Implementing the National Programme for IT
BEST CURRENT EVIDENCE STRATEGY
CONSULTATION PAPER – MARCH 2006
Comments to J A Muir Gray
Version
Version 1.0
Date
21 March 2006
NPFIT/Bestcurrentevidence/29.3.06
Prepared by
J A Muir Gray, following a meeting with patient
representatives.
Consultation period open until 31 May 2006
1
CONTENTS

Knowledge is the enemy of disease.

Best Current Evidence – concepts and plans

List of appendices

Appendix 1: Providing clean clear knowledge for busy clinicians and patients

Appendix 2: Decision Support Programme – knowledge support, computer-based clinical
decision support systems, and patient decision aids

Appendix 3: National Library of Tools and Rules – project initiation document

Appendix 4: The 500 most common problems encountered in primary care
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KNOWLEDGE IS THE ENEMY OF DISEASE
The application of what we know will have a bigger impact on health and disease than any single
drug or technology likely to be introduced in the next decade. By putting knowledge into practice,
we can prevent or minimise the seven universal problems of healthcare:
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unknowing variation in clinical practice and service delivery;
errors of commission and omission;
waste;
failure to implement new knowledge and technology systematically and appropriately;
over-use and under-use – inappropriate care;
unsatisfactory patient experience;
poor quality clinical practice.
Evidence is one particular type of knowledge, namely the knowledge derived from research, and
clinical practice and healthcare are evidence-based activities. Evidence is necessary but, of course,
not sufficient; it has to be combined with the condition of the individual patient and the values of
each patient, but without evidence it is impossible for patients, professionals, and those who manage
resources to make good decisions, and we must ensure that patients, professionals, managers and
public health professionals can base their decisions on best current evidence.
The National Knowledge Service has three main themes of work:
 the Best Current Evidence Service, set out in more detail in this paper;
 the National Library for Health, responsible for organising and mobilising the evidence;
 the National Knowledge Infrastructure containing technical standards, tools and services.
Obviously Connecting for Health is only one contributor to the Best Current Evidence Service
because it holds only a limited number of the relevant contracts and it is, of course, not a producer of
evidence in the way that NICE or the Research and Development Programme or the Health
Protection Agency are producers of evidence. Connecting for Health, therefore, has to work with
knowledge partners and all of the key national knowledge partners are described in this paper which
attempts to set the Connecting for Health resources in context.
A partner of particular importance is NHS Direct. The principle on which the National Library for
Health has been developed is that patients should have full access to all the knowledge to which
clinicians have access. This is for a number of simple and practical reasons, notably because many
patients are at least as intelligent as clinicians but also because almost all patients have more time
than clinicians, even if they have not had the basic biological training required to understand all of
the terms used in all of the clinical documents.
This paper, however, is about the production and procurement of evidence primarily for clinicians;
in parallel a Ministerial review is being undertaken on the basis of the White Paper to consider all
the sources of evidence primarily for patients and how they should evolve.
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This consultation takes place in a time of resource constraints. The case is being made to invest
more resources in the production, procurement and mobilisation of evidence, but it is hard to justify
more money until the publicly funded knowledge services have co-ordinated their production and
procurement so weakly. This consultation paper focuses not only on the needs of the users but also
on the needs of all those public agencies involved in the production and procurement of knowledge
to work even more closely together.
This strategy consultation is part of the refresh of the strategy paper produced by the Service
Implementation Directorate of Connecting for Health which set out the National Knowledge Service
strategy and indicated that Connecting for Health had been given lead responsibility for the
development of the National Library for Health.
Comments to Muir Gray by 31 May 2006
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BEST CURRENT EVIDENCE
CONCEPTS AND PLANS
J A Muir Gray
March 2006
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EXECUTIVE SUMMARY

Best current evidence needs to be produced and procured as a basis for a National
Knowledge Service. This consultation paper focuses primarily on knowledge for
professionals. A separate Ministerial review of knowledge for patients is underway.

Evidence is knowledge produced by research; it needs to be linked to the knowledge
produced from data analysis, sometimes called statistics, and knowledge from the experience
of clinicians and patients.

Ignorance is a type of knowledge, and a Database of Uncertainties about the Effects of
Treatments needs to be developed to complement the database of evidence.

Evidence is generalisable and relevant across the country and often internationally. To be
useful it needs to relate to a particular patient and a particular service; the National Care
Record Service allows the former, the Map of Medicine, mobilised through NHS Broadband,
NHS e-mail and Internet, will allow the latter.

Studies: a wide range of journals are currently procured; the peer review system is so
unreliable that these are not suitable for busy clinicians and patients unless the journals
conform to very strict protocols. Steps are being taken to promote and facilitate the
introduction of such protocols.

This strategy is based on the Four S approach developed in McMaster University – Study
reports, Systematic reviews and guidelines, Synopses, and Systems.

This strategy is based on studies of the needs of end users.

Systematic reviews and guidelines: these are the most valid source of knowledge, for
example the Cochrane Database of Systematic Reviews and NICE guidelines, but they are
not always easy to use in their current form.

Synopses: these are readable documents produced from systematic reviews and guidelines.

Systems: the introduction of the Care Record Service allows the incorporation of knowledge
in systems. A National Library of Pathways is being developed and will be launched in
2006. In addition a National Library of Tools and Rules is being developed. These will
complement the National Library for Guidelines and all of the documents reporting research
findings and systematic reviews already in the National Library for Health.

Knowledge support is simple and effective; clinicians and patients should be offered
knowledge just in time, where and when they need it.

A set of quality assured pathways, tools and rules will be provided to all information system
providers as a National Clinical Decision Support Service.
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
More complicated computer-based decision support has not been shown to be effective
except for a few conditions. Further work will be done with NICE to develop criteria and
systems to appraise decision support systems.

Patient decision aids are of vital importance.

Work will be done with all the national agencies producing knowledge to make all of their
knowledge available through a search engine in a consistent form. The procurement of an
NHS-wide search engine will allow all of these sources to be searched through a one stop
shop.

The seven sources of synopses currently procured by the Department of Health or the NHS
will be more closely related to one another and when current contracts run out the
procurement, the business case for which was approved in September 2005, will be for an
integrated Clinical Synopsis Service.

A National Library for Medicines will be created; all advertising will be removed from NHS
computers.

Steps will be taken to procure sources of study reports which have filters in addition to peer
review to reduce the number of articles which clinicians have to search and provide them
with assurance that these articles are valid, relevant and new.

The knowledge for common problems will be co-ordinated and presented in National
Knowledge Weeks, for example the Breast Cancer Knowledge Week.

Open access to the Cochrane Library will be provided.

The Map of Medicine will be used to allow best current evidence to be represented in the
form of national care pathway templates. The Map of Medicine will also be used to provide
localised versions of the national care pathway templates, allowing generablisable
knowledge to be set in the context of local constraints and opportunities.

The Best Current Evidence Service will cover both the 50 biggest health problems and the
500 conditions most commonly seen in primary care and walk-in centres.

Rare diseases will receive separate consideration and a National Library for Rare Diseases
will be prepared.

The Best Current Evidence Service will be developed in partnership with the National
Library for Health to create a National Knowledge Service, based on a common technical
infrastructure and using to the full the skills of librarians and their local services.
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1.
Developing a National Knowledge Service
The mission of the National Knowledge Service is to provide best current evidence where and when
it is needed for patients, clinicians, and for those who manage resources.
The benefits that will result from this will be not only an improvement in the health of the
population but also a dramatic change in the quality of the health service and the value derived from
the resources invested in health care. The application of what we know from research, from the
analysis of routinely collected audit data, and from experience will have a bigger impact on health
and disease than any other single drug or technology likely to be introduced in the next decade and
contribute significantly to the reduction of the seven most common problems in health care:







unknowing variation in clinical practice and service delivery;
errors of commission and omission;
waste;
failure to implement new knowledge and technology systematically and appropriately;
over-use and under-use – inappropriate care;
unsatisfactory patient experience;
poor quality clinical practice.
The components of the National Knowledge Service are shown in the diagram below (Figure 1).
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National Knowledge Service
Production &
Procurement
Organisation
Question
Answering
Service
Localisation
Mobilisation
Utilisation
Best Current Evidence Service
National Library of Health
NHS Direct Online
Map of medicine
Best Current Evidence Service
(Pathways, Tools and Rules)
Patient & professional education
Better Consultations, Better Decisions,
Better Communication
Figure 1
The mission of the Best Current Evidence Service is to ensure that best current evidence is produced
or procured for organisation, mobilisation and, the end goal, utilisation by patients, clinicians, and
those who make decisions about health care. This paper focuses on the evidence that is primarily
written for clinicians, although the aim is for it to be open to patients also.
2.
Three types of generalisable knowledge
There are many definitions of knowledge and within the National Knowledge Service three different
types of generalisable knowledge are distinguished:



knowledge from research, sometimes called evidence;
knowledge from the analysis of routinely collected and audit data, sometimes called
statistics; and
knowledge from the experience of clinicians and patients.
The priority of the National Knowledge Service is to provide easy access to evidence, namely to
knowledge derived from research. Working in partnership with organisations such as the Public
Health Observatory and Dr Foster, the Information Centre for health and Social Care , we will be
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identifying ways in which direct links can be made to relevant statistics. Knowledge from the
experience of clinicians and patients, either presented as guidelines from a professional association
or as patient experience, for example through the Database of Individual Patient Experience
(DIPEX), will also be made available, but the main focus of this paper is on evidence.
2.1
Ignorance as a type of knowledge
It is important to emphasise that it is often important to clinicians and patients to be certain that
there is no answer to a particular question. One of the benefits of the National Library for Health
will be to help the person who asks the question to find the best available answer, and to be clear
whether or not there is an answer. For this reason a Database of Uncertainties about the Effects of
Treatment (DUETS) is being developed in partnership with the Department of Health and the
Medical Research Council. The lead organisation in this work is the James Lind Library and the
work is being done in partnership with the Medical Research Council and the R&D Directorate of
DH. In future, therefore, when there are uncertainties about effects, these will be made explicit.
It is essential to help the clinician or patient find out if nobody knows the answer to a question; this
then allows the patient to make a decision on the basis of their values.
3.
Generalisable knowledge and particular knowledge
Best current generalisable knowledge needs to be related to knowledge about:


this particular patient, and
this particular service.
The integration of the National Library for Health with the National Care Record Service will allow
the former link to be easily and automatically made.
However, with increasing reliance on agency and locum staff in the NHS, together with more rapid
turnover of staff, it is necessary to link generalisable knowledge to information about the particular
service with which the clinician and the patient are engaging. This will be greatly facilitated by N3,
the system which will ensure that 18,000 healthcare locations have Broadband connection, and
Contact, the NHS e-mail system. The use of the Map of Medicine software will not only allow
evidence to be related to local constraints and opportunities but will also set out explicitly how
evidence-based care is delivered both nationally and within each health community. This
consultation is linked to the Integrated Service Implementation Programme.
4.
The four S approach
In a landmark article, Brian Haynes, who has contributed so much to knowledge management
research, proposes a simple classification of knowledge into four types:


studies – research reports which appear in journals, paper or digital;
systematic reviews and guidelines – summaries of syntheses of studies;
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

synopses - brief readable chunks of knowledge prepared primarily for ease of use while not
losing accuracy, specifically for busy end users who are not familiar with the research
literature and its deficiencies;
systems – ways in which knowledge can be incorporated into the electronic patient record or
into the many documents that clinicians and patients receive, for example appointment
letters, radiology request forms, or laboratory reports.
A diagram illustrating the relationship between these four types of source is set out below (Figure
2).
Systems
Synopses
Systematic reviews
and guidelines
Study reports in journal articles
Figure 2
5.
The needs of the end user
A number of studies have been conducted on end user needs. Obviously clinicians are learners and
researchers as well as practitioners, but the main focus of the Best Current Evidence Service is to
provide evidence for clinicians to help them with patient care.
Primary responsibility for the provision of knowledge for patients rests with NHS Direct, a special
health authority responsible not only for the telephone support service but also for NHS Direct New
Media, including NHS Direct Online. This work is being done in close partnership with NHS
Direct which is currently involved with the Department of Health in undertaking a major review of
all information for patients and the public, stimulated by the White Paper Our Health, Our Care,
Our Say.
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There are about a hundred different professional groups within the National Health Service, in
addition to those people primarily responsible for education and those involved in research, and the
main groups identified as a focus for the production and procurement of evidence are listed below:
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nurses;
midwives;
district nurses;
practice nurses;
mental health professionals;
learning disability professionals;
allied health professions;
healthcare scientists;
Foundation Year doctors;
clinicians in specialist training;
GP registrars;
general practitioners;
consultants;
managers.
User needs have been evaluated systematically and work will continue with the National Advisory
Group of the National Clinical Leads of Connecting for Health to ensure continuing involvement of
users in providing feedback to those who produce and procure evidence for decision-making.
A user group has been set up and will be expanded in consultation with the National Advisory
Groups of Connecting for Health.
6.
Relevance of the four types of knowledge to healthcare professionals
6.1
Studies
Professional education rightly emphasises the important contribution that research has made and
continues to make to patient care and health care management. The development of peer reviewed
scientific literature has made a major contribution to the evolution of clinical practice and health
care in the last fifty years. However, research into the peer review process, and the scientific
literature, has revealed a number of very important weaknesses. The introduction of peer review
undoubtedly improved the editing of scientific journals but it is a system whose limitations, both in
terms of scope and execution, are now well documented (Appendix 1). There is good evidence, for
example, that:

journals are more likely to publish articles with positive findings – “positive publication
bias”;

information about harm is less well presented than information about benefit;
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
unless abstracts conform to CONSORT and QUORUM criteria, they tend to reinforce the
positive effects of publication bias by emphasising the positive and beneficial results within
studies;

peer reviewers and editors fail to spot methodological and statistical mistakes;

there is a failure to base both the research and the reporting of the research on a synthesis of
pre-existing knowledge; the articles by Iain Chalmers, Mike Clarke and Phil Alderson, cited
in Appendix 1, make powerful reading;

the way in which journal articles are published often makes it impossible for the busy
clinician or patient, or even research worker, reading the article to spot the deficiencies;

sometimes it is easy to identify the weaknesses in published trials, and Chalmers, Clarke and
Alderson report a study that was brilliant in its conception but relatively simple in its
execution. In contrast Chan and colleagues report a study, cited in Appendix 1, (which was
also brilliant in its conception but very time-consuming and difficult to carry out), which
demonstrates how researchers selectively forget the results that are less impressive or less
interesting.
For all these reasons journal articles, even those peer-reviewed and published in “good” journals,
must be treated with great circumspection and should not be brought to the attention of the busy
clinician or patient without careful appraisal and a health warning.
Primary responsibility for the procurement of journals rests with library services. There is national
procurement of electronic access to a set of journals but no additional quality criteria other than peer
review are used to define the set.
6.2
Systematic reviews and guidelines
A systematic review is a synthesis of research findings which follows an explicit methodology,
namely:
1.
2.
3.
4.
5.
the identification of best sources of research;
the conduct of a search for studies with an explicit search strategy;
agreement on the use of quality criteria to divide the studies found into those of adequate
quality and those that are unacceptable;
the synthesis of the results of the studies of adequate quality;
the publication of the systematic review, providing references not only to the acceptable but
also to the unacceptable studies to allow the reader of the systematic review to identify
evidence that was not included in the review; this emphasises the fact that the choice of
explicit criteria, set out objectively, involves value judgements.
Some systematic reviews are regularly kept up to date, for example the reviews in the Cochrane
Database of Systematic Reviews. The Department of Health’s R&D Programme also funds an
excellent abstracting service of systematic reviews through the Centre for Reviews and
Dissemination in York.
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A guideline has been defined as “systematically developed statements to assist practitioner and
patient on decisions about appropriate health care for specific clinical circumstances”. The adverb
“systematically” refers in part to the basing of a guideline on a systematic review, although it also
includes other steps including the involvement of clinicians and patients in the production of the
guideline. One of the criteria used for the inclusion of guidelines in the National Library for
Health’s “Guidelines Finder”, to be re-launched as the National Library of Guidelines, is that they
are prepared on a systematic review of the literature.
Systematic reviews and guidelines are often, of necessity, complex documents, and although their
results are expressed in a structured abstract, they are not particularly easy for the busy clinician to
use, and for this reason synopses are required.
6.3
Synopses
A synopsis is a document prepared about a clinical topic, based on a systematic review of the
evidence but designed primarily for readability and usability. Obviously there is a risk that
something is lost in distillation but the producers of quality assured synopses take steps to ensure
that this is not a major problem, for example by checking back with the authors of the original
guideline or systematic review.
One of the standards set by the National Knowledge Service is that knowledge should be able to be
read in under 15 seconds with the synopsis itself being able to be read in two minutes. The
production of 15 second reads offers the opportunity for embedding knowledge within synopses.
6.4
Systems
The National Knowledge Service is also responsible for the National Clinical Decision Support
Service, on which it works with the National Institute for Health and Clinical Excellence (NICE).
A paper describing the decision support service is attached as Appendix 2.
There are two different ways of considering knowledge delivered as part of systems. The first
relates to the representation of knowledge, the second to the relationship of the knowledge to the
decision.
6.4.1 Representation of knowledge
Study reports, systematic reviews, and synopses are documents written in flowing prose.
Knowledge can, however, be presented in different ways. An integrated care pathway is a
document that describes the process in a discrete element of a service. It may be represented as a
pathway, for example in the Map of Medicine which uses elegant software to represent pathways
diagrammatically, or it may be represented to the clinician as a form which guides the clinician, or
the patient because many pathways are used by patients, through a process of gathering and
assimilating knowledge. A National Library of Pathways is being developed and will be launched
in 2006.
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At certain points in the pathway tools are made available to the clinician to help with decisionmaking, and simple rules can be incorporated. A National Library of Tools and Rules is being
developed to complement the National Library for Guidelines and the National Library of Pathways
(Appendix 3).
The availability of knowledge presented as tools and rules allows this incorporation in all the
documents that are routinely used in health care, and the tools and rules that are being assembled
will need to be made “machine readable” for easy incorporation in the Care Record Service and
related documentation.
6.4.2 Relating knowledge to decision-making
The distinction made in the work being done to develop a National Decision Support Service
between knowledge support and decision support has proved useful. In knowledge support the
clinician or patient is offered knowledge based on a single piece of clinical information, for example
the patient’s diagnosis. In this context the computer is strengthening and supplementing the
memory of the clinician. There is good evidence that this approach, often delivered as prompts and
sometimes as reminders and alerts, is effective and cost-effective.
A second approach has been to seek to use computers to replicate the powers of inference of the
clinician.
The diagram that has been used to described decision-making processes is set out below and the
primary function of knowledge support is to provide evidence where and when it is needed (Figure
3).
Knowledge
Support provides
evidence ‘just in
time’
Evidence
The values the patient
places on benefits and
harms of the options
Choice
Decision
Patient’s clinical
condition; other diagnoses
& risk factors
Figure 3
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Computer-based decision support seeks to combine the evidence with the patient’s condition. At
present there is little research to support the widespread use of computers in this way but research
should continue in this area and will be done in partnership with NICE.
It is important also to emphasise that patient decision aids, which allow the patient to reflect not
only on the evidence and how it relates to their condition but also on their values, have been shown
to be effective in improving decision quality and are being supported by the National Knowledge
Service.
7.
The evidence base available at 31 March 2006
7.1
Evidence produced by national agencies
Each year the Department of Health and NHS spend about £100 million producing knowledge of
high quality. The agencies listed below are major producers of knowledge for busy healthcare
professionals and patients:
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the Department of Health’s guidance and knowledge base, including that of the are Service
Improvement Partnership;
the NHS Institute;
NICE;
the National Patient Safety Agency;
the Medicines and Healthcare Products Regulatory Agency;
the National Screening Committee;
the Health Protection Agency;
the British National Formulary;
the HTA and Service Delivery and Organisation Reports of the NHS R&D Programme;
the UK National Screening Committee;
NHS Direct new media;
the Social Care Institute of Excellence;
the products of organisations acting as agencies for, or on contract to, these organisations, for
example the National Histopathology Academy, the National Radiological Academy, the
Pathology Modernisation Programme, and Royal College and professional association
guidelines that meet adequate quality standards.
These producers of knowledge provide both studies and systematic reviews. Increasingly they are
also providing synopses, and in future they will provide very small knowledge objects that can be
inserted into, for example, laboratory request forms or radiology reports or other types of
“knowledge vector” and resources are included in the plan to facilitate this. The procurement of an
NHS-wide search engine will allow all of these sources to be searched through a one stop shop.
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7.2
Procured information
7.2.1 Studies
A wide range of journals are procured by libraries with a number of library services procuring
variations on a common core. Many of these are now made available digitally through the Core
Content contract..
Librarians, the most valuable resource in any library, are being helped to improve their skills in
educating clinicians.
7.2.2 Systematic reviews and guidelines
The main sources of systematic reviews at present are the Cochrane Database of Systematic
Reviews and the Database of Reviews of Effectiveness, but the specialist libraries of the National
Library for Health will be asked to identify other systematic reviews.
Discussions are currently taking place with the publisher of the Cochrane Database of Systematic
Reviews with a view to obtaining these without cost because of the investment the Department of
Health currently makes in the Cochrane Collaboration.
A wide range of guidelines are produced either by the Department of Health and other national
bodies or by national professional societies. These are assembled in the Guidelines Finder of the
National Library for Health which will be re-launched as the National Library of Guidelines.
7.2.3 Synopses
Currently there are five synopses services available to clinicians. These are produced in a relatively
unco-ordinated fashion, with the contracts being held by different parts of the Department and
Connecting for Health. The relationship of these is shown in Figure 4.
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GP
Notebook
Clinical
Evidence
Prodigy
Mentor
BNF
Figure 4
These resources are:
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Mentor, made available to 60% of primary care staff though the EMIS system;
GP Notebook, available through the Isoft GP system and now working in partnership with
Mentor;
the British National Formulary, made available to all clinicians, and now supplemented by
the British National Formulary for Children;
Clinical Evidence, procured from BMJ Knowledge by Connecting for Health;
Prodigy, procured from the Sowerby Centre for Health Informatics Ltd by Connecting for
Health.
In addition there are two other synopses which are produced on a regular basis but are not
comprehensive knowledge bases. These are:


the Drugs and Therapeutics Bulletin, procured by the Department of Health from the
Consumers’ Association; and
the Bulletins from the National Prescribing Centre which are commissioned by NICE.
Of course many of the producers of Departmental guidance also produce synopses of guidance and
the position for medicines is particularly complicated, as shown in Figure 5.
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GP
Clinical Prodigy
Notebook Evidence
FDB &
Multium
ukmi
BNF
Mentor
DTB
NICE
MHRA
NPC
NPSA
Figure 5
The development of a National Library for Medicines is a high priority for the National Knowledge
Service.
It is important to note that some of the GP information systems use synopses which carry drug
advertising. The Service Implementation Board of Connecting for Health wishes this practice to
cease.
7.2.4 Systems at present
At present the delivery of evidence through systems is chaotic. Numerous tools and rules and a few
decision support systems are in place but virtually none have been formally appraised, and very few
are derived from the systematic reviews described in the previous section.
8.
Best Current Evidence Base – Development Plan 2006/7
8.1
Studies
A number of changes are taking place in journal publishing and distribution which will have an
impact on anything done by the NHS, notably:

the move to open access publishing, namely the requirement by research funders that the
products of their investment will be made available without charge to the reader;
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

the development of digital document delivery;
the move away from paper to digital journal publication.
To provide a service for clinicians, patients and those who manage health care it is necessary to put
in additional quality filters; peer review is necessary but not sufficient.
8.1.1 The MORE Service
The team at the Health Informatics Research Unit in McMaster University has been responsible for
developing the filters used in the PubMed search engine of the National Library of Medicine.
Furthermore, no team in the world has done more research on the quality of articles published in the
scientific literature. This gives them a unique opportunity to develop a knowledge filtering service.
Funded by the National Library of Medicine and the government of Canada, they have developed a
service to provide to physicians and nurses working in rural Canada a subset of the scientific
literature, about 1%.
The first step in the process is the identification of high quality articles and a team of trained
librarians undertakes this task. An international panel of clinicians then assesses the articles found
for relevance and novelty. At present the 120 most important medical journals are searched, and
although this does not cover the needs of all health care professionals the possibility of accessing the
MORE knowledge service would allow us to offer to clinicians a knowledge service in which 99%
of poor quality articles had been filtered out.
8.1.2 Procurement of journals of secondary publication
A journal of secondary publication is one that uses a system like the system which leads to the
production of the MORE knowledge service; in the case of some journals of secondary publication
the MORE service is the service used. The articles found are then turned into structured abstracts,
because in most journals the preparation of abstracts is biased, leading to an over-emphasis on the
positive aspects of a research report, and the structured abstract is then strengthened by the provision
of a declarative title, namely a title that summarises the conclusion and not the objective of the
research project.
These journals of secondary publication also produce the literature for a specialty to about 2% of the
total literature published in the relevant journals, and such journals exist for:




nursing;
medicine;
dentistry;
mental health.
The procurement of access to the journals of secondary publication digitally as part of the Core
Content Service would allow nurses, mental health professionals, physicians and dentists easy
access to a highly filtered and structured subset of the relevant literature relating to about 400
journals.
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8.1.3 The development of National Knowledge Weeks
The specialist libraries of the National Library for Health, in partnership with NHS and Higher
Education libraries, are now developing National Knowledge Weeks, namely weeks in which they
will present to the service all of the important information published in the preceding year. For
example, in the first of these weeks the 8,569 articles published on breast cancer were reduced to
less than 50 articles by the National Library for Cancer. In the long term it is planned to develop
National Knowledge Weeks for the 50 most common health problems.
8.1.4 Improving the quality of the knowledge found
The steps listed below are being taken to improve the quality of the knowledge found by readers
searching journals.

A request has been made to the Core Content Purchasing Group to purchase all of the
journals of secondary publication. Each of these has an explicit methodology for selecting
journal articles and the process usually results in no more than one or two percent of articles
in journals being presented to the reader.

The National Knowledge Service has commissioned the Centre for Statistics in Medicine at
Oxford to promote the use of CONSORT and other tools to improve the quality of research
reporting (www.nks.nhs.uk).

The National Library for Health, with the support of the National Knowledge Service, is
negotiating for access to the article filtering process managed by the Health Informatics
Research Unit at McMaster University. In this process over a hundred journals are scanned
regularly by a team of librarians specially trained and working to explicit quality criteria.
They select articles that are methodologically sound, and these are then appraised for their
relevance and novelty by a panel of clinicians.

The Knowledge Management Specialist Library will make critical appraisal checklists
available.
8.1.4 Caveat lector
Priority will continue to be given not only to the education of clinicians and patients in the skills of
critical appraisal but also to the development of librarians as educators.
8.2
Systematic reviews and guidelines
In addition to establishing best links to the guidelines being produced by Departmental and national
bodies, the National Knowledge Service will also seek to provide access to high quality systematic
reviews. The MORE service will also identify systematic reviews which are not Cochrane Reviews
as part of this service. Open access to the Cochrane Database of Systematic Reviews, the Database
of Abstracts of Reviews of Effectiveness, the reviews produced by R&D, and the reviews which
underpin NICE guidance, provide a firm foundation for clinicians and patients.
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8.2.1 The Database of Abstracts and Reviews of Effectiveness
This database is maintained by the Centre for Reviews and Dissemination which is supported by the
Department of Health and these reviews will be included in the National Library for Health search
engine.
8.2.2 DUETS
The Database of Uncertainties about the Effects of Treatments systematically identifies questions
for which there is no answer expressed in a systematic review. This database, which can be
described as expressing certain uncertainty, namely emphasising that no-one knows the answer, will
be used not only to provide information to clinicians and patients but also to provide invaluable
input to the research process by indicating research priorities.
8.2.3 National Library of Guidelines
A National Library of Guidelines will be launched in 2006, in partnership with NICE.
8.3
Synopses
The following work will be undertaken in 2006/7.
8.3.1 Mentor and GP Notebook
Mentor is available to only 60% of GPs at present. Some other GP information system providers
provide synopses that include pharmaceutical company information and advertising. Priority must
be given to replacing this during 2006/7.
8.3.2 Prodigy and Clinical Evidence
The contracts for these two synopsis services come to an end this year and the business case for their
replacement was approved by Connecting for Health in September 2005.
8.3.3 Integrating synopses
Priority will also be given to helping those who prepare systematic reviews, for example NICE and
the R&D Programme, to produce a quality readable synopsis to complement the high quality
systematic reviews they already produce. The procurement of synopses will be to complement and
supplement the resources produced by the Department of Health and related national bodies.
8.3.4 Development of the National Library of Medicines
The National Library for Health will be responsible for organising all the knowledge about
medicines in a more systematic fashion. Discussions will take place with the relevant part of the
Department of Health responsible for the Drugs and Therapeutics Bulletin, with the British National
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22
Formulary, and with NICE which is responsible for National Prescribing Bulletins, to ensure that
there is an integrated source of medicines knowledge based on the British National Formulary and
available both digitally through searching and incorporated into the electronic prescribing service.
8.3.5 Evidence-based books
By nature of the publishing process, books can get out of date between editions unless they are
produced by “print on demand”. Work is starting in McMaster University to develop quality
criteria for books, either paper or digital, which would allow the reader to know the currency and
quality of the knowledge provided.
The National Knowledge Service will support this work.
8.3.6 Quality assurance of synopses
Lost in translation is a common experience and any attempt to précis a long document or present it
in other ways means careful handling. At present the methods used by Prodigy are run through an
Audit Committee chaired by the Director of Clinical Knowledge, Process and Safety. Explicit
methods for ensuring the quality and safety of the other synopses need to be developed.
8.4
Systems – a National Decision Support Service
The development of the National Library of Rules and Tools and the National Library of Pathways,
and the signing of a contract with the Map of Medicine, will allow the systematic appraisal of rules,
tools, and, pathways to be organised. The work with NICE to develop criteria and methods for
appraising decision support systems will also make an important contribution to the development of
a National Decision Support Service (Figure 6).
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23
Evidence
from the
National
Library for
Health
National Library of
Tools and Rules
National
Library of
Guidelines
National
Library of
Pathways
National decision support service
Common user
Interface team
Local
Health
Communities
Map of Medicine
NASP’s
EMIS
CSC Accenture BT Fujitsu
iSoft
IDX
Cerner
Figure 6
8.4.1 Quality assurance of the Map of Medicine
An process analogous to that used for synopses arises with the Map of Medicine which is a
framework for knowledge and not the originator of knowledge. Nevertheless, the translation of a
document that may be 100 pages or more long into five or six pathways offers the opportunity for
differences to occur during the process of translation. The Map is currently available to 60% of the
country through Accenture and CSC. Negotiations are taking place which will lead to a contract
between Connecting for Health and Informa, the company owning the Map, which will allow the
investment of resources, for example to allow a clinician from the British Society of
Gastroenterology to work closely with the Map team on the development of pathways derived from
BSG guidance. In the interim the Map pathways are checked by the Directorate of Clinical
Knowledge, Process and Safety which has responsibility for the quality of the knowledge of the
NHS, to ensure a single knowledge source. The focus has been on the safety of the Map and, with
the ability to look at the processes used by the Map, and a report has been made to the Risk and
Safety Board of Connecting for Health that the Map presentation of knowledge is at least as safe as
any other form of synopsis currently offered to the NHS. It is important to note that there is no
scrutiny at all for some of the knowledge made available to clinicians or patients.
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9.
Scope of Best Current Evidence
Priority will be given to the more common conditions.
The “Big Fifty” list prepared for the Do Once and Share project lists those conditions which make
the biggest use of health service resources, and the specialist libraries will focus primarily on them.
These conditions are listed below.
Allergy
Intensive care
Alzheimer’s disease
Renal failure
Child health
Oral health
Asthma
TB
HIV and AIDS
Prostate hypertrophy and cancer
Stomach cancer
Bowel cancer
Skin cancer
Breast cancer
Lung Cancer
Rheumatoid Arthritis
Osteoarthritis
Glaucoma
Visual failure
Deafness
Stroke
Parkinson’s
Epilepsy
Multiple sclerosis
Sexual health
Headache
Chest pain
Heart failure and rhythm disorders
Coronary disease
Diabetes
Renal failure
Falls
Complex problems of later life
Incontinence
Inflammatory bowel disease
Hepatitis and Liver failure
Disability
Pain
COPD (Bronchitis)
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Psoriasis
Acne
Eczema
Dysmenorrhoea and Menorrhagia
Antenatal care
Depression
Schizophrenia
Drug and alcohol dependence
Osteoporosis
Obesity
From the point of view of primary care, however, there is a much wider range of conditions which
are now dealt with in a variety of settings, for example walk-in centres. A review was conducted of
the existing sources of knowledge by a knowledge management company called Bazian and they
found, as expected, overlaps and gaps. In addition to ensuring that the Big Fifty problems, listed
below, are covered, the 500 most common problems encountered in primary care will also be
covered by a synopsis service (Appendix 4).
For each of these conditions and health problems, synopses will be procured relating to:
prevention;
screening, if relevant;
diagnosis;
self-care and informal care;
treatment;
drug treatment;
complementary medicine;
long-term care;
service organisation.
9.1
Rare diseases
Rare diseases require separate consideration. The National Office for Rare Diseases in the United
States has about 6,000 conditions on its inventory, many of which will be encountered only once or
twice in the lifetime of a clinician.
A project will be carried out in 2006/7 to develop a National Library for Rare Diseases, perhaps
giving direct access to web sites approved by the National Office for Rare Diseases or, in the UK,
by Contact a Family, a charity with a special interest in rare diseases. Other sources of information
about rare diseases are found in the disciplines of clinical genetics and the medical and laboratory
specialty dealing with inherited metabolic disorders, and these two will be included in the National
Library for Rare Diseases development project.
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26
10.
Best Current Evidence and the National Library for Health
The production and procurement of Best Current Evidence is the first step in the development of a
National Knowledge Service. The evidence has to be organised and delivered, and this paper needs
to be read in association with the strategy for the National Library for Health.
J A Muir Gray, CBE, DSc, MD, FRCP, FRCPSGlas, FCILIP
Director of Clinical Knowledge, Process and Safety
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APPENDICES
1.
Improving the quality assurance of knowledge for clinicians and patients
2.
Decision Support Programme – knowledge support, computer-based clinical decision
support systems, and patient decision aids
3.
National Library of Tools and Rules – project initiation document
4.
The 500 most common problems encountered in primary care
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APPENDIX 1
IMPROVING THE QUALITY ASSURANCE OF KNOWLEDGE
FOR CLINICIANS AND PATIENTS
J A Muir Gray
Version
Date
Version 1.0 17 November 2004
Version 2.0 7 December 2004
Version 3.0 8 July 2005
Version 4.0 21 December 2005
Version 5.0 2 March 2006
NPFIT/Bestcurrentevidence/29.3.06
Prepared by
J A Muir Gray
J A Muir Gray following review by Paul Glasziou,
Director of Centre for Evidence-Based Medicine
J A Muir Gray following meeting with Tom
Jefferson, author of Peer Review in Health Sciences
J A Muir Gray
J A Muir Gray – addition of evidence contained in
references 17, 29, 30, 31, 32.
29
EXECUTIVE SUMMARY

The peer review research report about an intervention with apparent clinical benefit should
not be used by a reader, either clinician or patient, unless it is a report of a systematic review
of the literature on a particular topic.

Important safety information is an exception, but this type of knowledge should be actively
implemented and not disseminated through journal publication.

Research reports published in journals are primarily written by researchers for researchers.

Clinicians, managers and patients cannot rely on the peer review process alone and should be
offered, and use, resources which have been treated by additional measures to minimise bias
and error.
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PROVIDING CLEAN CLEAR KNOWLEDGE FOR BUSY CLINICIANS AND PATIENTS
The provocative title of a BMJ Editorial, The Scandal of Poor Medical Research (1), highlighted
two major problems of clinical research that was either badly designed or badly conducted, or both.
To this pair a third problem can now be added – poor reporting. This has very significant
implications for clinicians and those who educate them because the scientific approach to medical
education has, until recently, emphasised the need for clinicians to look to journals to answer
questions and to put their faith in peer reviewed articles as quality assured and reliable knowledge.
1.
Misplaced faith in peer review
There is evidence that peer review and editing can improve the quality of medical research reporting
(2) but peer reviewing, although beneficial, has severe limitations.
Clinical journals consist of a number of different types of documents, of which the two main types
consulted by readers in search of evidence were, for many years, review articles, including
editorials, and peer reviewed articles. In the former some senior member of a specialty or
profession was asked to review a topic and the review was published backed by their reputation and
sapiential authority. These review articles were popular because they were often written for the
clinician, whereas the peer reviewed reports of research were written primarily by researchers for
researchers. Useful though such reviews and editorials were, their deficiencies were also
significant, as two landmark studies in the eighties revealed (3, 4).
These classic studies had two effects. The first was to highlight the need for systematic reviews of
research which were explicit in their methods of literature searching, appraisal and data synthesis,
culminating in the creation of the Cochrane Collaboration which was committed not only to these
principles but also to the need to ensure that the reviews were kept up to date. The second effect
was to highlight the benefits and weaknesses of the peer review process. Review articles written by
a person generally considered to be an authority were usually only scrutinised by the editor and not
reviewed by the writer’s peers, namely other authorities than the one who had been invited to write;
they were not peer reviewed. For this reason the term “peer reviewed” came to be synonymous with
the term “quality assured”, but the peer review process, although an improvement on the editor’s
scrutiny, was shown to have many flaws when it itself was examined (5).
2.
The failures of peer review
Because of the “scandal of poor medical research” (1), which had obviously existed long before this
article, peer review was introduced but peer reviewers fail to spot errors of chance and bias. For
example studies that have yielded relatively dramatic results are more likely to be cited in reports of
subsequent similar studies than previous studies yielding unremarkable point estimates of effects,
and in a study of manufacturer-supported trials of nonsteroidal anti-inflammatory drugs in the
treatment of arthritis, Rochon and colleagues found that the data presented did not support the
claims made about toxicity in about half the articles (6). Anyone managing or using scientific
literature needs to understand the weaknesses of peer review.
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2.1
The failure of peer review to spot poor literature retrieval
Recent research has shown that the very foundation of the scientific article, namely the prior state of
knowledge on which the research hypothesis was formulated, is all too often flawed. In a landmark
article Chalmers and Clarke (7) examined reports of randomised controlled trials in a single month
in the five major medical journals. The results are shown below (Figure 1).
Discussion sections in reports of controlled trials published in
general medical journals: Islands in Search of Continents
Clarke M and Chalmers I (1998) JAMA, 280: 280-282
Method: 26 trials published in the Big 5 general medical journals
(Lancet, BMJ, NEJM, JAMA and Annals) in May 1997 were appraised.
Six of the 26 trials claimed to be reports of the first trial addressing
a particular question. However, “following a search of the Cochrane
Controlled Trials Register and discussions with relevant Cochrane
Review Groups, similar previously published trials were identified for
5 of the 6 trials.
26 trials
1 report was
of a genuine
first trial
2 reports
discussed the
results in the
context of a
systematic review
4 reports
mentioned previous
systematic reviews
but made no effort
to integrate the
results of the trials
in these reviews
19 reports gave
no information
about how the
trials cited in the
references were
identified or
selected
Figure 1
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Depressingly they found that the position had not improved three years later (8).
What this demonstrates is that research studies are based on an inaccurate estimate of the current
state of knowledge and then fail to add any results that emerge from the study to the existing
knowledge base, thus making it very difficult for the reader to assess their implications.
2.2
The failure of peer review to detect statistical problems
Some of the problems in the published reports of randomised controlled trials may be very difficult
for the busy clinical reader to spot, as a recent analysis by statisticians of fifty clinical trials in a
three month period in four top journals – BMJ, JAMA, Lancet and New England Journal of
Medicine – demonstrated (9).
The findings of the review included:
“about half the trials inappropriately used significance tests for baseline comparison”;
“methods of randomisation …. were often poorly described”;
“two-thirds of the reports presented sub-group findings, but most without appropriate
statistical tests for interaction”;
“many reports put too much emphasis on sub-group analysis that commonly lacked
statistical power”.
Another review (10) concluded that the CONSORT Statement which recommended a standard
approach to the reporting of clinical trials, has not yet produced a standardised approach to
reporting. They conclude that “there are substantial risks of exaggerated claims of treatment effects
arising from post-hoc emphases across multiple analyses. Sub-group analyses are particularly
prone to over-interpretation and one is tempted to suggest “don’t do it” (or at least “don’t believe
it”) for many trials.
2.3
Failure of peer review to spot unsystematic systematic reviews
Words are tools. A word initially performs helpful functions, defining and clarifying the concept or
object and providing a new tool for people to use. However, as the word gets more widely used, its
meaning often changes or multiplies, and there comes a time when a word has so many meanings
that it causes more confusion than clarity; one of the principles of linguistic philosophy, proposed
by Wittgenstein, was that when a word caused more confusion than clarity it should be discontinued.
The term “systematic review” is still a useful term if rigorously defined but it can no longer be
accepted on face value as indicating reliable evidence, for there is good evidence that systematic
reviews are often unreliable.
A critical evaluation of systematic reviews and meta-analyses on the treatment of asthma (11) found
that of all the 50 systematic reviews and meta-analyses included in the study:
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33




12 reviews were published in the Cochrane Library and 38 were published in peer review
journals;
40 of the reviews were judged to have “serious or extensive flaws”;
all 6 reviews associated with industry had “serious or extensive flaws”;
7 out of the 10 most rigorous reviews were published in the Cochrane Library (Table 1).
Most rigorous
Least rigorous
Cochrane Reviews
7
5
“Systematic reviews” in peer
reviewed journals
3
35
Table 1
The critiques of review articles published in 1987 and 1988 have been repeated, and a team carrying
out an analysis of “review articles” identified 158 review articles in 12 “core” medical journals,
using the Science Citation Index to define the core journals. Of the 158 review articles:



only 2 satisfied all 10 methodological criteria of good quality;
less than one quarter described how evidence was identified, evaluated or integrated;
of the 111 reviews that made treatment recommendations, only 45% cited randomised
controlled clinical trials to support their recommendations (12).
2.4
The failure of peer review to spot duplicate publication
In a study of “covert duplicate publication” (13), the authors found:





17% of published full reports of trials and 28% of patient data were duplicated;
none of these reports cross-references the original source;
covert publication can take place because articles submitted for publication are “masked” by
change of authors or language or by adding extra data;
duplication [of data] leads to an overestimation of ondanestron’s antiemetic efficacy by 23%;
trials reporting greater treatment effects were significantly more likely to be duplicated.
Peer review is the best process that we have at present but it is not a reliable process for producing
journal articles, particularly for busy clinicians who have to read at speed.
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3.
Positive publication bias
The general effect of these flaws in the peer review system is to emphasise the beneficial effects of
interventions and therefore lead the reader to overestimate the benefits and underestimate the harms
of an intervention. These effects are compounded by other factors with the same effect, for
example the tendency of authors to submit, and editors to publish, studies with a positive result
rather than no result. The combined effect is known as positive publication bias and one estimate is
that this bias overestimates the benefits of treatments by up to one-third (14).
4.
Solutions
For all these reasons services which can help the busy reader compensate for, and mitigate the
effects of, these problems are needed. There are a number of actions that can be taken, each
focusing on a different part of the knowledge production line.








4.1
better reviewing and selection of research applications;
better conduct of research;
more complete and accurate reporting;
better reporting;
filtering out of poor quality research before publication;
systematic reviews of high quality research;
regular updating of systematic reviews;
critical appraisal skills training for peer reviewers and clinicians.
Better reviewing of research applications
The failure of peer review occurs not only in journal editing but also in research management (5).
Steps taken to improve research governance should include steps taken to improve the process of
peer review, particularly the need to base research on a comprehensive synthesis, or systematic
review, or previous work in the field.
4.2
Better conduct of research
Even when the correct method has been chosen, it still has to be managed, and steps have been taken
to provide better information for trials managers and other research managers which will reduce this
problem even though it will never be solved.
4.3
More complete reporting
An important cause of positive publication bias is the failure of researchers, particularly those
supported by the pharmaceutical industry, to report negative findings. It is only by relating the
outputs of research to registers of trials approved for implementation that the failure to report
negative findings can be identified, and, after thirty years of campaigning, steps have been taken to
ensure that all trials will be registered in future; as a Leader in JAMA said: “a great idea switches
from ignored to irresistible” (15). The systematic review of clinical trials stopped earlier than
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planned because of apparent benefit (16) concluded that: “clinicians should treat the results of such
trials with scepticism” because they were incomplete reports.
4.4
Better reporting
The 21st century should not, however, be viewed as a time when this paradigm was realised. In a
trenchant report of a study in which Chalmers and Clarke repeated their study of discussion sections
of controlled trials four years after the first study, and after the publication of CONSORT guidelines
which were intended to improve the reporting of controlled trials, they came to a sombre conclusion.
Their conclusion was that: “Between 1997 and 2001 there was no evidence of progress in the
proportion of reports of trials published in general medical journals that discussed the new results
written in the context of, or with reference to, up-to-date systematic reviews of relevant evidence
from other controlled trials” (8). However, other aspects of trial reporting had appeared to improve.
It is important to emphasise the many weaknesses in the peer review process, if only because many
professionals assume that “peer reviewed” means “quality assured”. The more closely journals are
studied, the more problems are found. For example, one study comparing the protocols of
randomised controlled trials to the published articles found that the reporting of trial outcomes was
frequently incomplete, was also biased, and inconsistent with protocols. 50% of outcomes relating
to efficacy and 65% of outcomes relating to harm in the controlled trial protocols were incompletely
reported. Even more worryingly, when the authors of the articles were contacted, 86% denied the
existence of unreported outcomes “despite clear evidence to the contrary” (17). Even when journal
editors try to help the reader by introducing structured abstracts, and the case for structured abstracts
is very strong, these abstracts do have their problems and can themselves contributed to positive
reporting bias. For this reason the Annals of Internal Medicine, which first introduced structured
abstracts, has now included a compulsory section called “Limitations” which is put immediately
before “Conclusions” because, the editors surmised, this was “a spot that should attract the attention
of the most hurried reader” (18). Obviously this is an evolving field and CONSORT is continually
renewed, improved and extended (19). For example, “because CONSORT is primarily aimed at
improving the quality of reporting efficacy”, members of the CONSORT group published a new
CONSORT statement with “10 new recommendations about harm related issues” in 2004 (20). In
addition a number of other similar tools have been introduced, notably:

QUOROM, for “Improving the quality of reports of meta-analyses of randomised controlled
trials” (21);

STARD, an initiative “towards complete and accurate reporting of studies of diagnostic accuracy
(22);

STROBE, an initiative to improve the “Standards for the Reporting of Observational Studies in
Epidemiology”, the need for which was highlighted in an editorial entitled “The Scandal of Poor
Epidemiological Research” (23), used by the British Medical Journal to draw attention to the
importance of an article reporting “issues in the reporting of epidemiological studies” (24).
This is the report of a study of 73 articles in public, environmental and occupational health
journals with an impact greater than 2, leading general medical journals and the highest impact
journals in circulation, and cancer. The result of the study was that “there is a serious risk that
some epidemiological studies reach the wrong conclusion”.
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
5.5
MOOSE, an initiative to improve the reporting of meta-analyses of observational studies (25).
Selection of better quality articles for clinicians and patients
In the last ten years a number of organisations have been developed to undertake the tasks of:

purifying the “primary research” evidence by identifying studies of low quality, even though
they have been peer reviewed;

synthesising the results of high quality studies, if necessary using the technique called metaanalysis to combine the statistics of individual studies;

writing the conclusions in a style that is useful for busy clinicians and patients;

keeping the evidence base up to date by identifying new studies of high quality for inclusion in
the synthesis of research.
5.5.1 Purification
The first step in synthesising research is the removal of impurities, namely the identification and
removal of studies which, although they have passed the peer review filter, have such significant
flaws in methodology that they are unfit to be included in the systematic review of the research
evidence. Explicit criteria are used to appraise articles, all of them based on the work originally
done by clinical epidemiologists at McMaster University and published as a landmark series of
articles in the Journal of the American Medical Association to constitute the scientific basis of
critical appraisal. The impure articles are filtered out leaving only the pure articles, and these can
be either converted into systematic reviews, or published in journals of secondary publication, or
made available as a filtrate of the research literature. Three such filtrates are available:

PEDro, a database of quality assured articles specifically aimed at physiotherapists;

OTSeeker, a similar database specifically aimed at occupational therapists;

MORE, a filtrate of general medicine and primary care journals which are used as the basis for
the journals of secondary publication Evidence-Based Medicine, Evidence-Based Mental Health
and Evidence-Based Nursing, and in addition are made directly available to clinicians in Canada
who work in areas far distant from libraries.
5.5.2 Journals of secondary publication
No-one can keep up with the literature; Dave Sackett estimated that a general physician would need
to read about 19 papers a day simply to keep up. These 17 pages are a small subset of no more than
1,500 indexed in Medline each day so how can we find the right 19? During the 1990s, the
American College of Physicians developed its ACP Journal Club, a journal which:

developed explicit methods for scanning over 100 top medical journals;
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




selected journal articles based on strict and explicit quality criteria;
selected a sub-set of these articles on the basis of their clinical relevance;
prepared structured abstracts of the selected articles;
invited a clinician with expertise in the topic to comment on the structured abstract;
prepared a “declarative title” which summarised the finding of the research study in a single
sentence that can usually be read in under fifteen seconds.
This model of a journal of secondary publication has been, rightly, widely copied and there now
exists:





Evidence-Based Medicine, now twinned with the ACP Journal Club;
Evidence-Based Mental Health;
Evidence-Based Cardiovascular Medicine;
Evidence-Based Oncology;
Evidence-Based Nursing.
These journals of secondary publication distil over 300 journals by selecting about two percent of
the articles that are both of high quality and relevant to the target readers, and they represent a new
and important source of quality improved knowledge.
An analysis of the work of the team filtering out poor quality published articles to identify those that
were both of good methodological quality and high clinical relevance revealed how much of the
published literature does not meet those standards (26). They reviewed 170 journals for the year
2000 and of the 60,352 articles in these journals only 3,059 original articles and 1,073 review
articles met those criteria. Furthermore, the journals did not make an equal contribution to this
total.
Journal title
Contributions
Number of journals in which
no article met the criteria
ACP Journal Club (Internal
medicine)
4 titles contributed 56.5%
27 title contributed 43.5%
55
Evidence-Based Medicine
(general practice/primary care)
5 titles contributed 50.7%
40 titles contributed 49.3%
0
Evidence-Based Nursing
7 titles contributed 51%
34 titles contributed 49%
33
Evidence-Based Mental Health 9 titles contributed 53.2%
34 titles contributed 46.8%
NPFIT/Bestcurrentevidence/29.3.06
8
38
The authors introduced the criteria of journal usefulness called the NNR – the Number Needed to
Read – namely, the number of articles that needed to be read before one that was of adequate quality
and clinically relevant was found. Obviously in those in which no article was found the NNR was
infinity but for many journals more than 100 articles had to be appraised by a trained librarian and
then assessed by a clinician to identify a single article that was of adequate quality and clinically
relevant. Top of the league table was the Cochrane Database of Systematic Reviews.
5.6
Systematic reviews
The problems highlighted in the papers by Cindy Mulrow and Oxman and Guyatt had been tackled
by the National Perinatal Epidemiology Unit in Oxford from 1979 onwards. This Unit undertook a
programme of work to:

find all the high quality evidence that was available, both published and unpublished;

develop quality criteria to determine which of the evidence, published and unpublished, met
explicit quality standards;

combined those pieces of evidence that met these explicit criteria into what became known as a
systematic review; when data are combined, a technique called meta-analysis can be used, but it
is not necessary to carry out meta-analysis within a systematic review and the two terms should
not be regarded as synonyms.
These systematic reviews covered the field of antenatal and perinatal care and, based on this
experience, the Director of the National Perinatal Epidemiology Unit, Iain Chalmers, proposed to
the first Director of the National R&D Programme in England that the same method be used to
cover the whole of healthcare. The R&D Programme funded a Centre to do this work and the UK
Cochrane Centre was created when Scotland, Wales and Northern Ireland joined with the English
R&D Programme to support this programme of work. The UK Cochrane Centre was able to build
on the work done by the National Perinatal Epidemiology Unit, not only because of the accumulated
expertise in preparing systematic reviews but also because of the dramatic developments that took
place in the early 1990s in the Internet and the various tools that were developed to create the World
Wide Web. From the work of the UK Cochrane Centre the international Cochrane Collaboration
has developed, committed to the production, maintenance and dissemination of reviews of the
effects of healthcare.
The characteristics of Cochrane Reviews, which are a sub-set of systematic reviews, are that, in
addition to the basic characteristics listed above, they:



are kept regularly up to date;
involve consumers at all stages in the process;
are published only electronically, in the Cochrane Library.
Systematic reviews can be prepared on any type of research finding and it is important that the term
should not be regarded as applying only to systematic reviews of randomised controlled trials. It is,
for example, possible to carry out a systematic review of qualitative research.
NPFIT/Bestcurrentevidence/29.3.06
39
As with peer review, which for many years has been regarded as a synonym for dependable quality
assurance, the fact that something is called a systematic review should not lull the reader into
accepting everything that is written simply because the authors say that it is a systematic review.
All that glisters is not gold; some reviews that claim to be systematic are not.
5.7
Regular updating
The evidence that a significant number of trials published in high prestige journals were
contradicted by subsequent articles emphasises the need that readers who are completely conversant
with the literature about a particular topic, that is anyone who is not actively involved in either
preparing or maintaining a systematic review, or in gathering new data based on a systematic
review, should not change their practice on the basis of a single paper (27).
Although Cochrane Reviews are noted for their commitment to updating, all documents have to be
updated either explicitly and regularly or treated with caution.
5.8
Developing the skills of critical appraisal
Readers should be suspicious of everything they read, no matter the eminence of the author or the
venerability of its source. They must learn to appraise papers and all sources of medical
information, including guidelines, advertisements, and articles in medical weeklies.
They need to appraise papers not only for their research quality and the quality of reporting but also
for their contribution to the solution of the problems of the individual patient or population for
which the professional is responsible. This often requires results to be rewritten to make them more
usable, for example by converting relative risk data into absolute risk data.
6.
Being aware of certain uncertainty
When a patient or professional is first faced with a problem they may be uncertain what to do, but
this uncertainty is usually what has been called “uncertain uncertainty”, namely the decision-making
does not know whether the knowledge that would help them make the decisions exists or not. By
organising knowledge properly, as described above, the person looking for knowledge can quickly
find whether an answer exists or whether no-one knows the answer, the latter type of uncertainty
being known as “certain uncertainty”.
The James Lind Library has set as its mission the development of a database of uncertainties about
the effects of treatments which will register the uncertainties which cannot be solved by the rigorous
analysis and appraisal of the research literature. This initiative, called DUETS, will allow the
knowledge cycle to be completed because it will allow a feedback to be built into the system so that
those who procure and produce knowledge are clear about the unanswered questions of
professionals and patients (28).
NPFIT/Bestcurrentevidence/29.3.06
40
7.
Supporting systematic reviews
The investment of resources in the production of systematic reviews by research funders is now
having a major impact, and meta-analyses are now cited more often than all other study designs
(29). The promise of increased investment in the Cochrane Collaboration made buy the English
Department of Health in its new R&D Strategy Best Research for Best Health (30), and the outputs
of the Centres for Evidence-Based Practice on both healthcare and systematic review methodology
summarised in a supplement to the Annals of Internal Medicine (31) will lead to further
improvements in the quality of systematic reviews. Not all systematic reviews are good reviews
(32).
8.
Supporting editors and peer reviewers
Of central importance in the improvement of research reporting is the contribution made by journal
editors. The publication of the Journal of the American Medical Association on 5 June 2002 was
based on the papers presented to the Fourth International Congress on Peer Review and Biomedical
Publication held in Barcelona in September 2001, and the scope of work is impressive and
encouraging, for example, the quality of peer review can be measured and reviewed systematically
(33). A Fifth Internal Congress has taken place and further progress was made at that meeting. It
would be expected that journal editors and publishers themselves should be primarily responsible for
this activity but it is important that those who use evidence also contribute by supporting education
and research in this area.
9.
Taking action to help the busy reader
The gap amount between the amount of information available and the time available to process it
yawns increasingly wide. For this reason providers of information have to take steps to help
readers but the process of synthesis and summarising is, as described above, one that can introduce
bias.
Busy clinicians and patients might be able to rely on peer reviewed reports of primary research but
even if all articles conformed perfectly to standards and reported without abbreviation, using the
Internet to supplement the conventional journal articles, the reader who is not familiar with all the
relevant literature would struggle. Good quality systematic reviews are more reliable but may be
equally difficult to read. What busy clinicians and patients need are synopses based on high quality
systematic reviews (34), combined with the opportunity to know that there is no reliable evidence
about a particular topic. Journals have a valuable contribution to make in research but not as a
source of knowledge support for clinicians and patients.
NPFIT/Bestcurrentevidence/29.3.06
41
References
1.
Altman, D. The scandal of poor medical research. BMJ, 1994; 308: 283-4.
2.
Goodman SN, Berlin J, Fletcher SW, Fletcher RH. Manuscript quality before and after peer
review and editing at Annals of Internal Medicine. Ann. Intern. Med. 1994; 121: 11-21.
3.
Mulrow CW. The medical review article: state of the science. Ann. Intern. Med. 1987;
106: 485-8.
4.
Oxman AD and Guyatt GH. Guidelines for reading literature reviews. Can. Med. Assoc. J.
1988; 128: 697-703.
5.
Jefferson T and Godlee F. Peer Review in Health Sciences BMJ Publications, 1999.
6.
Rochon PA, Gurwitz JH, Simms RW. et al. A study of manufacturer-supported trials of
nonsteroidal anti-inflammatory drugs in the treatment of arthritis. Arch. Intern. Med. 1994;
154: 157-163.
7.
Chalmers I and Clarke M. Discussion sections in reports of controlled trials published in
general medical journals: islands in search of continents. JAMA 1998; 280: 280-2.
8.
Clarke M, Alderson P and Chalmers I. Discussion sections in reports of controlled trials in
general medical journals. JAMA; 2002; 287: 2799-2801.
9.
Assman SF, Pocock SJ, Enos, LE. and Kasten LE. Subgroup analysis and other (mis)uses
of baseline data in clinical trials. Lancet, 2000; 355: 1064-69.
10.
Moher D, Schulz KF, Altman DG for the CONSORT Group. The CONSORT statement:
revised recommendations for improving the quality of reports of parallel-group randomised
trials. Lancet, 2001; 357: 1191-4.
11
Jadad AR, Moher M, Browman GP, Booker L, Sigouin C. et al. Systematic reviews and
meta-analyses on treatment of asthma: critical evaluation. BMJ, 2000; 320: 537-40.
12.
McAlister FA, Clark HD, van Walraven C, Straus SE. et al. The medical review article
revisited: has the science improved? Ann. Intern. Med. 1999; 131: 947-51.
13.
Tramer MR, Reynolds DJM, Moore, R.A. and McQuay, H.J Impact of covert duplicate
publication on meta-analysis: a case study. BMJ, 1997; 315: 635-40.
14.
Schulz KF, Chalmers I, Haynes RJ and Altman DG. Empirical evidence of bias:
dimensions of methodological quality associated with estimates of treatment effects in
controlled trials. JAMA 1995; 273; 408-12.
15.
Rennie D. Trial registration: a great idea switches from ignored to irresistible. JAMA
2004; 292: 1359-62.
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16.
Montori VM, Devereaux PJ, Adhikari NKJ, Burns KEA et al. Randomized trials stopped
early for benefit. A systematic review. JAMA, 2005; 294: 2203-9
17.
Chan A-W, Hróbjartsson S, Haahr MT, Gøtzsche PC and Altman DG. Empirical evidence
for selective reporting of outcomes in randomized trials. Comparison of protocols to
published articles. JAMA, 2004; 291: 2457-65.
18.
Editorial: Addressing the limitations of structured abstracts. Ann. Intern. Med. 2004; 140:
480-1.
19.
Altman DG, Schulz KF, Moher D, Egger M, Davidoff F et al for the CONSORT Group.
The Revised CONSORT Statement for reporting randomized trials: explanation and
elaboration. Ann. Intern. Med. 2001; 134: 663-94.
20.
Ioannidis JPA, Evans SJW, Gøtzsche PC, O’Neill RT, Altman DG, Schulz K, and Moher D.
for the CONSORT Group. Better reporting of harms in randomized trials: an extension of
the CONSORT statement. Ann. Intern. Med. 2004; 141: 781-8.
21.
Moher D, Cook DJ, Eastwood S, Olkin I et al. for the QUOROM Group. Improving the
quality of reports of meta-analyses of randomised controlled trials: the QUOROM
Statement. Lancet, 1999; 354: 1896-1900.
22.
Bossuyt PM, Retisma JB, Bruns DE, Gatsonis CA et al. Towards complete and accurate
reporting of studies of diagnostic accuracy: the STARD initiative. Family Practice, 2004;
21: 4-10.
23.
von Elm E and Egger M. The scandal of poor epidemiological research. BMJ 2004; 329:
868-9.
24.
Pocock SJ, Collier TJ, Dandreo KJ, de Stavola BL, Goldman MB, Kalish LA, Kasten LE and
McCormack VA. Issues in the reporting of epidemiological studies: a survey of recent
practice. BMJ. doi:10.1136/bmj.38250.571088.55 (published 6 October 2004).
25.
Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, Moher D, Bekcer BJ,
Sipe TA and Thacker SB. For the Meta-analysis of Observational Studies in Epidemiology
(MOOSE) Group. Meta-analysis of observational studies in epidemiology: a proposal for
reporting. JAMA 2000; 283: 2008-2012.
26.
McKibbon KA, Wilczynski NLK and Haynes RB. What do evidence-based secondary
journals tell us about the publication of clinically important articles in primary healthcare
journals? BMC Medicine, 2004; 2: 33-47.
27.
Ionnides, JPA. Contradicted and initially stronger effects in highly cited clinical research.
JAMA, 2005; 294: 218-228.
28.
Chalmers, I. Well informed uncertainties about the effects of treatments. Brit. Med. J.,
2004; 328: 475-6.
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29.
Patsopoulos NA et al. Relative Citation Index of various study designs in the health
sciences. JAMA, 2005; 293: 2362-66.
30.
Department of Health. Best Research, Best Health. London, 2006.
31.
Atkins D, Fink K and Slutsky J. Better information for better health care: the EvidenceBased Practice Center Program and the Agency for Healthcare Research and Quality. Ann.
Intern. Med. 2005; 142: 1035-41.
32.
Biondi-Zoccai G, Lotrionte M, Abbate A, Testa L, et al. Compliance with QUORUM and
quality of reporting of overlapping meta-analyses on the role of acetylcysteine in the
prevention of contrast associated nephropathy: case study. BMJ, 2006; 332: 202-6.
33.
Haynes RB. Of studies, summaries, synopses and systems: the 4 S evolution of services for
funding current best evidence. Evidence-Based Nursing, 2005; 8: 4-6.
NPFIT/Bestcurrentevidence/29.3.06
44
APPENDIX 2
DECISION SUPPORT PROGRAMME –KNOWLEDGE SUPPORT,
COMPUTER-BASED CLINICAL DECISION SUPPORT SYSTEMS, AND
PATIENT DECISION AIDS
J A Muir Gray
Version
Version 1.0
Version 2.0
Author
J A Muir Gray
J A Muir Gray
Date
20.09.03
26.11.03
Version 3.0
J A Muir Gray
2.12.03
Version 4.0
J A Muir Gray
17.12.03
Version 5.0
J A Muir Gray
21.12.03
NPFIT/Bestcurrentevidence/29.3.06
Amendments
First draft prepared by NeLH Team.
Comments by National Programme for IT
incorporated
Patient decisions aids and governance sections
added, the latter after consultation with Chair of
National Clinical Advisory Board
Additional section on evaluation and quality
assurance added, based on input from NHSIA
Information Standards Board
References to algorithms and clinical prediction
rules
45
CONTENTS
Executive Summary
1.
Background questions and foreground questions
2.
Three types of knowledge
3.
Knowledge for diagnosis and knowledge for treatment.
3.1
3.2
3.3
4.
Knowledge for diagnosis
Knowledge for treatment
Guidelines, protocols and pathways
The determination of searches by people and machines
4.1
4.2
Person-determined delivery
Machine-determined delivery
4.2.1 Knowledge support
4.2.2 Computer-based clinical decision support systems
5.
The evidence base
6.
Harnessing existing resources
6.1
6.2
6.3
6.4
6.5
Integrating knowledge and care records
Knowledge support for diagnosis
Knowledge support for treatment decisions
Developing a framework for knowledge support
Patient decision aids
7.
Evaluation and quality assurance
8.
Governance
8.1
8.2
8.3
8.4
9.
Governance of content
Technical standards
Clinical governance
Evaluation of decision support and decision aids
Project management
References
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46
EXECUTIVE SUMMARY
The aim of this paper is to set out definitions of a range of terms commonly used when knowledge is
being mobilised and delivered to clinicians and patients.
The paper covers terms such as guidelines, protocols and pathways.
The definitions of these are set out below.

Facts are propositions which describe relationships based on information, for example aspirin
given to people who have had a myocardial infarction is associated with reduced risk of a second
infarction.

Guidance sets out for the health service a wide range of measures that should be put in place,
including the configuration of services, for example guidance on cancer services includes action
that the service should take to increase specialisation.

Guidelines are propositions which either stand alone or appear in guidance documents which
make recommendations relevant to patient and clinician behaviour, for example clinicians
should discuss with patients the benefits and risks of aspirin following myocardial infarction.

Protocols are local versions of guidelines, a definition introduced by the Changing Workforce
Programme in 2003. A protocol would be a local version of guidance or guidelines which take
into account local circumstances, for example the availability of CT scanning, and also
summarise local responsibilities for different aspects of the guideline or guidance.

Pathways are forms which set out the protocol, or guideline if there is no localised protocol, for
clinicians to follow to minimise the risk of errors of omission or commission, and to ensure that
the necessary data are collected for audit. Pathways, sometimes called care pathways, describe
the patient journey, and the term patient journey is sometimes used as a synonym for pathway.
They may also be called integrated care pathways if they cut across primary and secondary care.
Pathways may be made available in either paper or electronic form.
The paper also sets out definitions for different types of activity commonly referred to generically as
“decision support”. It is recommended that the term “decision support” should not be used and that
three terms be used in its place.

Knowledge support when knowledge is delivered to clinicians and patients at the point of
knowledge need, either in the form of facts or the form of guidelines or protocols, or embedded
in the pathway; in knowledge support one variable in the patient’s condition, for example the
diagnosis, is used to alert or remind the clinician, and if possible the patient, about the existence
of relevant knowledge.
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47

Computer-based clinical decision support systems are tools that incorporate two or more data
items from the patient record and produce individualised advice about a particular patient’s
clinical situation; clinical prediction rules serve a similar function.

A clinical prediction rule or clinical decision rule has been defined as “a clinical tool that
quantifies the individual contributions that various components of the history, physical
examination, and basic laboratory tests make towards the diagnosis, prognosis or likely response
to treatment in a patient. The term triage algorithm is used to describe rules used for rapid
triage. These rules can be presented on paper or digitally.

Patient group direction is the term applied when the clinical decision rule relates to treatment.

Decision aids are tools primarily for patients but because they facilitate shared decision-making
they also have implications for clinicians.
In addition there is a need for a framework for knowledge support which allows such tools to be
made available through the NHS Care Record Service.
A project has been funded by the National Knowledge Service to develop the Decision Support
Programme. This project would agree appraisal criteria that could be used when considering new
tools and maintain an inventory of the tools deemed to be of sufficient quality to be used in the
service.
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48
SUPPORTING DECISIONS – COMPUTER-BASED KNOWLEDGE SUPPORT, DECISION
SUPPORT SYSTEMS, AND PATIENT DECISION AIDS
Clinicians ask questions frequently. The easier the access to knowledge, the more often they ask
questions, and by integrating NHS Direct Online, the National electronic Library for Health (NeLH)
and the Integrated Care Record System (ICRS) it will be possible to provide clinicians, and patients,
who share in many clinical decisions, with easy access to best current knowledge where and when it
is needed. However, the terms “knowledge” and “decision support” are so widely used that they
have different meanings to different individuals, and it is necessary to develop a common
nomenclature for knowledge and decision support guidance.
1.
Background questions and foreground questions
In Evidence-based Medicine, David Sackett and colleagues distinguished between background and
foreground questions (Figure 1).
Background
Foreground
Figure 1

Background questions are general questions such as: “What are the symptoms of
hyperthyroidism?” and “What are the best treatments for hyperthyroidism?”.

Foreground questions relate to individual patients, for example: “Is drug A or drug B better for
this 55-year-old woman with hyperthyroidism and rheumatoid arthritis?”.
Students ask background questions; clinicians still have a need for background questions but
increasingly formulate foreground questions and need support by the provision of knowledge.
2.
Three types of knowledge
The definition of the term “knowledge” is also necessary and for the purpose of this paper the
definitions below have been used.
Data are generated by research, by experience, and by the measurement of healthcare activity.
Information is produced when data are assimilated into research reports or systematic reviews,
audit reports, healthcare statistics, and case studies based on experience.
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49
Knowledge is produced when information is mobilised for decision-making.
Thus there are three sources of knowledge:



research;
regular or audit measurements of healthcare or public health activity;
experience of professionals and the public.
When dealing with individual patients the clinician needs knowledge from research but they often
need knowledge from experience and obtain this from a colleague more experienced in the
management of that particular type of problem.
It is also important to distinguish between questions asked to establish a diagnosis and questions
about treatment.
3.
Knowledge for diagnosis and knowledge for treatment
The types of knowledge required for diagnosis and treatment are different.
3.1
Knowledge for diagnosis
The process of diagnosis is still poorly understood but diagnosis involves three questions:
1. on the basis of the patient’s symptoms and signs, what is the likely diagnosis, or diagnoses, on
the basis of probability? This is the process of defining pre-test probability;
2. what test or tests would increase the probability of confirming a diagnosis or exclude some
options? This is the process of test selection;
3. having the test results, how does that change the probability and does it result in a definite
diagnosis? This is the process of defining the post-test probability which will exclude some of
the options identified before testing and may confirm one of the options as the diagnosis.
Knowledge about the pre-test probability is listed in what is usually called the differential diagnosis.
Knowledge about the appropriateness of a test and the meaning of its result can be contained within
the test request forms and report forms.
3.2
Knowledge for treatment
In the textbook Evidence-Based Medicine the authors postulate that there are a number of questions
in all treatment decisions, notably:




What is the preferred treatment for a patient with this condition?
How does this compare with other treatment options, including no treatment?
What is the probability of benefit and the probability of harm associated with each option?
How strong is the evidence for each option?
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50
The clinician then has to tailor this knowledge to take into account the condition of the individual
patient and their values, as shown in the figure below (Figure 2).
Patients’ values
and expectations
EVIDENCE
CHOICE
DECISION
Baseline risk
Figure 2
3.3
Facts, guidance, guidelines, protocols and pathways
Knowledge is presented in a number of different types of proposition.
Facts are propositions which describe relationships based on information, for example
aspirin given to people who have had a myocardial infarction is associated with reduced risk
of a second infarction.
Guidance sets out for the health service a wide range of measures that should be put in place,
including the configuration of services, for example guidance on cancer services includes
action that the service should take to increase specialisation.
Guidelines are propositions which either stand alone or appear in guidance documents which
make recommendations relevant to patient and clinician behaviour, for example clinicians
should discuss with patients the benefits and risks of aspirin following myocardial infarction.
Protocols are local versions of guidelines, a definition introduced by the Changing
Workforce Programme in 2003. A protocol would be a local version of guidance or
guidelines which take into account local circumstances, for example the availability of CT
scanning, and also summarise local responsibilities for different aspects of the guideline or
guidance.
Pathways are forms which set out the protocol, or guideline if there is no localised protocol,
for clinicians to follow to minimise the risk of errors of omission or commission, and to
ensure that the necessary data are collected for audit. Pathways, sometimes called care
pathways, describe the patient journey, and the term patient journey is sometimes used as a
synonym for pathway. They may also be called integrated care pathways if they cut across
primary and secondary care. Pathways may be made available in either paper or electronic
form.
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51
4.
The determination of searches by people and machines
Both background knowledge and foreground knowledge can be delivered by persons and machines.
4.1
Person-determined delivery
Passive delivery is by an unprompted search of a web site by a human being – a professional or a
patient. At present this is not possible in many places in which consultations and clinical decisionmaking take place, but this barrier is reducing and many clinicians now have access to the Internet
without leaving their desk. The National electronic Library for Health (NeLH) will be integrated
in the Integrated Care Record Service, allowing people to search the NeLH during the consultation
or, more probably, before or after the consultation. Furthermore, the NeLH team is working to
identify bottom lines that can be read in 15 seconds and asking all providers of knowledge to
prepare their outputs in this way.
4.2
Machine-determined delivery
The use of machines, computers and the Internet, allows the delivery to the clinician and to the
patient.
Background knowledge about a disease and its diagnosis and treatment can be delivered actively by
sending e-mails to clinicians, and each community of practice within the NeLH will be developing
its own e-mail list, facilitated by the growth of the e-mail within the NHS. However, the Integrated
Care Record Service also allows the opportunity for the active presentation of knowledge, providing
knowledge to support decision-making, building on the foundation laid by the NeLH and the
national network of NHS and Higher Education libraries.
4.2.1 Knowledge support
Prompts, reminders, alerts and aids – these terms are used confusingly and the definitions listed
below are proposed.

Prompts: by taking one or more data items and applying some knowledge rules, the machine
prompts the user to do something.

Reminder: this is a special form of prompt which highlights to the healthcare professional
and/or patient that a planned action is due.

Alerts: by taking one or more data items and applying some knowledge rules, the machine
questions the action the user is planning.

Aids: by taking one or more data items and applying some knowledge rules, the machine aids
the user in interpretation of the data and offers one or more options.
They identify some feature about the patient’s condition from the record and draw the attention of
the clinician to the existence of relevant knowledge in the knowledge base.
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52
The features that can be identified are:




the patient’s age and gender;
the principal diagnosis;
other diagnoses already made;
medications prescribed for the patient.
The type of knowledge that could be provided from the knowledge base include:






evidence from research;
guidelines and pathways;
the existence of controlled trials that the patient may wish to enter;
relevant online educational opportunities;
patient information to improve shared decision-making and reduce the risk of litigation;
specialist services, for example tertiary referral services, of which the clinician may be unaware,
a particular feature for rare diseases.
4.2.2 Computer-based clinical decision support systems
“Computer-based clinical decision support systems” is a term used in the best systematic review of
their effectiveness to describe not only the delivery of knowledge from the knowledge base at points
in care determined by the machine but also personalised advice about a particular patient by the
identification of factors such as those listed above or other variables, for example the patient’s blood
pressure, and the incorporation of these additional variables in an algorithm to tailor advice about a
particular patient. This is an example of a system giving foreground as well as background
knowledge and trying to make the decision about an individual patient, and was first defined as “a
tool that uses clinical knowledge to produce patient-specific advice using two or more items of
patient data (1).
4.2.3 Clinical prediction rules
A clinical prediction rule or clinical decision rule has been defined as “a clinical tool that quantifies
the individual contributions that various components of the history, physical examination, and basic
laboratory tests make towards the diagnosis, prognosis or likely response to treatment in a patient.
The term “triage algorithm” is used to describe rules used for rapid triage. These rules can be
presented on paper or digitally.
The term “patient group direction” is applied when the clinical decision rule relates to treatment.
5.
The evidence base
The evidence base for knowledge and computer-based clinical decision support systems is strong
and is growing, and this is co-ordinated by a team at McMaster University, Ontario (2). They are
about to issue a new version of the systematic review last published in the Journal of the American
Medical Association in 1998. In that review there was clear evidence about the effectiveness of
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53
prompts, alerts and reminders but little evidence about the beneficial effects for patients from more
complex types of computer-based decision support.
6.
Harnessing existing resources
6.1
Integrating knowledge and care records
The NeLH, primarily for clinicians, and NHS Direct Online, primarily for patients, will be
completely interoperable using the standards set out in the National Knowledge Infrastructure
(Appendix 1). Thus knowledge will be able to made available through the Integrated Care Record
Service.
6.2
Knowledge support for diagnosis
We have an important range of resources to support the process of diagnosis and these can be linked
to the framework for knowledge support and delivered where and when they are needed, as shown
in Figure 3.
Patient presents
with symptoms
and signs
Provisional
diagnosis or
diagnoses
Choice of tests
ISABEL
Royal College of
Radiology
Guidelines
www.labtestsonline.org
(being adopted for UK)
www.assayfinder.co.uk
Interpretation
of test results
National electronic
Library for
Communicable Disease
Figure 3
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54
6.3
Knowledge support for treatment decisions
Once a diagnosis has been made, the clinician and patient set off on a new pathway (Figure 4).
Patient with
established diagnosis
Knowledge resources like
Clinical Evidence, Mentor
or the other resources
listed in Table 1
Treatment options
Shared decision-making
tools like Dipex
Drug treatment chosen
British National Formulary
Patient education
Self-management
documents like Dipex
Figure 4
One of the aims of the National Knowledge Service is to promote interoperability of all the sources
of knowledge procured, commissioned or produced by the Department of Health and the NHS
nationally. Between £20 million and £30 million is used to produce the knowledge sources listed in
the table below.
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Table 1: Sources of knowledge



















The National Network of Health Libraries,
The Cochrane Library,
Clinical Evidence,
Mentor,
GP Notebook,
Drugs and Therapeutics Bulletin,
MeReC Bulletins,
The British National Formulary,
R&D Outputs,
Pharmacovigilance Bulletins,
NICE guidance,
NPSA alerts,
Public health information from the HPA and the National Screening
Committee,
Prodigy,
CHI Reports,
National Screening Committee recommendations,
NHS Direct CAS system,
Evidence-based journals,
DIPEX.
These sources often cover the same topics and the degree of overlap is being mapped at present. It
is entirely appropriate to have more than one way of expressing knowledge as clinicians and patients
have different needs at different times. Further work will need to be done to ensure that the
knowledge is expressed in a way that can be read quickly by clinicians and patients, and the NeLH
accepts responsibility for negotiating with the producers of knowledge to ensure that it is produced
not only to high standards of quality but also to high standards of usability.
6.4
Developing a Framework for Knowledge Support
The Map of Medicine, a system that allows generalised knowledge, including national guidelines, to
be localised to each healthcare trust, for example by including local forms and telephone numbers,
thus greatly increasing its attractiveness to clinicians. It can also act as a framework for knowledge
support, allowing the specific components within NeLH, described in Sections 6.2 and 6.3, to be
made available in every type of care record (Figure 5).
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Machine-determined
NHS
Direct
Online
Framework
for knowledge
support
Patient
ICRS
NeLH
Clinician
Person-determined
Figure 5
Prodigy Release 2.0 can also act as a support for knowledge services other than its own, and the
NHSIA Disease Management Systems Programme is also piloting care pathways.
6.5
Patient decision aids
There are about two million consultations in the NHS, probably about ten million decisions because
many decisions, for example those about laboratory results, do not take place in consultations.
Some decisions are made by clinicians alone or by patients alone, for example the decision to
consult or not to consult, and some are made by patients and clinicians together – shared decisionmaking, as shown in the diagram below (Figure 6).
Clinicians’
decisions
Shared
decisions
Patients’
decisions
Figure 6
Within shared decision-making there is a continuous spectrum of participation, as shown in Figure
7.
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57
Clinical-led decisions
Patient-led decisions
Figure 7
The satisfaction of the patient with the process of decision-making depends in part on the degree to
which the clinician identifies the patient’s “preferred consulting style” and then provides
information accordingly.
Knowledge support and computer-based clinical decision support systems for professionals often
help the professional identify options; decision aids for patients help the patient come to a decision
about which option to choose. In 1999 the first systematic review of 17 randomised controlled
trials evaluating decision aids was published and since then many other decision aids have been
produced and evaluated. The Cochrane Collaboration has now set up an inventory of patient
decision aids, the lead being taken by Professor O’Connor of the University of Ottawa as part of an
ongoing Cochrane systematic review of patient decision aids. The goals of the inventory are to
catalogue patient decision aids and their development and to appraise the quality of available
decision aids using a pre-defined set of criteria, the CREDIBLE criteria. Public access to the
inventory is at www.ohri.ca/decisionaid. There are now over 400 decision aids in the inventory and
the number is growing. The Integrated Care Record Service will undoubtedly wish to make
decision aids for patients available because decision aids “explain options, clarify values, and
develop skills in shared decision-making” and are now seen as an essential adjunct to the
counselling of a clinician. The systematic review currently being prepared for the Cochrane Library
indicates that the appropriate use of patient decision aids has significant impacts on decisionmaking.
These are complementary to knowledge support and decision support primarily for clinicians.
7.
Evaluation and quality assurance
Clinicians have always used knowledge in the consultation and there are now valid and reliable
techniques for assessing the quality of the research that produced the evidence, and therefore the
strength of the evidence itself, whether that knowledge is presented as a simple conclusion or in the
form of a guideline. The NeLH and NHS Direct Online have criteria by which they appraise some
of the evidence and the National Knowledge Service is doing further work on the most appropriate
way of describing and presenting information which describes the quality of the knowledge
presented.
Computer-assisted decision support systems require a different approach, however. Such a system
is an intervention which the clinician uses in addition to their clinical skills and best current
knowledge. It is an intervention analogous to a biochemical test or a drug or an operation, and
should be evaluated with equal rigour because computer-assisted decision support systems can do
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58
harm as well as good. The randomised controlled trial is therefore the best method for evaluating a
computer-assisted decision support system, with a systematic review being prepared if more than
one trial has been conducted (3). The need for care is important because of the possibility of
publication bias, namely positive trials being more likely to be published.
It is also important to appreciate that clinical decision or prediction rules and algorithms are also
decision support systems, even if they exist as a list on paper rather than being expressed in
software. Such rules and algorithms also need rigorous evaluation (4, 5).
The evaluation of decision aids for patients also needs this approach but the approach is complicated
by the fact that decision aides are used to achieve different outcomes, ranging from better clinical
outcomes to greater satisfaction with decision-making. Nevertheless, each decision aid also needs
rigorous evaluation because a decision aid is an intervention distinct from the direct provision of
best current knowledge to patients (6).
The clinician, of course, can also be regarded as an intervention because there is now considerable
evidence that the way in which the clinician presents the evidence influences the choice made (7)
and methods are also being developed to appraise the input of the clinician, and tools and training
designed to reduce the bias that the professional can unknowingly impart (8, 9).
8.
Governance
One of the problems encountered by people who wished decisions made on knowledge support,
decisions support and patient decision aids is the very process of decision-making itself, namely
decision-making by the public sector
It is not possible to identify any one organisation which has the authority or skills to manage all
aspects of this process and the following governance process is proposed.
8.1
Governance of content
Content of knowledge support and decision support, patient decision aids, other than those produced
by a body with clear processes for quality assured knowledge such as NICE, rests with NeLH and
NHS Direct Online.
8.2
Technical standards
There are two types of technical standard involved in these resources.
The first are those technical standards that relate to document management and these are the
responsibility of the National Knowledge Service, expressed in the National Knowledge
Infrastructure, a document which sets out a set of web document management standards which
comply with the Office of the e-Envoy’s metadata framework.
Messaging standards are the standards that relate to the interaction between these resources and the
National Programme for IT but rest with the NHSIA Information Standards Board. These cover
issues such as messaging standards.
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8.3
Clinical governance
The main source of advice on clinical relevance will be the National Clinical Advisory Board of the
National Programme for IT.
8.4
Evaluation of decision support and decision aids.
The responsibility for formal evaluation of these two technologies rests with the R&D Programme
and with NICE.
9.
Project management
It is clear that there needs to be a programme that co-ordinates the work being done on knowledge
support, computer-based clinical decision support systems, and patient decision aids, and a
development project has been funded for a six month period by the National Knowledge Service to
set up this programme. The responsibility for the project has been given to the National electronic
Library for Health by the National Knowledge Service which is managed by the Modernisation
Agency.
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REFERENCES
1.
Wyatt J and Spiegelhalter D. Field trials of medical decision-aids: potential problems and
solutions. Pp 3-7 in Clayton P (Ed). Proc. 15th Symposium on computer Applications in
Medical Care, Washington 1991. New York: McGraw Hill Inc. 1991.
2.
Hunt DL, Haynes RB, Hanna ST, Smith K. Effects of computer-based clinical decision
support systems on physician performance and patient outcome: a systematic review.
JAMA, 1998; 280: 1339-46.
3.
Bennett JW and Glasziou PP. Computerised reminders and feedback can improve provider
medication management; a systematic review of randomised controlled trials. Med. J.
Aust. 2003; 178: 217-22.
4.
Sox HC. A triage algorithm for inhalational anthrax. Ann. Int. Med. 2003; 139: 379-81.
5.
Laupacis A, Sekar N, and Stiell IG. Clinical prediction rules: a review and suggested
modifications of methodological standards. JAMA, 1997; 277: 488-94.
6.
O’Connor et al. Decision aids for patients facing health treatment or screening decisions:
a systematic review. Brit. Med. J. 1999; 319: 731-4.
7.
Gray JAM The Resourceful Patient. e-Rosetta Press, 2002.
8.
Guimond P et al. Validation of a tool to assess health practitioners’ decision support and
communication skills. Patient Education and Counselling, 2003; 50: 235-45.
9.
Edwards A et al. The development of COMRADE (Combined Outcome Measure for Risk
Communication and Treatment Decision-Making Effectiveness) – a patient-based outcome
measure to evaluate the effectiveness of risk communication and treatment decision-making
in consultation. Patient Education and Counselling, 2003; 50: 311-22.
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APPENDIX 3
NATIONAL LIBRARY OF TOOLS AND RULES
PROJECT INITIATION DOCUMENT
J A Muir Gray
Version
Version 1.0
Version 2.0
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Date
21 December 2005
28 March 2006
Prepared by
J A Muir Gray
J A Muir Gray
62
NATIONAL LIBRARY OF TOOLS AND RULES – PROJECT INITIATION DOCUMENT
1.
Background
Discussions have taken place about the need for libraries, i.e. the systematic collection of:




assessment tools;
monitoring tools to deal with chronic disease;
prescribing rules;
laboratory rules.
Rules are often embedded in tools.
Two papers have been produced as a result of meetings and these are attached for ease of reference.
2.
Rules, tools, pathways and guidelines
2.1
Guidelines
The distinction between these different ways of presenting knowledge is not always clear-cut.
Guidelines and guidance are high level documents, covering conditions such as lung cancer. The
definition of guidelines from NICE is that they are:
………. recommendations by NICE on the appropriate treatment and care of people with
specific diseases and conditions within the NHS. They are based on the best available
evidence. Guidelines help health professionals in their work, but they do not replace their
knowledge and skills.
Guidelines often contain pathways that should be followed, tools that should be used, and rules that
can increase the probability of effective, safe treatment.
2.2
Pathways
A care pathway has been defined as:
………….a document that describes the process for a discreet element of service. It sets out
anticipated, evidence-based, best practice and outcomes that are locally agreed and that that
reflect a patient-centred, multi-disciplinary, multi-agency approach. The ICP document is
structured around the unique ICP Variance Tracking tool. When used with a patient/client, the
ICP document becomes all or part of the contemporaneous patient/client record, where both
completed activities and outcomes, and variations between planned and actual activities and
outcomes, are recorded at the point of delivery.
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At distinct points in the pathway rules may operate.
2.3
Tools
The definition of “tools” as defined by the Oxford Shorter English Dictionary is “a means of
effecting something”. A tool is an instrument, relating certain inputs, for example data from
laboratory tests, to the possibility of an action. A rule may be linked to a tool. Tools can be used
for:



assessing risk;
reaching a diagnosis;
monitoring, namely the periodic measurement of a patient’s condition to manage a chronic
or recurrent health problem.
Libraries of guidelines, pathways and tools will be developed and linked to this library of rules.
2.4
Rules
A rule is a principle, regulation, or maxim governing individual conduct (Oxford Shorter English
Dictionary).
The meaning of a term is best defined by giving examples of its use. Examples of rules would
include:
“a chest x-ray should be carried out on patients who have been hoarse for more than three
weeks”;
“if the potassium is more than 6, the clinician who requested the test should be informed by
telephone”.
Using the simple model of decision-making set out in Figure 1, rules relate evidence to risk in
particular situations, but rule-making is not straightforward.
Patients’ values
and expectations
EVIDENCE
CHOICE
DECISION
Baseline risk
Figure 1
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64
2.4.1 Rules and heuristics
School rules had to be obeyed if punishment were to be avoided. Clinical rules are expressed with
the expectation that they will be followed, but the job of the clinician is often to make a decision that
does not conform to the rule. If the clinician does so they need to justify their action, and if they
have behaved reasonably that decision will be supported. The term “rules” sometimes applies to
closed systems, for example a nuclear power station, but clinical practice is an open system with the
values and expectations of individual patients, as well as their unique biological profile, requiring
the interpretation of rules. For this reason the term “heuristics” is preferable with the meaning of a
heuristic being a rule of thumb, the Oxford Shorter English Dictionary definition.
There are diagnostic and treatment rules;
A diagnostic rule suggests a course of action that a clinician should consider when trying to make a
decision; it is usually expressed in the form “if ………… then”, for example:
“If the result of the ELISA test for hepatitis C is above the reference range and the patient
lives in a low prevalence population then a PCR test should be used as a confirmatory test.”
A prescribing rule suggests a course of action that a clinician should consider when trying to make a
decision; it is usually expressed in the form “if ………… then”.
Rules may be presented to clinicians at specified points in a care pathway to prompt the clinician to
consider an action that is the next step to be taken. Two types of prompt are considered.
2.4.2 Displaying rules
Further discussions have taken place about the way in which rules should be presented. There
appears to be general agreement on the following uses of commonly employed words.

A prompt or reminder is an indication that the clinician should remember that there is a piece
of guidance or relevant documentation that they could consider before:
deciding to do something, or
deciding not to do something.

An alert is an indicator that the clinician should not take further action without taking into
account a piece of knowledge about the intervention or the patient or both.
The latter group has been further subdivided by some people into absolute and relative alerts:

the absolute alert is a complete contraindication;
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65

the relative alert indicates that action could be taken either because it is thought that the risk
justified the action or because the risk could be mitigated by some additional intervention or
action.
As we learn more about drug interaction databases, for example First DataBank, we learn that they
grade their warnings using four grades but usually present only two of them.
3.
Deliverables
The National Library of Tools and Rules will be collected, organised, and the 1.0 version will be
released to LSPs and suppliers by 1 April 2006.
This work will be co-ordinated by the Evidence-Based Content Service, the part of Knowledge,
Process and Safety focusing on the collation of knowledge and documents of different types and
sources for presentation to suppliers. The tools and rules in the National Library will be linked to
other relevant information relating to care processes and pathways.
J A Muir Gray, CBE, DSc, MD, FRCP, FRCPSGlas, FCILIP
Director of Clinical Knowledge, Process and Safety
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66
APPENDIX 4
THE 500 MOST COMMON PROBLEMS ENCOUNTERED IN PRIMARY
CARE
Topics to be covered by a synopsis service
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67
Term from original dataset
Synonyms/explanation
ICD 9 description
Bazian expansion of codes
acute URTI of multiple or unspecified site
contraceptive management
acute bronchitis & bronchiolitis
need for prophylactic vaccination & inoculation
asthma
disorders of conjunctiva
essential hypertension
disorders of external ear
acute pharyngitis
acute tonsillitis
ill defined intestinal infections
other and unspecified disorders of back
non suppurative otitis media and eustachian tube
disorders
neurotic disorders
common cold
osteoarthrosis and allied disorders
candidiasis
atopic dermatitis & related conditions
certain adverse effects NEC
allergic rhinitis
other disorders of urethra and urinary tract
other symptoms involving abdomen and pelvis
acute sinusitis
disorders of menstruation & other abnormal bleeding
from female genital tract
symptoms involving skin and other integumentary
tissue
functional digestive disorders NEC
other diseases due to viruses and chlamydiae
influenza
contact dermatitis & other eczema
diseases of sebaceous glands
peripheral enthesopathies and allied syndromes
symptoms involving head and neck
sprains and strains of other and unspecified parts of
the back
menopausal and postmenopausal disorders
suppurative and unspecified otitis media
disorders of function of stomach
dermatophytoses
normal pregnancy
pain and other symptoms associated with female
genital organs
acute laryngitis & tracheitis
health supervision of infant or child
spondylosis and allied disorders
migraine
NPFIT/Bestcurrentevidence/29.3.06
upper respiratory tract infection
assessment, screening and counselling before prescribing contraceptive pill; emergency
contraception; counselling about contraception
acute bronchitis; bronchiolitis
routine vaccination; pre-travel vaccination
acute or chronic asthma
conjunctivitis
hypertension without known cause
otitis externa; wax in ear; perichondritis of external ear
sore throat
acute tonsillitis
diarrhoea in the absence of causative organism
low back pain; unspecified back pain; spinal stenosis
middle ear infection; blocked ears
anxiety disorder; panic disorder; phobias; obsessive compulsive disorders
common cold
osteoarthritis; including occupationally induced; includes osteoarthritis of specific joints
vaginal or oral candidiasis; thrush
eczema
anaphylaxis; food allergy; adverse effects of drugs
hay fever
urinary tract infection
abdo or pelvic pain - unspecified diagnosis
acute sinusitis
menorrhagia; intermenstrual bleeding; oligomenorrhoea; amenorrhoea; post-coital
bleeding
rash, pallor, swelling, oedema, cyanosis, flushing, spontaneous bruising, jaundice.
(Only if in absence of specific diagnosis)
constipation; irritable bowel syndrome
mumps; viral hepatitis; chlamydial infection
influenza
nickel allergy; contact allergy
sebaceous cyst; acne; blackheads; whiteheads; comedones; 'spots'
tendinitis or bursitis of specific or unspecified site; non-specific shoulder pain; rotator
cuff syndrome; painful arc syndrome; adhesive capsulitis; frozen shoulder ;
epicondylitis; tennis elbow
headache, including chronic tension headache (excludes specific type eg migraine;
cluster etc); nosebleed
sprains and strains of the back
menopausal symptoms; atrophic vaginitis; post-menopausal bleeding
otitis media; chronic suppurative otitis media; chronic mastoiditis; chronic
tympanomastoiditis
dyspepsia; indigestion
ringworm; tinea (tinea capitis, tinea soleum; tinea corporis; tinea cruris - excludes tinea
blanca and tinea nigra)
normal pregnancy
vulvodynia; premenstrual syndrome; dyspareunia; vaginismus; mittelschmerz; stress
incontinence; pelvic congestion syndrome
croup and acute epiglottitis
routine child health visit; routine developmental check
any spondylosis of back (excluding ankylosing spodylitis) or of neck
migraine headache or migraine aura without headache
68
other disorders of ear
angina pectoris
diabetes mellitus
depressive disorder, not elsewhere classified
cystitis
other cellulitis and abscess
haemorrhoids
diseases of the oesophagus
chronic pharyngitis & nasopharyngitis
postpartum care & examination
special symptoms or syndromes not elsewhere
classified (mental health)
other disorders of cervical region
sprains and strains of ankle and foot
heart failure
varicose veins of lower extremities
other family circumstances
other disorders of breast
obesity & other hyperalimentation
other disorders of synovium tendon and bursa
herpes simplex
inflammation of the eyelids
symptoms involving urinary system
sprains and strains of knee and leg
erythematosquamous dermatosis
pruritus and related conditions
benign neoplasm of skin
gastritis and duodenitis
vertiginous syndromes and other disorders of
vestibular system
psoriasis and similar disorders
inflammatory disease of cervix, vagina and vulva
urticaria
chicken pox
erythematous conditions
impetigo
diseases of the oral soft tissues, excluding lesions
specific for gingiva and tongue
disorders of lipid metabolism
cellulitis & abscess of finger and toe
diseases of nail
symptoms involving cardiovascular system
corns and callosities
affective psychoses
iron deficiency anaemias
contusion of lower limb and of other unspecified sites
acquired hypothyroidism
herpes zoster
sprains and strains of shoulder and upper arm
chronic airways obstruction NEC
other forms of chronic ischaemic heart disease
cardiac dysrhythmias
chronic bronchitis
other local infections of skin and subcutaneous tissue
sprains and strains of sacroiliac region
NPFIT/Bestcurrentevidence/29.3.06
includes tinnitus, sudden hearing loss, earache without specific diagnosis; ear
discharge without specific diagnosis
stable angina; chronic stable angina; chest pain due to coronary/ischaemic heart
disease
type 1 or type 2 diabetes mellitus
depression
acute, recurrent or chronic cystitis
cellulitis / abscess of unspecified site
piles; haemorrhoids
oesophagitis; achalasia; oesophageal ulcer; oesophageal stricture; oesophageal
diverticulum; Mallory-Weiss tear/syndrome
chronic rhinitis; chronic pharyngitis; chronic nasopharyngitis
routine post-natal visit
anorexia; tics; bulimia; encopresis
non-specific neck pain syndromes eg whiplash
sprains and strains of ankle and foot
congestive heart failure; left ventricular failure
varicose veins
counselling for family problems; problems with caring for relatives; arranging respite
care; arranging or helping with care in the home
cosmetic concerns; galactorrhoea (milk leakage); breast mass/lump of unknown
diagnosis; nipple fissure/crack; mastitis
obesity, overweight
bunions; bursitis; ganglion; tendon rupture
genital herpes; oral herpes; cold sore; HSV1 ; HSV2
blepharitis; chalazion; sty
renal colic; dysuria; urinary retention; urge incontinence; frequency; discharge NB only
if a specific diagnosis is absent
sprains and strains of knee and leg
seborrhoeic dermatitis
pruritis ani; pruritis vulvi; lichen simplex chronicus; prurigo
benign mole; benign naevus; blue naevus; pigmented naevus; dermatofibroma
gastritis of any type
meniere's disease; labyrinthitis; vertigo; benign paroxysmal positional vertigo;
vestibular neuronitis
chronic plaque psoriasis; pityriasis; psoriatic arthropathy
cervicitis; vulvovaginitis; Bartholin's cyst/abscess
urticaria, hives
varicella zoster
toxic erythema; erythema nodosum; lupus (SLE); rosacea
impetigo (any type)
stomatitis; aphthous ulcers; cellulitis of mouth
hyperlipidaemia; hypercholesterolaemia; hypertriglyceridaemia; lipodystrophy
whitlow; herpetic whitlow; finger or toe cellulitis
fungally infected nails; ingrowing nail; onycholysis
murmur; tachycardia; palpitations
corns, calluses
mania; bipolar disorder; bipolar depression
iron deficiency anaemias
bruises (due to trauma) of leg
clinically low thyroxine, excluding congenital (ie people born with hypothyroidsim)
shingles
sprains and strains of shoulder/upper arm
COPD (chronic obstructive pulmonary disease); COAD (chronic obstructive airways
disease); smoker's lung
Acute myocardial infarction; old myocardial infarct; secondary prevention of ischaemic
or coronary events; angina pectoris; unstable angina
arrhythmias; atrial fibrillation; tachyarrhythmias; bradyarrhythmias; cardiac syncope
also COAD (chronic obstructive airways disease); COPD (chronic obstructive pulmonary
disease)
pyoderma; pyoderma gangrenosum
sprain; strain of low back
69
deafness
symptoms concerning nutrition, metabolism, and
development
sprains and strains of wrist and hand
other persons seeking consultation without complaint
or sickness
other intestinal helminthiases
other complications of procedures NEC
gout
(other) peripheral vascular disease
diseases of hair and hair follicles
other hernia of abdominal cavity without mention of
obstruction of gangrene
other dermatoses
intervertebral disc disorders
other open wound of head
rheumatoid arthritis & other inflammatory
polyarthropathies
adjustment reaction
epilepsy
Acariasis
cataract
diseases of pulp and periapical tissues
other disorders of intestine
sprains and strains of hip and thigh
duodenal ulcer
non-inflammatory disorders of vagina
pediculosis and phthirus infestation
disorders of penis
internal derangement of knee
open wound of finger(s)
superficial injury of hip, thigh, leg & ankle
inguinal hernia
inflammatory disease of ovary, fallopian tube, pelvic
cellular tissue and peritoneum
transient cerebral ischaemia
acute myocardial infarction
other disorders of bone and cartilage
disorders of lacrimal system
contusion of upper limb
acute but ill-defined cerebrovascular disease
acute reaction to stress
anal fissure & fistula
chronic sinusitis
delivery in a completely normal case
other viral exanthemata
phlebitis and thrombophlebitis
contusion of trunk
genital prolapse
disorders of sweat glands
other and unspecified arthropathies
diverticula of intestine
superficial injury of foot and toe(s)
lipoma
mononeuritis of upper limb and mononeuritis multiplex
glaucoma
visual disturbances
haemorrhage in early pregnancy
open wound of knee, leg (except thigh) and ankle
superficial injury of face, neck and scalp except eye
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conductive; sensorineural or mixed hearing loss
loss of appetite; unexplained weight loss or weight gain; difficulty swallowing;
excessive thirst
sprains and strains of wrist and hand
management of people with no specific symptoms or diagnosis
ascariasis; strongyloides; other gut helminths
postoperative complictions; dehiscence; fistula; blood loss; foreign body - all after
operation
gout, podagra
peripheral vascular disease; intermittent claudication; critical limb ischaemia; ischaemic
leg ulcer
alopecia; hirsutism
diaphragmatic hernia; femoral hernia; umbilical hernia --- only if they are not
complicated by acute symptoms
actinic keratosis; seborrhoeic keratosis
slipped disc; prolapsed disc
cut or laceration to head/scalp (not face or neck)
rheumatoid arthritis; Felty's syndrome; juvenile rheumatoid arthritis
adjustment disorder
any form of epilepsy or epileptic fit
mite infestation
cataract
periapical abscess; cavity
rectal prolapse; anal stricture; anal polyp
sprains and strains of hip/thigh
duodenal ulcer
old vaginal tear; vaginal polyp; vaginal dysplasia
head or pubic lice
balanitis; priapism (painful erection); erectile dysfunction secondary to some other
cause (eg diabetes) - not erectile dysfunction of unknown cause
meniscal tear; cartilage tear; chondromalacia patellae; cartilage defect; cruciate
ligament tear
cut, bite or traumatic amputation of finger or thumb
blister, cut, abrasion, foreign body (e.g. knife) in these sites
inguinal hernia
pelvic inflammatory disease
Transient ischaemic attack; amaurosis fugax
heart attack - excludes old myocardial infarct
osteoporosis; pathological fracture; costochondritis
dacryoadenitis; epiphora
bruises (due to trauma) of arm
stroke; cerebrovascular accident
stress reaction
anal fissure; anal fistula
chronic sinusitis
normal vaginal delivery following uncomplicated pregnancy
rash due to presumed and unknown virus
phlebitis or thrombophlebitis (NB this excludes deep vein thrombosis)
bruising (due to trauma) to trunk
uterine or uterovaginal prolapse
anidrosis / heat rash
unspecified arthropathies, other than disorders of spine
diverticulosis; diverticulitis
foot/toe blisters or splinters in foot/toe
lipoma
carpal tunnel syndrome; median, radial or ulnar nerve palsy
any type of glaucoma
; diplopia (double vision); night blindness
first trimester bleeding; threatened abortion
avulsion; laceration; animal bite; cut to these sites
blisters/ abrasions/ insect bites/ splinters in these sites
70
chronic ulcer of skin
other ill defined and unknown causes of morbidity and
mortality
superficial injury of hand(s) except finger(s) alone
drug dependence
other disorders of eye
pleurisy
acute lymphadenitis
fracture of radius and ulna
contusion of face, scalp and neck except eye(s)
dermatomycosis other & unspecified
senile and presenile organic psychotic conditions
benign mammary dysplasias
other and unspecified infectious and parasitic diseases
nondependent abuse of drugs
other noninfective gastroenteritis and colitis
disorders of fluid, electrolyte and other acid-base
balance
other deficiency anaemias
chronic venous ulcers; decubitus ulcer; non-decubitus ulcer; bedsore; pressure
necrosis; pressure sore
death due to unknown cause
blisters/ abrasions/ insect bites/ splinters in these sites
any drug dependence
scleritis; episcleritis; nystagmus of unknown cause
pleurisy with or without pleural effusion
lymphadenitis; abscess of lymph gland or node; painful, tender, inflamed lymph nodes
open or closed fracture of forearm; broken forearm
bruising (due to trauma) to these sites
pityriasis versicolor; tinea blanca; tinea nigra
alzheimer's dementia; dementia; multi-infarct dementia;
benign breast cyst; fibroadenosis; fibrocystic diease of breast; mammary duct ectasia;
fibrosclerosis of breast
pneumocystis carinii; Behcet's syndrome
nicotine addiction
non-infectious gastroenteritis (ie not due to micro-organisms); colitis or ileitis/jejunitis NB excludes Crohn's and ulcerative colitis. Also excludes food poisoning
dehydration; hypo- or hypernatraemia or hypo- or hyperkalaemia; acidosis; alkalosis
unspecified deficiency anaemia (excludes iron; b12, folate deficiency and pernicious
anaemia)
infertility, female
any cause of female infertility (eg ovarian, tubal, hypoythalamic dysfunction)
malignant neoplasm of female breast
breast cancer; adenocarcinoma of breast
personality disorders
any personality disorder
sexual deviations and disorders
psychosexual dysfunction, including premature ejaculation; anorgasmia
parkinsons disease
Parkinson's disease (not parkinsonism)
orchitis and epididymitis
orchitis or epididymitis
spontaneous abortion
any spontaneous abortion/miscarriage
contact with or exposure to communicable diseases
post-exposure prophylaxis or prophylaxis for close contacts for any infectious disease
need for prophylactic vaccination & inoculation against routine immunisation; travel vaccination
single disease
disturbance of conduct NEC
conduct disorder
dentofacial anomalies including malocclusion
temporomandibular joint disorder
infections of kidney
pyelonephritis (acute or chronic) or renal abscess
redundant prepuce and phimosis
tight foreskin, phimosis
other disorders of male genital organs
testicular torsion; testicular atrophy; disorders of ejaculation
superficial injury of trunk
blisters/ abrasions/ insect bites/ splinters in these sites
alcohol dependent syndrome
alcoholism; alcohol addictoin; alcohol dependence
other disorders of eyelids
ectropion (out-turned lids)
diseases of hard tissues of teeth
caries
peptic ulcer, site unspecified
gastroduodenal ulcer or presumed gastric or duodenal ulcer, in which the site (gastric
or duodenal) is not known
hyperplasia of prostate
benign prostatic hyperplasia (benign enlarged prostate)
sprains and strains of elbow and forearm
excludes tennis elbow
other extrapyramidal disease and abnormal movement benign essential tremor; tics; torticollis; huntingtons chorea and other chorea;
disorders
other retinal disorders
diabetic retinopathy; age related macular degeneration
bronchopneumonia, organism unspecified
pneumonia
gastrointestinal haemorrhage
gastrointestinal bleed; haematemesis; melaena; PR (per rectum) bleed
concussion
concussion (with or without loss of consciousness) due to trauma
open wound of hand except finger(s) alone
animal bite, cut, laceration to hand (excluding fingers)
foreign body on external eye
foreign body in eye/cornea/sclera
infectious mononucleosis
glandular fever; epstein barr virus;
schizophrenic psychoses
any type of schizophrenia
physiological malfunction arising from mental factors
any psychosomatic disorder or physical symptom of psychogenic origin
hypotension
low blood pressure
cholelithiasis
gallstones and gall stone disease or biliary colic
non-inflammatory disorders of cervix
cervical dysplasia; cervical ectropion
polymyalgia rheumatica
polymyalgia rheumatica
acquired deformities of toe
bunions; hallux valgus
fracture of rib(s), sternum, larynx and trachea
rib fracture
streptococcal sore throat & scarlatina
strep throat
NPFIT/Bestcurrentevidence/29.3.06
71
specific diseases due to Coxsackie virus
transient organic psychotic conditions
pneumonia, organism unspecified
other diseases of respiratory system
diseases and other conditions of the tongue
idiopathic proctocolitis
other disorders of gall bladder
other complications of pregnancy NEC
other hypertrophic and atropic conditions of skin
ankylosing spondylitis and other inflammatory
spondylopathy
non-specific findings on examination of urine
intracranial injury of other and unspecified nature
superficial injury of eye and adnexa
thyrotoxicosis with or without goitre
other disorders of blood and blood-forming organs
trigeminal nerve disorders
strabismus and other disorders of binocular eye
movements
other disorders of tympanic membrane
other diseases of upper respiratory tract
diseases of the salivary glands
infections of the breast and nipple associated with
childbirth
osteochondropathy
infections specific to the perinatal period
open wound of elbow, forearm and wrist
superficial injury of shoulder and upper arm
malignant neoplasm of other and ill-defined sites
blindness and low vision
nasal polyps
chronic disease of tonsils and adenoids
emphysema
gingival and periodontal diseases
excessive vomiting in pregnancy
burn of wrist(s) and hand(s)
effects of reduced temperature
rubella
intestinal infections due to other organisms
malignant neoplasm of trachea; bronchus and lung
NPFIT/Bestcurrentevidence/29.3.06
hand, foot and mouth disease; carditis due to coxsackie virus
delirium
pneumonia
pneumothorax; empyema
glossitis; glossodynia (tongue pain); burning tongue/mouth; geographic tongue
ulcerative colitis; pseudopolyposis of the colon; pseudopolyposis coli; ulcerative
proctitis
acute cholecystitis; cholecystitis; hydrops of gallbladder; gallstones; gallbladder
perforation; gallbladder fistula ; cholelithiasis
excessive weight gain in pregnancy; peripheral neuritis / peripheral neuropathy in
pregnancy; bacteruria in pregnancy; urinary tract infection in pregnancy; jaundice in
pregnancy (exclude hypertension in pregnancy and exclude pre-eclampsia/eclampsia)
circumscribed scleroderma; acquired keratoderma; acquired acanthosis nigricans;
striae atrophicae; keloid
ankylosing spondylitis; spinal enthesopathy; sacroiliitis; inflammatory spondylopathies,
abnormal urinanlysis; abnormal urine dipstick; proteinuria; haemoglobinuria;
myoglobinuria; biliuria; glycosuria; acetonuria; cells or casts in urine.
brain/cerebral injury; intracranial injury, cerebral contusion; contre-coup injury.
(exclude: head injury that involves open wound of head without intracranial injury,
skull fracture alone, intracranial injury with skull fracture).
superficial injury (including abrasion) of eyelids, orbit, cornea/conjunctiva of eye
hyperthyroidism, thyroid storm, thyrotoxic crisis, thyrotoxic storm; thyrotoxicosis.
(excl. neonatal thyrotoxicosis, endocrine and metabolic disturbances specific to the
foetus and newborn.), with or without goitre or thyroid nodule
secondary (NOT primary) polycythaemia; lymphadenitis; hypersplenism;
methaemoglobinaemia; NB EXCLUDE anaemia of pregnancy
trigeminal neuralgia; atypical face pain.
esotropia; exotropia; heterotropia; strabismus; diplopia
myringitis (without otitis media); perforation of ear drum / tympanic membrane;
vocal cord paralysis; vocal cord or laryngeal polyp; laryngeal oedema; allergic or
hypersensitive reaction involving upper respiratory tract or larynx
salivary gland (or duct) atrophy/hypertrophy/abscess/fistula/stone; sialoadenitis;
sialolithiasis; xerostomia
puerperal abscess / breast abscess / mastitis associated with new baby
osteochondrosis; slipped upper femoral epiphysis; osteochondritis dissecans (exclude
specific arthritis e.g. rheumatoid / osteoarthritis).
congenitally / perinatally acquired infection: congenital rubella/CMV (cytomegalovirus)
infection/ HIV infection; neonatal tetanus/ tetanus neonatorum; omphalitis of newborn;
neonatal infective conjunctivitis / neonatal herpes.
animal bite / laceration / cut of elbow, forearm, and wrist. (exclude: burn, crushing,
puncture of internal organs, superficial injury, but include if it occurs along with
dislocation or fracture or other more generalised trauma; internal injury; intracra
superficial injury of axilla and/or scapula region. superficial abrasion; friction burn;
blister; insect bite; foreign body in shoulder/scapula and/or upper arm/axilla.
malignant neoplasm / malignancy of / cancer of head, face, and neck, or other sites if
not specific (e.g. exclude breast cancer; lung cancer; sarcoma; melanoma etc).
involving one or both eyes: blindness; profound visual impairment; legal
blindness(USA); unspecified visual loss.
nasal polyp; polypoid sinus degeneration; sinus polyp.
chronic tonsillitis or chronic adenoiditis; tonsillar/adenoid hypertrophy
emphysema; emphysematous bulla/bullae
caries; periodontitis; gingivitis
vomiting during pregnancy, hyperemesis gravidarum,
(exclude: friction burns, sunburn).
frostbite; trenchfoot (immersion foot); chilblains; hypothermia.
rubella / German measles
bacterial or viral or infective colitis/diarrhoea/dysentery/gastroenteritis/
enterocolitis/enteritis due to following specified organisms: E.coli; aerobacter
aerogenes/proteus/any and all viruses (if organism unspecified, then capture under “illdefined i
bronchial adenocarcinoma, bronchogenic/bronchial carcinoma; lung cancer/ tracheal
cancer
72
other malignant neoplasm of skin
benign neoplasm of breast
multiple scelrosis
hypertensive heart disease
other and ill-defined cerebrovascular disease
regional enteritis
abscess of anal and rectal regions
calculus of kidney and ureter
other complications of labour and delivery, not
elsewhere classified
congenital anomalies of genital organs
fracture of metacarpal bones
fracture of one or more phalanges of hand
fracture of neck of femur
fracture of tibia and fibula
fracture of ankle
fracture of one or more tarsal and metatarsal bones
open wound of foot except toes alone
contunsion of eye and adnexa
malignant neoplasm of prostate
uterine leiomyoma
ovarian dysfunction
keratitis
old myocardial infarction
other diseases of endocardium
diseases of capillaries
pneumococcal pneumonia
gastric ulcer
intestinal obstruction without mention of hernia
other disorders of bladder
hydrocele
endometriosis
pilonidal cyst
certain congenital musculoskeletal deformities
senility without mention of psychosis
sudden death, cause unknown
fracture of face bones
burn of lower limb(s)
other venereal diseases
malignant neoplasm of colon
other disorders of pancreatic internal secretion
purpura and otherhaemorrhagic conditions
specific non-psychotic mental disorders following
NPFIT/Bestcurrentevidence/29.3.06
BCC, basal cell carcinoma; Bowen’s disease, focal dermal hypoplasia syndrome (Goltz),
Goltz’s syndrome, Goltz-Gorlin syndrome, Gorlin syndrome, malignancy of skin or lips
(exclude melanoma, rodent ulcer, squamous cell carcinoma).
benign cystosarcoma phylloides, benign breast lump; benign neoplasm of breast,
breast trichoepithelioma, breast fibroadenoma, papillomatosis.
multiple sclerosis
hypertensive cardiomyopathy; left ventricular hypertrophy or cardiomegaly due to
hypertension; hypertensive heart failure.
cerebral atherosclerosis; generalised ischaemic cerebrovascular disease; hypertensive
encephalopathy; nonruptured cerebral aneurysm; intracranial sinus thrombosis;
transient global amnesia (exclude acute cerebrovascular events e.g stroke,
haemorrhage, tra
Crohn’s disease; Crohn’s colitis/enteritis/enterocolitis/ileitis
(excludes pilonidal sinus/cyst)
kidney stone, nephrolithiasis, renal calculi, renal stone, ureteral/urinary stone/calculus.
maternal distress in labour and delivery; maternal shock/hypotension associated with
labour and delivery; instrumental delivery (forceps/vacuum extraction/ventouse
delivery; breech delivery; caesarean delivery/section).
undescended and retracted testicle/testes; hypospadias, epispadias; indeterminate sex;
pseudohermaphroditism; congenital anomalies of reproductive organs/ genitalia;
fracture of any metacarpal bone (whether or not other hand/finger bones involved)
finger fracture, phalanx/phalangeal fracture; thumb fracture (whether or not other
hand/finger bones involved)
femur neck fracture / fractured neck of femur/ femoral neck fracture; transcervical
femoral fracture
(exclude: Dupuytren’s fracture, ankle fracture, Pott’s fracture, pathological or
spontaneous fracture). closed/open fracture of lower leg, unspecified part.
fracture of malleolus/ malleoli; ankle fracture
fracture of calcaneus; fracture of other tarsal and metatarsal bones.
animal bite, avulsion, laceration, cut, open wound of foot or heel. (exclude if only toes
are so injured.)
black eye; contusion/bruising of eyelids/orbit/eyeball.
prostate/prostatic cancer, prostate/prostatic carcinoma.
uterine fibroids/ uterine leiomyoma uterine myoma.
hyperoestrogenism ovarian failure; polycystic ovarian disease; PCOS; polycystic ovary
syndrome
corneal ulcer; keratitis; keratoconjunctivitis; corneal neovascularisation;
ECG diagnosis of old MI; healed MI; old heart attack. old coronary artery thrombosis.
cardiac valvular disease; mitral valve disorder; aortic valve disorder; tricuspid valve
disorder; pulmonary valve disorder; endocarditis.
hereditary haemorrhagic telangiectasia; benign nevus.
pneumococcal pneumonia; pneumonia due to streptococcus pneumoniae; lobar
pneumonia (even if pneumococcus not specified as causative organism)
gastric/ stomach ulcer; peptic ulcer; prepyloric ulcer; pyloric ulcer; stomach ulcer.
intestinal obstruction (exclude if associated with hernia)
vesical fistula; bladder diverticulum; atonic bladder; functional bladder disorder; urinary
retention.
hydrocele/hydrocoele (of testis/tunica vaginalis).
endometriosis, endometrioma.
coccygeal fistula/abscess, coccygeal sinus, pilonidial fistula; pilonidial sinus, pilonidal
abscess, pilonidial cyst with/without abscess.
congenital dislocation of hip; congenital deformities of long bones of legs; varus
deformities of feet; valgus deformities of feet; club foot; talipes
ageing; age related degeneration/degenerative changes/debility/debilitation; old age;
senescence; senility.
SIDS/ cot death; sudden death (of unknown cause).
fracture of facial/face bones; nasal fracture; fracture of mandible/mandibular fracture;
malar and/or maxillary fracture; orbital floor fracture/ blowout fracture of orbit
burn of lower limb(s)/legs;
chancroid; lymphogranuloma venereum; granuloma inguinale; Reiter;s disease;
nongonococcal urethritis; chlamydial infection of reproductive tract.
adenocarcinoma of colon; colon cancer (include colorectal cancer)
hypoglycaemic coma; hypoglycaemia
allergic purpura; platelet dysfunction; purpura; thrombocytopenia.
mental disorder following brain damage
73
organic brain damage
specific delays in development
dyslexia; dyscalculia/acalculia; learning difficulties; developmental language or speech
disorder; development disorder; developmental delay; autism/autistic spectrum
disorder
other cerebral degenerations
Alzheimer’s disease; Pick’s disease; senile degeneration of the brain; dementia
didorders of iris and ciliary body
iridocyclitis; disorders of iris and/or ciliary body.
acute pulmonary heart disease
acute cor pulmonale; pulmonary embolism and pulmonary infarction; acute pulmonary
heart disease.
deflected nasal septum
deviated/deflected/crooked nasal septum.
bronchiectasis
bronchiectasis; bronchiolectasis.
disorders of tooth development and eruption
teething; teething pain.
appendicitis, unqualified
appendicitis
chronic liver disease and cirrhosis
alcoholic liver disease; alcoholic hepatitis/steatohepatitis; cirrhosis (of the liver);
chronic hepatitis; biliary cirrhosis
non-inflammatory disorders of ovary, fallopian tube
ovarian cyst; follicular cyst of ovary; corpus luteum cyst; prolapse of ovary and/or
and broad ligament
fallopian tube; ovarian torsion/torsion of ovary
legally induced abortion
(induced) abortion (exclude spontaneous abortion)
other current conditions in the mother classifiable
specific diseases in the mother, only if complicating childbirth: diabetes mellitus;
elsewhere but complicating pregnancy, childbirth and
thyroid dysfunction (hypo- or hyperthyroidism); anaemia; drug dependence/ substance
the puerperium
abuse; mental disorder; cardiovascular disease; musculoskeletal disorders
other disorders of the breast associated with childbirth, only if associated with childbirth and breastfeeding: Retracted nipple / cracked nipple;
and disorders of lactation
engorgement of breasts; failure of lactation; galactorrhoea
lichen
lichen planus; lichen nitidus
other congenital anomalies of upper alimentary tract
congenital tongue tie; cleft palate/ cleft lip; tracheoesophageal fistula; oesophageal
atresia and/or stenosis; congenital oesophageal anomalies; congenital pyloric stenosis;
congenital hiatal hernia
fracture of humerus
fracture of humerus
fracture of carpal bones
carpal bone fracture; scaphoid fracture
fracture of one or more phalages of foot
toe fracture; fracture of phalanges of foot
effects of other external causes
radiation sickness; barotrauma; exposure
measles
measles; morbilli; rubeola; measles complications
viral hepatitis
viral hepatitis; Hepatitis A, B or C; unspecified viral hepatitis
mumps
mumps; mumps orchitis; mumps meningitis; mumps encephalitis; mumps pancreatitis;
mumps complications
malignant neoplasm of bladder
adenocarcinoma of bladder; bladder cancer; carcinoma of bladder; transitional cell
carcinoma of bladder.
secondary malignant neoplasm of other specified sites secondary cancer (i.e. metastasis/ metastatic deposit / metastatic tumour / secondary
tumour)
haemangioma and lymphangioma, any site
angioma; haemangioma; cavernous angioma; glomus tumor; lymphangioma;
arteriovenous malformation
simple and unspecified goitre
simple goitre; goitre (NB if associated with hyperthyroidism then capture under
hyperthyroidism/thyrotoxicosis).
paranoid states
paranoia; paranoid delusions; paranoid disorders; paraphrenia; (exclude paranoid
schizophrenia, which is captured under schizophrenia)
other nonorganic psychoses
psychotic state due to environmental factors; emotional stress; reactive psychosis
hemiplegia
hemiplegia (exclude congenital, infantile, or hemiplegia due to stroke or other
cerebrovascular accident)
facial nerve disorders
seventh nerve palsy; Bell’s palsy;
disorders of refraction and accommodation
hyperopia; myopia; astigmatism; anisometropia; aniseikonia; presbyopia;
accommodative disorders
other venous embolism and thrombosis
Budd-Chiari syndrome; thrombophlebitis migrans; deep vein thrombosis; venous
thromboembolism (regardless of site – include vena caval thrombosis/ renal vein
thrombosis). (exclude pulmonary embolism)
other disorders of circulatory system
haemorrhage; postpheblitic syndrome;
chronic laryngitis and laryngotracheitis
laryngitis/laryngotracheitis (exclude acute laryngitis/laryngotracheitis)
acute appendicitis
acute appendicitis
chronic renal failure
chronic renal failure; end stage renal disease; chronic uraemia.
inflammatory diseases of prostate
acute/chronic prostatitis; prostate abscess.
inflammatory diseases of uterus, except cervix
unspecified inflammatory disease/inflammation of uterus.
venous complications in pregnancy and the
varicose veins (of legs or of genitalia/perineum) in pregnancy; haemorrhoids in
puerperium
pregnancy; thrombophlebitis in pregnancy; venous thrombosis / deep vein thrombosis
in pregnancy
diffuse diseases of connective tissue
multi-system collagen diseases; systemic lupus erythematosus; systemic sclerosis;
Sjogren's disease; dermatomyositis; polymyositis; eosinophilia myalgia syndrome.
flat foot
acquired arch weakness; acquired pes planus; broken arches; fallen arches; flat foot.
NPFIT/Bestcurrentevidence/29.3.06
74
other acquired deformaties of limbs
other congenital muscoskeletal anomalies
nonspecific abnormal histological and immunological
findings
fracture of vertebral column without mention of spinal
cord legion
fracture of clavical
dislocation of shoulder
open wound of toe(s)
superficial injury of finger(s)
crushing injury of upper limb
foreign body in ear
burn of upper limb, except wrist and hand
other salmonella infections
erysipelas
trichomoniasis
malignant neoplasm of rectum, rectosigmoid junction
and anus
other benign neoplasm of connective and other soft
tissue
carcinoma in situ of breast and genitourinary system
neoplasm of uncertain behaviour of other and
unspecified sites and tissues
disorders of carbohydrate transport and metabolism
other and unspecified disorders of metabolism
mononeuritis of lower limb
inflammatory and toxic neuropathy
corneal opacity and other disorders of cornea
diseases of mitral valve
occlusion of cerebral arteries
aortic aneurysm
polyarteritis nodosa and allied conditions
peritonsillar abscess
other disorders of biliary tract
intestinal malabsorption
infertility, male
ectopic pregnancy
hypertension complicating pregnancy, childbirth and
the puerperium
other derangement of joint
curvature of spine
congenital anomalies of eye
NPFIT/Bestcurrentevidence/29.3.06
mallet finger; acquired deformities of finger / hand/ wrist/ arm/ forearm/ hip/ leg/
knee/ ankle/ foot.
congenital anomalies of skull and facial bones/spine/diaphragm/abdominal
wall/abdominal muscle/tendon/fascia/cervical rib; chondrodystrophy; osteodystrophy.
abnormal cervical pap smear; non-specific abnormality on chromosomal analysis; nonspecific positive culture findings; non-specific reaction to tuberculin skin test (without
active TB)
vertebral fracture; crush fracture of vertebra; neural arch fracture; spinal fracture;
fracture of spinous process or transverse process; fractured neck; back; sacrum or
coccyx; cervical spine fracture
clavical/ calvicular fracture; fracture of collar bone
dislocation of shoulder (exclude congenital dislocation).
animal bite; avulsion; cut/laceration of toe(s)
superficial injury / abrasion /blister /insect bite / foreign body / splinter in finger,
fingernail, thumb, thumbnail
crush injury of shoulder and upper arm/elbow and forearm/wrist and hand(s) (exclude
such injuries if confined to finger(s) alone).
foreign body in ear; foreign body in external auditory canal/ external auditory meatus;
foreign body in auricle.
burn of upper limb/ arm/ forearm/ wrist/ hand/fingers.
salmonella gastroenteritis; salmonella septicaemia; salmonella infection.
erysipelas.
trichmonas vaginalis infection; trichmoniasis
anal cancer; rectal cancer; include colorectal cancer
benign lump or neoplasm of connective tissue
carcinoma in situ (include CIS breast/cervix/uterus/other female
genitalia/prostate/penis/other male genitalia/bladder/urinary organs); also include
DCIS (ductal carcinoma in situ); vaginal intraepithelial neoplasi (VIN); cervical
intraepithelial neoplasi
breast lumps (when malignant/benign status unknown); suspicious skin lesions (when
malignant/benign status unknown); histiocytoma; plasmacytoma; polycythemia vera.
inborn error of (carbohydrate) metabolism: glycogenosis; galactosemia; hereditary
fructose intolerance; intestinal disaccharidase deficiencies; renal glycosuria.
cystic fibrosis; porphyria; amyloidosis; disorders of bilirubin excretion;
mucopolysaccharidosis; metabolic syndrome X.
sciatica; sciatic neuropathy; lateral cutaneous nerve compression; common peroneal
nerve lesion; lesion of medial popliteal nerve; tarsal tunnel syndrome; plantar nerve
lesion
neuritis; mononeuritis multiplex; diabetic neuropathy; alcoholic neuropathy;
malignancy-induced neuropathy; vascular neuropathy; Guillain-Barre syndrome;
unspecified inflammatory or toxic neuropathy.
corneal scars and opacities; corneal pigmentations and deposits; corneal oedema;
corneal dystrophy; keratoconus;
mitral stenosis; mitral reflux/regurgitation; mitral valve prolapse.
cerebral thrombosis; cerebrovascular thrombosis; cerebral/cerebrovascular
thromboembolism; cerebral/cerebrovascular embolism.
aortic aneurysm; aortic dissection; dissecting aortic aneurysm.
polyarteritis nodosa; Kawasaki disease; hypersensitivity angiitis; Wegener’s
granulomatosis; giant cell arteritis; thrombotic microangiopathy; Takayasu’s disease;
temporal arteritis.
peritonsillar abscess; peritonsilitis; quinsy.
cholangitis (include sclerosing cholangitis); choledocholithiasis; bile duct obstruction;
bile duct perforation; bile duct fistula; sphincter of Oddi spasm.
coeliac disease; tropical sprue; blind loop syndrome; pancreatic steatorrhoea.
azoospermia; oligospermia; male infertility.
abdominal/tubal/ovarian/other/unspecified site ectopic pregnancy.
benign essential hypertension in pregnancy; transient HT of pregnancy; pregnancyinduced hypertension; pre-eclampsia; eclampsia.
articular cartilage disorder; loose body in joint; recurrent dislocation (not current
injury); contracture of joint; ankylosis (exclude ankylosing spondylitis).
kyphosis; lordosis; kyphoscoliosis; scoliosis.
anophthalmos; microphthalmos; buphthalmos; congenital cataract and lens anomalies;
coloboma.
75
fracture of other and unspecified parts of femur
dislocation of knee
open wound of eyeball
open wound of other and unspecified sites, except
limbs
open wound of shoulder and upper arm
superficial injury of elbow, forearm and wrist
certain early complications of trauma
complications peculiar to certain specified procedures
shigellosis
other food poisoning (bacterial)
bacterial infection in conditions classified elsewhere
and of unspecified site
malignant neoplasm of oesophagus
malignant neoplasm of stomach
malignant melanoma of skin
malignant neoplasm of cervix uteri
malignant neoplasm of ovary and other uterine adnexa
malignant neoplasm without specification of site
benign neoplasm of other and unspecified sites
nontoxic nodular goitre
other disorders of thyroid
deficiency of b-complex components
disorders of mineral metabolism
drug psychoses
other organic psychotic conditions (chronic)
other condition of brain
retinal detachments and defects
disorders of the orbit
secondary hypertension
cardiomyopathy
conduction disorders
intracerebral haemorrhage
occlusion and stenosis of precerebral arteries
atherosclerosis
varicose veins of other sites
noninfective disorders of lymphatic channels
viral pneumonia
other bacterial pneumonia
pneumothorax
other alveolar and parietoalveolar pneumopathy
other diseases and conditions of the teeth and
supporting structures
diseases of the pancreas
urethritis, not sexually transmitted, and urethral
syndrome
urethral stricture
disorders of uterus, not elsewhere classified
noninflammatory disorders of vulva and perineum
missed abortion
NPFIT/Bestcurrentevidence/29.3.06
fracture of femur (exclude fractured neck of femur).
subluxation/dislocation of knee; meniscus/meniscal tear; dislocation of patella/patellar
dislocation.
animal bite /cut /puncture/laceration of eyeball, (ocular laceration).
wounds of trunk / torso /abdomen/ chest.
animal bite /avulsion of/cut /laceration of shoulder and upper arm.
superficial abrasion/injury or friction burn/ insect bite to/ foreign body in elbow,
forearm, and wrist.
air / fat embolism after trauma; haemorrhage after trauma; posttraumatic wound
infection; traumatic shock; traumatic anuria; rhabdomyolysis after trauma; Volkman’s
contracture; traumatic subcutaneous emphysema.
complications following implants/prostheses/graft/transplant
bacillary dysentery; shigella; shigellosis
(bacterial) food poisoning
sepsis/toxaemia/septicaemia/toxic shock/diseminated infection due to bacteria.
cancer of oesophagus; oesophageal cancer/carcinoma.
gastric cancer/carcinoma/adenocarcinoma; cancer of stomach
malignant melanoma
cervical cancer; cancer of cervix
ovarian cancer; cancer of ovary
cancer of unknown or no specific site; disseminated malignancy
benign neoplasm of lymph nodes
thyroid adenoma; thyroid nodule (EXCLUDE if associated with hyperthyroidism)
thyroid cyst; thyroid haemorrhage.
vitamin B deficiency (inc all vit B components).
pernicious anaemia; intrinsic factor deficiency; Wilson’s disease; haemachromatosis;
hyperparathyroidism; hyper/hypocalcaemia; hyper/hypomagnesaemia;
hyper/hypophosphataemia
drug withdrawal syndrome; drug psychosis; drug intoxication; drug induced paranoia
and/or hallucination;.
amnestic syndrome; dementia
cerebral cyst; anoxic brain injury; cerebral hypoxia/anoxia; pseudotumor cerebri;
encephalopathy; cerebral oedema.
retinal detachment; retinoschisis; retinal cysts; retinal defects.
orbital cellulitis; inflammation of orbit; exophthalmos; enophthalmous
renovascular hypertension; secondary hypertension, (excluding HTN complicating
pregnancy or childbirth); malignant hypertension.
myocardiopathy; cardiomyopathy (of any cause, include also hypertrophic
cardiomyopathy); myocardial fibrosis; endomyocardial fibrosis
atrioventricular block; heart block; bundle branch blocks.
cerebral/cerebellar/ brain stem haemorrhage
carotid (artery) stenosis; vertebral artery stenosis; basilar artery stenosis;
embolism/thrombosis/thromboembolism of these arteries.
atherosclerosis; atherosclerotic disease; atheromatous disease; atheroma;
cardiovascular disease/cerebrovascular disease/peripheral vascular disease
oesophageal varices sublingual varices; pelvic varices; vulval varices.
lymphoedema; lymphangitis.
viral pneumonia; viral pneumonitis; respiratory syncytial virus (RSV) pneumonia;
bronchiolitis
pneumonia due to specified bacteria other than pneumococcus; legionnaires disease.
pneumothorax
pulmonary haemosiderosis; fibrosing alveolitis
loss of teeth due to trauma; tooth extraction; periodontal disease; caries.
pancreatitis; pancreatic cyst / pancreatic pseudocysts
urethritis; non-specific urethritis (exclude gonococcal; chlamydial).
urethral stricture
uterine polyp; uterine hypertrophy; uterine/endometrial hyperplasia; haematometra;
uterine inversion/retroversion/ retroverted uterus.
vulval/vaginal atrophy/dystrophy; clitoral hypertrophy; labial hypertrophy; labial polyp.
missed miscarriage; missed abortion; retained products of conception.
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antepartum haemorrhage, abruptio placentae, and
placenta praevia
early or threatened labour
other fetal and placental problems affecting
management of mother
postpartum haemorrhage
bullous dermatosis
osteomyelitis, periostitis and other infections involving
bone
osteitis deformans and osteopathies associated with
other disorders classified elsewhere
congenital anomalies of ear, face and neck
bulbus cordis anomalies and anomalies of cardiac
septal closure
other congenital anomalies of limbs
fracture of pelvis
fracture of patella
fracture of unspecified bones
dislocation of finger
other, multiple and ill-defined dislocations
open wound of ocular adnexa
open wound of ear
open wound of genital organs (external), including
traumatic amputation
multiple and unspecified open wound of lower limb
crushing injury of lower limb
foreign body in genitourinary tract
burn of face, head and neck
burn of trunk
burn, unspecified
injury to periferal nerve(s) of shoulder girdle and
upper limb
injury to other and unspecified nerves
toxic effect of other substances, chiefly nonmedicinal
as to source
complications of medical care, not elsewhere specified
other protozoal intestinal diseases
pulmonary tuberculosis
whooping cough
meningococcal infection
tetanus
septicaemia
actinomycotic infections
other non-arthropod-borne viral diseases of central
nervous system
malaria
gonococcal infections
other and unspecified helmithiases
sarcoidosis
malignant neoplasm of pancreas
malignant neoplasm of larynx
malignant neoplasm of body of uterus
malignant neoplasm of testis
malignant neoplasm of kidney and other and
NPFIT/Bestcurrentevidence/29.3.06
placenta previa; abruptio placentae/ placental abruption; antepartum haemorrhage.
preterm labour/premature labour; threatened preterm/premature labour; early onset of
delivery.
foetal-maternal haemorrhage; rhesus incompatibility; ABO isoimmunisation; haemolytic
disease of the newborn; foetal distress; intrauterine foetal death; intrauterine growth
retardation; microsomia; macrosomia; oligohydramnios; polyhydramnios; placental i
postpartum haemorrhage
dermatitis herpetiformis; bullous dermatosis; pemphigus; pemphigoid.
osteomyelitis;.
osteitis deformans; osteitis deformans; hypertrophic pulmonary osteoarthropathy
congenital anomaly of ear/ face/ neck; accessory auricle; branchial cleft; cyst or fistula;
preauricular sinus; webbing of neck.
ventricular septal defect; common trunchus; transposition of great vessels; tetraology
of fallot; common ventricle; atrial septal defect; endocardial cushion defect.
polydactyly; syndactyly; micromelia; amelia.
pelvic fracture; acetabular fracture; pubic fracture
fracture of kneecap/ patella; patellar fracture
fracture of unspecified bone(s); fractures in general
dislocation/subluxation of finger/thumb/phalanx/phalanges
vertebral/cervical/thoracic/lumbar dislocation/subluxation
animal bite to/avulsion of/cut to/laceration of/ foreign body in periorbital area, eyelid,
tear ducts.
animal bite to/avulsion of/cut to/foreign body in tissue of /amputation of / laceration to
ear/ auricle/pinna.
animal bite to/avulsion of/cut to/foreign body in tissue of / amputation of / laceration
to penis; scrotum; testes; vulva; vagina.
multiple: animal bite to/avulsion of/cut to/foreign body in tissue of / amputation of /
laceration of lower limbs
crush injury of any part of leg (hip/thigh/knee/ankle/foot, excluding toes alone)
foreign body in bladder/urethra/uterus/vulva/vagina/penis.
burns of face, head, and neck
burns of trunk
burn or burns, not otherwise specified; burns in general
axillary/median/ulnar/radial/musculocutaneous/cutaneous sensory/digital nerve injury;
injury to nerves of hand/fingers
injury to superficial nerves of head and neck; nerve injuries in general
poisoning [due to ingestion or systemic introduction of any substance (exclude drug
overdose)]. Include stings,venom,industrial and agricultural and household products.
complications of dialysis/ extracorporeal circulation/ parenteral nutrition/percutaneous
intra-gastric nutrition/infusion /inhaler/nebuliser/ /injction
/inoculation/vaccination/perfusion/transfusion/ anaphylaxis folowing medical treatment.
amoebiasis; balantidiasis; giardiasis; coccidiosis; intestinal trichmoniasis;
cryptosporidosis; cyclosporiasis.
pulmonary tuberculosis; tuberculosis.
pertussis; whooping cough.
meningococcal meningitis; meningococcal septicaemia; waterhous-friedrichson
syndrome; meningococcal encephalitis.
tetanus; lockjaw.
bacterial sepsis; bacterial septicaemia.
actinomycosis; actinomadura infection; actinomyces infection; actinomycotic
mycetoma; nocardia infection; streptomyces infection. .
abacterial meningitis; viral meningitis; viral encephalitis; viral meningo-encephlitis;
lymphocytic choriomeningitis
malaria; blackwater fever; other pernicious complications of malaria.
gonococcal infection of any site; gonorrhoea.
helminthiasis; toxocariasis; gnathostomiasis.
sarcoid; sarcoidosis.
pancreatic cancer; pancreatic carcinoma/adenocarcinoma
laryngeal cancer
endometrial cancer; uterine cancer
testicular cancer; cancer of testis; testicular carcinoma
renal cell carcinoma; kidney cancer; renal cancer; cancer of ureter/urethra. (exclude
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unspecified urinary organs
malignant neoplasm of brain
malignant neoplasm of thyroid gland
other malignant neoplasm of lymphoid and histiocytic
tissue
multiple myeloma and immunoproliferative neoplasms
lymphoid leukaemia
myeloid leukaemia
leukaemia of unspecified cell type
benign neoplasm of lip, oral cavity and pharynx
benign neoplasm of other parts of digestive system
benign neoplasm of bone and articular cartlidge
benign neoplasm of ovary
benign neoplasm of male genital organs
benign neoplasm of kidney and other urinary organs
benign neoplasm of brain and other parts of nervous
system
benign neoplasm of thyroid gland
carcinoma in situ of respiratory system
neoplasm of uncertain behaviour of digestive and
respiratory systems
neoplasm of uncertain behaviour of genitourinary
organs
neoplasm of uncertain behaviour of endocrine glands
and nervous system
congenital hypothyroidism
thyroiditis
disorders of parathyroid gland
disorders of adrenal glands
other endocrine disorders
other nutritional deficiencies
hereditary haemolytic anaemias
coagulation defects
diseases of white blood cells
alcoholic psychoses
disturbance of emotions specific to childhood and
adolescence
hyperkinetic syndrome of childhood
mental retardation
meningitis of unspecified cause
encephalitis, myelitis and encephalomyelitis
spinocerebellar disease
anterior horn cell disease
other diseases of spinal cord
infantile cerebal palsy
NPFIT/Bestcurrentevidence/29.3.06
bladder cancer and prostate cancer)
astrocytoma; brain cancer/tumour; glioblastoma; glioma
thyroid carcinoma/cancer of any type; malignant goitre; phaeochromocytoma of
thyroid; hazard-crile tumor; hurthle cell carcinoma.
lymphoma; mycosis fungoides
multiple myeloma; plasma cell leukaemia
lymphocytic/lymphonbalstic/lymphoid/lymphogenous leukaemia.
myeloid/myeloblastic/myelogenous/myelocytic/myelosclerotic leukaemia
other/unspecified leukaemia (unspecified cell type).
benign neoplasm of lip/tongue/major salivary glands/ mouth
benign neoplasm of oesophagus/stomach/small intestine/colon/rectum/anus/liver/bile
ducts /pancreas.
benign bone/cartilage/periosteal tumour; chondroblastoma; osteoblastoma; giant
osteoid osteoma; fibroma of bone.
benign ovarian tumour/teratoma; Brenner’s tumor; endometrioid
cyst/cystadenofibroma; ovarian cyst.
benign neoplasm/tumour of testicle/penis/prostate/epididymis/scrotum.
benign neoplasm/tumour of kidney /ureter/bladder/urinary tract.
benign neoplasm/tumour of brain/cranial nerves/ meninges/spinal cord
carcinoma in situ of larynx/trachea/bronchus/lung
lump if unknown whether malignant or benign in following sites: salivary glands/lip;
oral cavity; pharynx/stomach; gastrointestinal tract/liver/ biliary tree/retroperitoneum
and peritoneum; larynx/trachea; bronchus; and lung/pleura; thymus and mediastinum
lump if unknown whether malignant or benign in following sites:
uterus/placenta/ovary/vulva/vagina/testis/prostate/penis/bladder/urinary tract.
lump if unknown whether malignant or benign in following sites: pituitary gland/pineal
gland/adrenal gland/brain and spinal cord/meninges; neurofibromatosis.
congenital hypothyroidism; congenital myxoedema; congenital subthyroidism;
congenital thyroid insufficiency; cretinism; Pendred’s syndrome.
thyroiditis.
hyperparathyroidism; hypoparathyroidism.
Cushing’s syndrome; hyperaldosteronism; Conn’s syndrome; adrenocortical
insufficiency
delayed sexual development; precocious sexual development; carcinoid syndrome;
ectopic hormone secretion
vitamin K deficiency; other vitamin deficiency (exclude B deficiency); mineral
deficiency.
haemolytic anaemias; thalassaemia; sickle-cell trait; sickle-cell anaemia;
haemoglobinopathy; other hereditary haemolytic anaemia.
bleeding disorder; coagulation abnormalities; clotting disorder/deficiency;
coagulopathy; haemorrhagic disorder; haemophilia; factor XIII deficiency; factor IX
deficiency; factor XI deficiency; clotting factor deficiency; Von Willebrands disease;
dissemin
agranulocytosis; neutropenia; leukopenia; neutrophil dysfunction; neutrophilia;
eosinophilia.
alcoholic/ alcohol-induced psychosis; alcohol withdrawal; alcoholic dementia
overanxious disorder; misery and unhappiness disorder; shyness; social withdrawal;
childhood mixed emotional disorder; emotional disturbance/ disorder in
childhood/adolescence. (exclude these conditions if in adults)
attention deficit disorder/ attention deficit hyperactivity disorder/ADHD; hyperkinetic
disorder/syndrome
mental retardation
meningitis/meningoencephalitis/arachnoiditis, regardless of chronicity. Exclude if cause
is specified (e.g. viral meningitis; pneumococcal; meningococcal).
encephalitis; myelitis and encephalomyelitis; whether or not cause is specified.
Friedrich’s ataxia; cerebellar ataxia; hereditary spastic paraplegia; spinocerebellar
atrophy.
amyotrophic lateral sclerosis; motor neurone disease; spinal muscular atrophy; anterior
horn cell disease.
syringomyelia; syringobulbia; vascular myelopathy; subacute combined degeneration of
spinal cord; myelopathy.
cerebral palsy.
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other paralytic syndromes
other and unspecified disorders of the nervous system
hereditary and idiopathic peripheral neuropathy
myoneural disorders
muscular dystrophies and other myopathies
chorioretinal inflammations and scars and other
disorders of choroid
disorders of optic nerve and visual pathways
mastoiditis and related conditions
other disorders of middle ear and mastoid
otosclerosis
NPFIT/Bestcurrentevidence/29.3.06
quadriplegia; paraplegia; cauda equina syndrome; spinal cord compression; paralysis
not further specified
unspecified disorders of central nervous system; other CNS disorders. Reaction to
lumbar puncture; nervous system complication from surgically implanted device;
disorder of meninges, not elsewhere classified; other specified/unspecified disorder of
nervo
hereditary peripheral neuropathy; peroneal muscular atrophy; hereditary sensory
neuropathy; hereditary sensorimotor neuropathy; Refsum’s disease.
Myasthenia gravis
muscular dystrophy; myopathy; familial periodic paralysis
chorioretinitis/retinochoroiditis; chorioretinal scar; choroidal
degeneration/dystrophy/haemorrhage/detachment
papilloedema; optic atrophy; optic neuritis
mastoiditis; petrositis
tympanosclerosis; cholesteatoma
otosclerosis
79