Maggie Westby

Diagnosis, prevention, and management of delirium: summary of NICE guidance

Delirium is a complex clinical syndrome characterised by disturbed consciousness, cognitive function, or perception. Sometimes known as acute confusional state, delirium has an acute onset, a fluctuating course, and is associated with serious adverse outcomes such as death, dementia, and the need for long term care.1 Although common in general hospitals (affecting as many as about 30% of inpatients)1 and care homes, delirium is often poorly recognised1; however, it can be prevented in about one third of patients at risk.1 This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) guideline on how to recognise, prevent, and treat delirium.2 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the experience of the Guideline Development Group and their opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Assessment of risk factors [ Based on moderate and low quality evidence from prospective cohort studies ] ### Interventions to prevent delirium

Introducing GRADE across the NICE clinical guideline program

OBJECTIVES Grading of Recommendations Assessment, Development and Evaluation (GRADE) is a system for rating the confidence in estimates of effect and grading guideline recommendations. It promotes evaluation of the quality of the evidence for each outcome and an assessment of balance between desirable and undesirable outcomes leading to a judgment about the strength of the recommendation. In 2007, the National Institute for Health and Clinical Excellence began introducing GRADE across its clinical guideline program to enable separation of judgments about the evidence quality from judgments about the strength of the recommendation. STUDY DESIGN AND SETTING We describe the process of implementing GRADE across guidelines. RESULTS Use of GRADE has been positively received by both technical staff and guideline development group members. CONCLUSION A shift in thinking about confidence in the evidence was required leading to a more structured and transparent approach to decision making. Practical problems were also encountered; these have largely been resolved, but some areas require further work, including the application of imprecision and presenting results from analyses considering more than two alternative interventions. The use of GRADE for nonrandomized and diagnostic accuracy studies needs to be refined.

Diagnosis and management of chronic hepatitis B in children, young people, and adults: summary of NICE guidance

Chronic hepatitis B describes a spectrum of disease resulting from chronic hepatitis B virus (HBV) infection. About a third of the world’s population has serological evidence of past or present HBV infection, and 350-400 million people have chronic HBV infection.1 In the UK about 326 000 people are thought to have chronic hepatitis B.2 In some people, chronic hepatitis B may cause liver fibrosis, cirrhosis, and hepatocellular carcinoma; in others it is inactive and does not lead to important health problems.3 Antiviral therapy suppresses HBV replication and decreases the risk of progressive liver disease.4 This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on the diagnosis and management of chronic hepatitis B in children, young people, and adults.5 NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Assessment and referral in primary care #### Children, young people, and adults who are seropositive for HBV surface antigen (HBsAg)

Implantable loop recorders are cost-effective when used to investigate transient loss of consciousness which is either suspected to be arrhythmic or remains unexplained.

AIMS To assess the cost-effectiveness of implantable loop recorders (ILRs) in people with transient loss of consciousness (TLoC), which, after initial assessment and specialist cardiovascular assessment, is either suspected to be arrhythmic in origin or remains unexplained. This analysis was conducted to inform clinical guideline recommendations made by the National Institute for Health and Clinical Excellence (NICE) on the management of TLoC. METHODS AND RESULTS Decision analytic modelling was used to estimate the costs and benefits of using ILRs compared with a strategy of no further diagnostic testing. Diagnostic outcomes were estimated from a systematic review and used to populate a decision tree model. To capture the main consequences of diagnosis, the costs and benefits of treatment for several clinically significant arrhythmias were estimated within the model. We used a cost-utility approach, in which benefits are measured using quality adjusted life years (QALYs), and took a UK National Health Service (NHS) and personal social services perspective. The cost per QALY was £17,400 in patients with unexplained syncope and £16,400 in patients with suspected arrhythmic syncope. Sensitivity analysis found that the cost-effectiveness estimates are fairly robust despite the areas of uncertainty identified in the evidence and assumptions used to inform the model. CONCLUSIONS Implantable loop recorder monitoring is likely to be a cost-effective strategy in people presenting to the UK NHS who are experiencing infrequent episodes of TLoC which either remain unexplained or are suspected to be arrhythmic after initial assessment and specialist cardiovascular assessment. Implantable loop recorder monitoring has been recommended by NICE for these populations.

Synopsis of the National Institute for Health and Clinical Excellence Guideline for Management of Transient Loss of Consciousness

DESCRIPTION Transient loss of consciousness (TLoC) is common and often leads to incorrect diagnosis, unnecessary investigation, or inappropriate choice of specialist referral. In August 2010, the National Institute for Health and Clinical Excellence published a guideline that addressed the initial assessment of and most appropriate specialist referral for persons who have experienced TLoC. The guideline focused on correct diagnosis and relevant specialist referral and did not make treatment recommendations. This synopsis describes the principal recommendations concerning assessment and referral of a patient with TLoC. METHODS The National Clinical Guideline Centre developed the guidelines by using the standard methodology of the National Institute for Health and Clinical Excellence. A multidisciplinary guideline panel generated review questions, discussed evidence, and formulated recommendations. The panel included a technical team from the National Clinical Guideline Centre, who reviewed and graded all relevant evidence identified from literature searches published in English up to November 2009 and performed health-economic modeling. Both guideline development and final modifications were informed by comments from stakeholders and the public. RECOMMENDATIONS The panel made clear recommendations regarding the assessment of a person after TLoC, which emphasized the importance of clinical reasoning in diagnosis. Persons with uncomplicated faint, situational syncope, or orthostatic hypotension should receive electrocardiography but do not otherwise require immediate further investigation or specialist referral. Persons with features that suggest epilepsy should be referred for specialist neurologic assessment; brief seizure-like activity was recognized as a common occurrence during syncope that should not be regarded as indicating epilepsy. Persons with a suspected cardiac cause for TLoC or in whom TLoC is unexplained after initial assessment should receive specialist cardiovascular assessment. Guidance was provided on the appropriate choices of cardiovascular investigation, according to the presenting clinical circumstances.

Transient loss of consciousness—initial assessment, diagnosis, and specialist referral: summary of NICE guidance

Transient loss of consciousness is a spontaneous loss of consciousness with complete recovery, affecting a quarter to half of the population at some point in their lives.1 2 3 The condition has many possible causes, including cardiovascular disorders (ranging from cardiac arrhythmias to vasovagal syncope), epilepsy, and psychogenic attacks. Diagnosis is often inaccurate, inefficient, and delayed, and management varies considerably.1 Experience shows that the importance of obtaining information on the event itself and the need for early electrocardiography are not widely appreciated. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of transient loss of consciousness in people aged 16 and over.4 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. The recommendations emphasise elements of the diagnostic algorithm published in the Quick Reference Guide version of the NICE guidance, to which the reader should refer.4 Evidence levels for the recommendations are given in italic in square brackets ### Initial assessment

Tilt testing is more cost-effective than implantable loop recorder monitoring as a means of directing pacing therapy in people with recurrent episodes of suspected vasovagal syncope that affect their quality of life or present a high risk of injury

Objective To assess the cost-effectiveness of implantable loop recorders (ILRs) and tilt testing (TT) to direct pacing therapy in people with recurrent episodes of transient loss of consciousness that are adversely affecting their quality of life or represent a high risk of injury and are suspected to be vasovagal. Design Decision analytical modelling was used to estimate the costs and benefits of diagnostic testing including the costs and benefits of treatment for several clinically important arrhythmias following diagnosis. Setting A UK National Health Service and personal social services perspective was taken. Patients People with recurrent episodes of transient loss of consciousness that are adversely affecting their quality of life or represent a high risk of injury and which are suspected to be vasovagal. Interventions The diagnostic test strategies compared were TT alone, TT followed by ILR (if TT ‘negative’), ILR alone and no further testing. Main outcome measures Benefits measured using quality-adjusted life years and incremental cost-effectiveness ratios (ICER) are reported. Results The ICERs for TT alone, ILR alone and TT followed by ILR were £5960, £24 620 and £19 110, respectively, compared with no testing. ILR alone was extendedly dominated by the other strategies, meaning that it is never the most cost-effective option. Sensitivity analysis found that the cost-effectiveness estimates were robust despite the areas of uncertainty identified in the evidence and assumptions used to inform the model. Conclusions TT alone is likely to be the most cost-effective strategy in this population.

Authors’ reply to Balzer and colleagues

We thank Balzer and colleagues for their response to our summary.1 2 For the risk assessment tool recommendation, two reviews were undertaken—“test and treat” effectiveness of risk assessment tools (two randomised controlled trials (RCTs) and predictive ability of risk assessment tools (44 studies). For full details, refer to chapter 7 of the full guideline.3 The National Institute for Health and Care Excellence …