Two articles in the Annals of Internal Medicine provide a detailed look at how the British National Institute for Clinical Excellence produces guidelines and conducts cost-effectiveness studies. (Annals Abstract) (Annals Abstract) NICE is a governmental agency charged with helping ensure that appropriate health care is delivered and paid for. It became controversial because it was willing to say it didn’t make sense to pay for some high-cost treatments with limited benefit, particularly in a world where there cannot be unlimited resources devoted to health care. Cancer therapies, in particular, were often not approved or found cost-effective, which given the sympathetic nature of the disease and patients, led to frequent condemnation of NICE by some patient groups and policymakers. NICE has become a negative comparator for US comparative effectiveness efforts.
What is apparent is that whether you agree with the end policy use of its conclusions or not, NICE generally does very thorough high quality work in providing care guidelines and the cost and clinical effectiveness reviews underlying the guidelines. The first article details and makes very transparent the guideline development process. The process begins with selection of topics based on factors such as disease burden and variation in care patterns and proceeds through evidence review and guideline drafting by a team of clinicians, economists and others. The drafts are reviewed by an independent panel and an opportunity for comment is available for all affected constituencies. The entire process takes on average 18 months or so and guidelines are automatically reviewed every 3 years for updating. NICE has recently been developing quality of care standards which are tied to its guidelines.
The second article discussed how cost-effectiveness or economic evaluations are conducted. The authors begin by saying that the NICE reviews are not intended to save money but to maximize what money is spent by ensuring it goes to produce the greatest amount of health benefit. The reviews may simply compare two treatment options but often are looking at multiple choices. The decision rules basically compare the degree to which treatments improve clinical outcomes and how much they cost. Treatments that improve health and lower cost are obviously recommended and the opposite, obviously denied. In between is where more judgment comes into play. The most controversial aspect is probably the assignment of utility to treatments, which is usually done by use of QALYs. Despite the criticism it has endured, NICE plays a very valuable role in the health system and plays it very well.