Karin Lowson

What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews

Abstract Objectives To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE). Design Interrupted time series analysis, review of case notes, survey, and interviews. Setting Acute and primary care trusts in England and Wales. Participants All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts. Main outcome measures Rates of prescribing and use of procedures and medical devices relative to evidence based guidance. Results 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P < 0.002) and orlistat for obesity (P < 0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimers disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued. Conclusions Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context.

Postacute care for older people in community hospitals: a multicenter randomized, controlled trial.

OBJECTIVES: To compare the effects of community hospital care on independence for older people needing rehabilitation with that of general hospital care.

Effects of locality based community hospital care on independence in older people needing rehabilitation: randomised controlled trial

Abstract Objective To determine the effects on independence in older people needing rehabilitation in a locality based community hospital compared with care on a ward for elderly people in a district general hospital. Design Randomised controlled trial. Setting Care in a community hospital and district general hospital in Bradford, England. Participants 220 patients needing rehabilitation after an acute illness that required hospital admission. Interventions Patients were randomly allocated to a locality based community hospital or to remain within a department for the care of elderly people in a district general hospital. Main outcome measures Primary outcomes were Nottingham extended activities of daily living scale and general health questionnaire 28 (carer). Secondary outcomes were activities of daily living (Barthel index), Nottingham health profile, hospital anxiety and depression scale, mortality, destination after discharge, satisfaction with services, carer strain index, and carers satisfaction with services. Results The median length of stay was 15 days for both the community hospital and the district general hospital groups (interquartile range: community hospital 9-25 days; district general hospital 9-24 days). Independence at six months was greater in the community hospital group (adjusted mean difference 5.30, 95% confidence interval 0.64 to 9.96). Results for the secondary outcome measures, including care satisfaction and measures of carer burden, were similar for both groups. Conclusions Care in a locality based community hospital is associated with greater independence for older people than care in wards for elderly people in a district general hospital.

Structured re-assessment system at 6 months after a disabling stroke: a randomised controlled trial with resource use and cost study

BACKGROUND national policy recommends routine re-assessment of disabled patients and their carers at 6 months after stroke onset. The clinical and resource outcomes of this policy were investigated. DESIGN prospective, single-blind, randomised controlled trial in two centres. PARTICIPANTS a total of 265 patients with a disabling stroke and their carers. INTERVENTIONS a structured re-assessment system for patients and their carers at 6 months post-stroke or existing care. OUTCOME MEASURES primary: patient independence (Frenchay activities index) and carer stress (general health questionnaire 28). Secondary: activities of daily living, mood state, satisfaction with services, carer strain index, health and social service resource use and costs. RESULTS independence at 12 months post-stroke was similar in both groups (Frenchay activities index, adjusted mean difference 0.64; 95% confidence interval -0.74-2.02). Emotional distress in carers was similar in both groups (general health questionnaire 28, mean difference 0.02; 95% confidence interval -0.95-1.00). Results for the secondary outcome measures and total mean costs were similar for both groups. The intervention group patients used 301 fewer hospital bed days and 1,631 fewer care home bed days. CONCLUSIONS the structured, systematic re-assessment for patients and their carers was not associated with any clinically significant evidence of benefit at 12 months. Health and social care resource use and mean cost per patient were broadly similar in both groups. TRIAL REGISTRATION International Standard Randomised Controlled Trial Register; number: ISRCTN55412871.

A cost effectiveness analysis within a randomised controlled trial of post-acute care of older people in a community hospital

Abstract Objective To assess the cost effectiveness of post-acute care for older people in a locality based community hospital compared with a department for care of elderly people in a district general hospital, which admits patients aged over 76 years with acute medical conditions. Design Cost effectiveness analysis within a randomised controlled trial. Setting Community hospital and district general hospital in Yorkshire, England. Participants 220 patients needing rehabilitation after an acute illness for which they required admission to hospital. Interventions Multidisciplinary care in the district general hospital or prompt transfer to the community hospital. Main outcome measures EuroQol EQ-5D scores transformed into quality adjusted life years (QALYs), and health and social service costs over six months from randomisation. Results The mean QALY score for the community hospital group was marginally non-significantly higher than that for the district general hospital group (0.38 v 0.35) at six months after recruitment. The mean (standard deviation) costs per patient of the health and social services resources used were similar for both groups: community hospital group £7233 (euros 10 567;

Evaluation of the implementation of the alert issued by the UK National Patient Safety Agency on the storage and handling of potassium chloride concentrate solution

13 341) (£5031), district general hospital group £7351 (£6229), and these findings were robust to several sensitivity analyses. The incremental cost effectiveness ratio for community hospital care dominated. A cost effectiveness acceptability curve, based on bootstrapped simulations, suggests that at a willingness to pay threshold of £10 000 per QALY, 51% of community hospital cases will be cost effective, which rises to 53% of cases when the threshold is £30 000 per QALY. Conclusion Post-acute care for older people in a locality based community hospital is of similar cost effectiveness to that of an elderly care department in a district general hospital.

Estimating the direct costs of bowel cancer services provided by the National Health Service in England

Objectives: To assess the effectiveness of the response of NHS hospital trusts to an alert issued by the National Patient Safety Agency designed to limit the availability of concentrated potassium chloride in hospitals in England and Wales, and to determine the nature of any unintended consequences. Design: Multi-method study involving interviews and a physical inspection of clinical areas. Setting: 207 clinical areas in 20 randomly selected acute NHS trusts in England and Wales between 31 October 2002 and 31 January 2003. Participants: Senior managers and ward based medical and nursing staff. Main outcome measures: Degree of staff awareness of and compliance with the requirements of the national alert, withdrawal of concentrated potassium chloride solutions from non-critical areas, provision of pre-diluted alternatives, storage and recording in accordance with controlled drug legislation. Results: All trusts required that potassium chloride concentrate be stored in a separate locked cupboard from common injectable diluents (100% compliance). Unauthorised stocks of potassium chloride were found in five clinical areas not authorised by the trust (98% compliance). All trusts required documentation control of potassium chloride concentrate in clinical areas, but errors were recorded in 20 of the 207 clinical areas visited (90% compliance). Of those interviewed, 78% of nurses and 30% of junior doctors were aware of the alert. Conclusions: The NPSA alert was effective and resulted in rapid development and implementation of local policies to reduce the availability of concentrated potassium chloride solutions. The success is likely to be partly due to the nature of the proposed changes and it cannot be assumed that future alerts will be equally effective. Continued vigilance will be necessary to help sustain the changes.

A baseline study of anticoagulant management in UK hospitals

OBJECTIVES Bowel cancer is the second most common cancer in England and Wales, accounting for approximately 13,000 deaths per year. Economic evaluations and national guidance have been produced for individual treatments for bowel cancer. However, it has been suggested that Primary Care Trusts develop program budgeting or equivalent methodology demonstrating a whole system approach to investment and disinvestment. The objective of this study was to provide a baseline framework for considering a whole system approach to estimate the direct costs of bowel cancer services provided by the National Health Service (NHS) in England. METHODS A treatment pathway, developed in 2005, was used to construct a service pathway model to estimate the direct cost of bowel cancer services in England. RESULTS The service pathway model estimated the direct cost of bowel cancer services to the NHS to be in excess of £1 billion in 2005. Thirty-five percent of the cost is attributable to the screening and testing of patients with suspected bowel cancer, subsequently diagnosed as cancer-free. CONCLUSIONS This study is believed to be the most comprehensive attempt to identify the direct cost of managing bowel cancer services in England. The approach adopted could be useful to assist local decision makers in identifying those aspects of the pathway that are most uncertain in terms of their cost-effectiveness and as a basis to explore the implications of re-allocated resources. Research recommendations include the need for detailed costs on surgical procedures, high-risk patients and the utilization of the methods used in this study across other cancers.

How well do NHS trusts react to patient safety alerts

Objectives To undertake a baseline study of the management of anticoagulants in order to allow later comparison of the impact of the National Patient Safety Agency (NPSA) patient safety alert (including a new patient held record) published in April 2007. Methods A multimethod study comprising semistructured interviews in 20 acute trusts and a telephone/email survey of general practitioners (GPs). Results The authors found a high degree of consensus concerning a number of problems in the management of anticoagulation services. Consultant haematologists and chief pharmacists expressed concern about the level of competence of junior medical and nursing staff and the quality of patient discharge from general inpatient wards. Patients were regularly discharged before being stabilised on Warfarin, pre-discharge information was not always given, patient-held records were not reliably completed nor follow-up arrangements made. At the ward level, there was some confusion about the responsibility for completing the yellow book on discharge and little awareness of the role of GPs in providing a monitoring service. GPs were largely dissatisfied with the quality of discharge information. Conclusion The baseline data present a significant cause for concern in the management of warfarin prior to the publication of the NPSA safety alert.

A national survey to explore the management of the safety alert broadcast system in the UK

The study, first published in 2007, used several methods to study the nature of patient safety alerts, find out how trusts received and implemented them, assessed their impact and recommended improvements. Methods included surveys and interviews of staff at different levels from 41 NHS organizations and an in-depth study of 11 alerts.