NICE clinical guidelines:
new challenges and how Cochrane
can help
Fergus Macbeth
NICE Clinical Guidelines
• Over 10 years NICE has published 129 guidelines
• 19 are updates
• Wide spectrum of topics covering most significant areas
of clinical practice
• Developed by 4 National Collaborating Centres and an
internal team (Short guidelines)
• Two year development following rigorous methodology
Implementation
• Support tools: audit tools, costing templates, slide sets
• Field team: 6 people for all England!
• System levers:
– An ´expectation’ by Inspectors that NICE guidelines
are used
– Used by commissioners to specifiy services
• Generally high profile
• Disseminated and supported by professional bodies
and patient groups
New challenges
• Significant efficiency savings needed over 3 years
• Requirement to deliver c150 new quality standards
based on NICE guidance over the next 4 years
• c60 new guidelines needed
• As well as updating existing output
When are guidelines out of date?
Proportion of clinical guidelines that need updating
at x years following publication:
Age of
guidelines
Percentage
needing updating
95% Confidence
interval
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Year 7
Year 8
0.90
4.09
14.53
33.15
50.40
61.42
61.42
83.47
0.13 - 6.20
1.55 - 10.57
8.48 - 24.29
23.15 - 45.98
37.98 - 64.27
47.75 - 75.28
47.75 - 75.28
59.01 - 97.35
How can Cochrane help?
Mapping of Cochrane use in NICE
clinical guidelines
• Review of 116 clinical guidelines published by end
February 2011
• Excluded 10 guideline updates
• Overall total =106 guidelines
• Searched text and appendices for citations of Cochrane
reviews
Results
• 731 citations of Cochrane reviews
– Range: 0 - 44 citations per guideline, mostly 1-10
– Mean: 7 citations
– Some Cochrane reviews >1 citation
– Use as supporting information: 23 citations
Citation of Cochrane Reviews
Citations of
Cochrane
Reviews
0
1 to 5
6 to 10
11 to 15
16 to 20
21 to 25
26 to 30
31 to 35
36 to 40
41 to 45
No. of guidelines
Percentage
20
45
19
9
4
2
3
0
3
1
19
42
18
8
4
2
3
0.0
3
1
How were reviews used in guidelines?
• 1 guideline from each NCC published since 2009
• CG81, Breast cancer (advanced) - February 2009
• CG87, Type 2 diabetes: newer agents (a partial update
of CG66) - June 2009
• CG90, Depression in adults (update) October 2009
• CG101, Chronic obstructive pulmonary disease
(update) - June 2010
• CG 102, Bacterial meningitis and meningococcal
septicaemia in children - June 2010 and Sept 2010
Summary
Total number
of questions
in guidelines
Cochrane
review used
unchanged
Cochrane
review
updated or
adapted
Cochrane
review used
as supporting
information
Cochrane
review not
used
61
39
13
5
4
Cochrane review updated or changed
• Newly-published studies added to Cochrane review (6)
• Some studies excluded because did not meet inclusion
criteria for question (2)
• Studies with a short follow up period excluded (1)
• Studies on specific treatments extracted (1)
• Studies on adults excluded for a guideline in children (1)
• Results from adults extrapolated for a guideline in children
(1)
• Studies on a specific microorganism extracted (1)
Cochrane review not used
• Developers did not plan to update section but
mentioned that further data was now available in the
Cochrane review (1)
• Studies in Cochrane review investigated vaccines no
longer used in clinical practice (1)
• Studies from Cochrane review assessed independently
in guideline (2)
NICE and Cochrane working together
• Breast cancer (advanced)
• Type 2 diabetes: newer agents
• Depression in adults
Breast cancer (advanced)
• Guideline question: What is the choice of first line
treatment for patients with metastatic breast cancer,
endocrine therapy of chemotherapy?
• Cochrane review: Wilcken N, Hornbuckle J and Ghersi
D (2006). Chemotherapy alone versus endocrine
therapy alone for metastatic breast cancer
• Used unchanged but with some comments
• Director of NCC was Cochrane Coordinating Editor,
review commissioned by NCC Cancer
Type 2 diabetes, newer agents
• Guideline question: Does the effectiveness differ between
NPH insulin and a long-acting insulin analogue (insulin
glargine, insulin detemir) when a basal insulin is
indicated?
• Cochrane review: Horvath K, Jeitler K, Berghold A et al
(2007). Long-acting insulin analogues versus NPH insulin
(human isophane insulin) for type 2 diabetes mellitus
• Used unchanged
Type 2 diabetes, newer agents
• Guideline question: 8 questions around DPP-4 inhibitors
• Richter B, Bandeira-Echtler E, Bergerhoff K et al (2008).
Dipeptidyl peptidase-4 (DPP-4) inhibitors for type 2
diabetes mellitus
• Used unchanged
• Populations of both Cochrane review and NICE
guideline matched
• NICE review undertaken by Aberdeen HTA group who
also prepare Cochrane reviews on diabetes
• One person was author of both Cochrane review and
review for NICE
Depression in adults
• Guideline question: What is the clinical effectiveness of
pharmacological/physical interventions in the treatment
of depression?
• Cochrane review: Geddes, J. R., Freemantle, N.,
Mason, J, et al (2002). Selective serotonin reuptake
inhibitors (SSRIs) for depression
• Review did not cover escitalopram which achieved its
UK licence in late 2001, a separate review undertaken.
72/126 studies in Cochrane review did not meet the
inclusion criteria set by the GDG
• Cochrane authors made their data available to NCC
Conclusions
• Cochrane reviews widely used directly in NICE
guidelines
• Can also provide useful supporting information
• Can be used unchanged when they address guideline
question directly
• Can be updated or specific sections selected
• Cochrane authors/review groups have worked with
guideline developers to update/adapt reviews
Meeting between NICE
and Cochrane UK: Sept 2011
• Explored ways of making better links to :
– Promote greater efficiency and appropriate
collaboration
– Avoid duplication
– Promote mutual feedback
Thank you
and to Phil Alderson, Toni Tan, Judith Thornton