant to the assessment. This study indicated VibraTip™ had a sensitivity of 0.79 (95 % CI 0.69-0.90) and specificity of 0.82 (95 % CI 0.74-0.90) for DPN using a neurothesiometer at 25 V as a reference standard. This was non-inferior to the comparators, but the sample size (n = 141) was too small to draw unequivocal conclusions and it is unclear how generalisable results were to clinical practice. The sponsor presented a de facto cost-minimisation model that in the base case showed minimal cost savings and, in sensitivity analysis which assumed diagnostic superiority of VibraTip™, showed large savings. The EAC appraised this model and concluded it was flawed as it was not evidence based and costs were likely to be unrealistic. The MTAC considered that the technology showed promise but decided the case for adoption was not proven, and therefore made a research recommendation as is reflected in NICE Medical Technology Guidance 22.
OBJECTIVES: To undertake a network meta-analysis (NMA) to assess the effectiveness of licensed interventions (aflibercept 2q8, ranibizumab PRN, pegaptanib and photodynamic therapy (PDT)) in the treatment of neovascular (wet) age-related macular degeneration (wet AMD).
METHODS: A systematic review was undertaken to identify trials comparing any of the interventions to treat neovascular AMD reporting change in best corrected visual acuity (BCVA). A NMA of the studies was carried out using WinBugs. Identified studies often reported results at multiple time points. Hence, a number of models were applied accounting for the time structure in the data. The deviance information criterion (DIC) was used to select the most appropriate model. Multiple separate networks were applied to the data to account for the fact that posologies were equivalent at some time points.
RESULTS: 21 trials were included in the network. Aflibercept and ranibizumab were found to be statistically superior to PDT and pegaptanib at 12 and 24 months. The mean change from baseline BVCA estimated between ranibizumab and PDT at 12 months was 18.85 [15.42 to 22.26] and at 24 months was 20.62 [17.25 to 23.96]. The mean change from baseline BVCA estimated between ranibizumab and pegaptanib at 12 months was 11.16 [2.93, 20.63] and at 24 months was 11.71 [3.31, 25.06]. Results for aflibercept were quantitatively similar. There was minimal difference in the effectiveness of ranibizumab and aflibercept at any time point: mean difference at 12 months numerically favoured ranibizumab by 0.05 [-1.33 to 1.52] and at 24 months by 0.02 [-1.36 to 1.44].
CONCLUSIONS: Aflibercept and ranibizumab are effective treatments for neovascular AMD demonstrating a clinically and statistically significant difference in BVCA compared with PDT and Pegaptanib. There were only minimal (non-statistically significant) differences in the relative effectiveness of aflibercept and ranibizumab at any time point.
INTRODUCTION: Increasing numbers of the population are living with long-term life-limiting conditions with a significant proportion characterised by multimorbidity. Patients with these conditions often experience high volumes of clinical interaction involving them, their caregivers and healthcare providers in complex patterns of organising, coordinating, negotiating and managing care. A better understanding of the sources of experienced complexity and multimorbidity, from the patient perspective is paramount to improve capacity and manage workload to promote improved experience of illness, more effective healthcare utilisation and improved healthcare outcomes. To better understand the sources of complexity we will undertake an evidence synthesis of qualitative studies of patient and informal carer experiences of three common long-term life-limiting conditions. We will investigate what is known about these diseases at different stages in disease progression, treatment regimens and places of care.
METHOD AND ANALYSIS: We will include qualitative studies of patients' and carers' (aged >18) accounts of their experiences of healthcare provision in a range of settings and healthcare systems. We will conduct an extensive electronic database search of publications in English between 2000 and 2014. Results and discussions sections of the papers will be regarded as formal data using the constant comparison method of qualitative analysis. From the meta-synthesis results, we will build a conceptual model of mechanisms and processes that shape patients' journeys towards end of life to suggest where in the patient journey new interventions to improve patient and carer experience can be developed and delivered. The study is being conducted between 1 December 2014 and 31 December 2015.
ETHICS AND DISSEMINATION: No human subjects or personal data are involved and no ethical issues are anticipated. An important element of dissemination is informing user communities about the practical implications of the work through workshops, meetings and social media. Scientific results will be published in peer reviewed journals and disseminated through conferences.
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BACKGROUND: A number of significant recent research studies have used techniques of economic modelling to demonstrate the potential benefits of increasing breastfeeding rates in the UK overall, and specifically in neonatal care. This paper complements this growing body of evidence by presenting an economic analysis of data from an actual intervention, the 'Getting It Right From the Start' programme, which took place in the north of the UK during 2011-12, with the aim of increasing breastfeeding and kangaroo skin-to-skin care rates in neonatal units.
METHODS: 'Getting It Right from the Start' was a pragmatic, multifaceted programme of change delivered under the auspices of the regional Health Innovation and Education Cluster, of which 17 were established in the UK in 2010. It engaged with 18 neonatal units in two Neonatal Networks with the aim of increasing kangaroo skin-to-skin care and breastfeeding rates. As part of the evaluation of the programme, we conducted an economic study comparing the overall costs and benefits of the intervention.
RESULTS: Overall, the economic analysis demonstrated that for every £1 invested in the intervention to increase kangaroo skin-to-skin care and breastfeeding rates, between £4.00 and £13.82 of benefit was generated. This was spread across different healthcare settings and the timescale for the realisation of benefits will vary. The increases in kangaroo skin-to-skin care generated the greatest cost savings, with potential cost savings ranging between £668,000 (minimum cost assumptions) to more than £2 m (maximum cost assumptions). Increases in breastfeeding associated with the project generated between £68,486 and £582,432. The majority of the cost savings generated were associated with reductions in cases of gastroenteritis and necrotising enterocolitis.
CONCLUSION: This was one of the first economic evaluations of an actual intervention to increase breastfeeding and kangaroo skin-to-skin care in neonatal units. It complements the existing economic models by demonstrating that a real intervention in clinical practice was both cost effective as well as clinically beneficial. Future interventions with similar methodology should be supported and considered likely to generate significant cost savings compared to outlay. Economic evaluation should be more frequently included in studies of practical interventions in clinical settings to increase breastfeeding.
