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NICE guidance and
implementation
Gillian Mathews
Implementation Consultant, NICE
Meeting 18 weeks and other challenges
Today’s journey
• Introducing NICE
– Guidance and cardiac disease
– Care pathways and 18 weeks
• Implementing guidance
• The way forward
What is NICE?
The National Institute for Health and
Clinical Excellence (NICE) is the
independent organisation responsible
for providing national guidance on the
promotion of good health and the
prevention and treatment of ill health.
• Public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• Health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS
• Clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.
We produce guidance in three areas
Core principles of all NICE guidance
• Comprehensive evidence base• Expert input• Patient and carer involvement• Independent advisory
committees• Genuine consultation• Regular review• Open and transparent
process.
Technology appraisals
Cardiac related appraisals include...
• Heart failure - cardiac resynchronisation
• Acute coronary syndromes – clopidogrel
• Angina and myocardial infarction – myocardial perfusion scintigraphy
• Cardiovascular disease – statins
• Dual-chamber pacemakers for the treatment of symptomatic bradycardia
• Myocardial infarction – thrombolysis
• Arrhythmia - implantable cardioverter defibrillators (ICDs)
• Acute coronary syndromes - glycoprotein IIb/IIIa inhibitors
• Ischaemic heart disease – coronary artery stents
Assessing Cost Effectiveness
Probability of rejection
Cost per QALY (£’000)
20 35
0
1
Coronary artery stents (review) Final appraisal determination• Drug-eluting stents are recommended for use in percutaneous
coronary intervention for the treatment of coronary artery disease, within their instructions for use, only if: – the target artery to be treated has less than a 3 mm calibre or the
lesion is longer than 15 mm,
and
– the price difference between drug-eluting stents and bare-metal stents is no more than £300.
• This FAD is now subject to one appeal, which will be heard on 14 April 2008.
• Final guidance will published following the outcome of the appeal
Interventional Procedures
Some cardiac IPs…• Short-term circulatory support with left ventricular assist devices as
a bridge to cardiac transplantation or recovery• Dynamic cardiac monitoring• Cryoablation for atrial fibrillation in association with other cardiac
surgery (also radiofrequency, microwave and high intensity focused ultrasound ablation)
• Endoaortic balloon occlusion for cardiac surgery• Balloon dilatation of pulmonary valve stenosis• Balloon valvuloplasty for aortic valve stenosis in adults and
children• Partial left ventriculectomy (the Batista procedure)• …and many more…
Implementing Interventional Procedures Guidance• IP guidance addresses the safety and efficacy of interventional
procedures – not their cost effectiveness
Research only – use only in the context of research governance
Do not use – evidence on safety and efficacy does not support use
May be used with special arrangements for consent, audit and clinical governance
May be used with normal arrangements for consent, audit and clinical governance
Clinical guidelines
Completed guidelines• Chronic heart failure• Hypertension• Myocardial infarction: secondary prevention • Type 1 diabetes • Type 2 diabetes• Atrial fibrillation• Prevention of venous thromboembolism (surgical inpatients)
Guidelines in development• Lipid modification• Acute chest pain• Prevention of venous thromboembolism (all patients)
What has all that got to do with 18 weeks?
Secondary prevention of MI
• Lifestyle • Cardiac rehabilitation after an acute MI • Drug therapy – after an MI in the last 12
months • Drug therapy – after a proven MI in the past
(more than 12 months ago)
Recommendation reminders
Core tasks
Translating“evidence”
Recommendations
Implementation/change in practice
The implementation programme
What are the main barriers to implementation?
• Clinician distrust
• Lack of organisational
support - structures and
processes
• Resources (or lack of them)
The NICE implementation programme
Three key aims - to:
• Motivate and inspire
• Provide practical support
• Evaluate impact and
uptake
Local leadership is essential
Motivating - integrating
• Clear, easily accessible guidance
• IT systems
• Education – CPD
• Financial arrangements – funding
direction, tariff and the QoF
• Practice-based commissioning
• Inspection processes
Embed in important relevant initiatives
Practical support
• ‘How to’ guide and ‘How to change practice’
• Educational tools
• Forward planner
• Shared learning database
• Commissioning guides
• Topic specific tools
• Implementation consultants
Implementation Consultants
• Six consultants based in the field - the ‘local face’ of NICE
• Providing people implementing NICE guidance with updates, advice and support for local implementation strategies
North EastGillian Mathews
EastVal Moore
London & South EastSteve Sparks
South WestJayne Chidgey-Clark
WestChris Connell
North WestJenny Lewis
Costing tools
1. National cost impact
reportNational
PopulationStandard
AssumptionsStandard
AssumptionsLocal
Assumptions
Total weighted population 182,545 182,545Weighted population as percentage 0.36% 0.36%
Adult in-patient service staff headcountClinical Staff 52,730 191 191
Non-clinical staff 9,500 34 34Emergency department staff headcount
Clinical Staff 18,050 65 65Non-clinical staff 6,100 22 22
Management of violence training - In-patient psychiatric settings
Cost per trainer day £194 £194 £194Ratio of students to 1 trainer, headcount 12 12 12Average attendance rate, % 80% 80% 80%Back fill costs £95 £95 £95
Current clinical staff trainingPercentage of currently trained staff 50% 50% 50%Percentage of backfill provided 100% 100% 100%Length of training course, days 3 3 3Number of courses 2636.5 9.5 9.5Course costs £1,534,443 £5,529 £5,529Backfill costs £7,514,025 £27,154 £27,154
Current non-clinical staff trainingPercentage of currently trained staff 25% 25% 25%Percentage of backfill provided 50% 50% 50%Length of training course, days 1 1 1Number of courses 237.5 0.9 0.9Course costs £46,075 £175 £175Backfill costs £112,813 £408 £408
Selected Population
5. Make any necessary alterations to the costing assumptions (highlighted in blue) by clicking on the buttons on the right.
6. Click NEXT to go to recurrent costing assumptions sheet.
Costing assumptions - non-recurrent costs
Next
Edit
Edit
Cost impact of NICE guideline on the management of violent and disturbed behaviour
- England
2. Spreadsheet template to help
local users assess local
impact
Cost of optimum care less cost of current care
= resource impact
Resource impact can be either a cost (+) or saving (-)
Total cost
-
5,000,000
10,000,000
15,000,000
20,000,000
25,000,000
1 2 3 4 5 6 7 8 9 10
Year
Co
st o
f u
pta
ke
Total
Cardiac resynchronisation therapy for heart failure
Key factors driving uptake of new medicines in acute trusts
NICE
Clinical attitudes and preference
Funding and financial status
National prioritiesPharma Industry
activity
Patient preference and adviceLow
Importance
HighImportance
From: Medicines and Industry Strategy Group report
Inspection results - appraisals
Self assessment results – NHS Trusts
2005/06 2006/07
Compliant 84.6% 89.3%
Insufficient assurance
11% 7.87%
Not met 4% 2.79%
Source: The Healthcare Commission, Annual Health Check
Evaluating uptake
• Evaluation and Review of NICE
Implementation Evidence (ERNIE)
• Searchable database providing
information on the implementation
and uptake of NICE guidance
• Studies graded as:• practice appears to be in line with
guidance
• practice appears not to be in line with
guidance
• doubts about or mixed impact
% High cost vs low cost statins
HIG
H C
OS
TL
OW
CO
ST
Hypertension guideline
0%
5%
10%
15%
20%
25%
30%
Ma
r-0
3
Ma
y-0
3
Jul-
03
Se
p-0
3
No
v-0
3
Jan
-04
Ma
r-0
4
Ma
y-0
4
Jul-
04
Se
p-0
4
No
v-0
4
Jan
-05
Ma
r-0
5
Ma
y-0
5
Jul-
05
Se
p-0
5
No
v-0
5
Jan
-06
Ma
r-0
6
Ma
y-0
6
Jul-
06
Se
p-0
6
No
v-0
6
Jan
-07
Ma
r-0
7
Month
Vol
ume
as a
%
ACE inhibitors Angiotensin-II receptor antagonists
Beta-blockers Calcium-channel blockers
Thiazides and related diuretics
Source: ePACT.net
NICE Guideline consultation - new pharmacological section
NICE Guideline published
HCC Service Review on Heart Failure
Source: The Healthcare Commission, Service Review on Heart Failure (July 2007)
Evidence-based treatment and monitoring
“Processes to assess the broader needs of patients were generally
comprehensive and in line with the recommendations in the NICE
guideline.”
Outcomes for patients
“wide variation in the level of observed [adjusted] re-admission and
mortality across PCTs in England”. “such variation reinforces the
need to apply the NICE guidelines much more assertively.”
The way forward
• NICE guidance can help your service to run better
• Commissioners are becoming more interested in compliance
• Implementation efforts are required at a national and local level
• Use the implementation tools to support the local strategy
• Please ask us for help!