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Cooper C.,University of Exeter | Levay P.,National Institute for Health and Care Excellence (NICE) | Lorenc T.,London School of Hygiene and Tropical Medicine | Craig G.M.,City University London
Journal of Clinical Epidemiology | Year: 2014

Objectives This article discusses how hard-to-reach population groups were conceptualized into a search filter. The objectives of this article were to (1) discuss how the authors designed a multistranded population search filter and (2) retrospectively test the effectiveness of the search filter in capturing all relevant populations (eg, homeless people, immigrants, substance misusers) in a public health systematic review. Study Design and Setting Systematic and retrospective analysis via a case study. Retrospective analysis of the search filter was conducted by comparing the MEDLINE search results retrieved without using the search filter against those retrieved with the search filter. A total of 5,465 additional results from the unfiltered search were screened to the same criteria as the filtered search. Results No additional populations were identified in the unfiltered sample. The search filter reduced the volume of MEDLINE hits to screen by 64%, with no impact on inclusion of populations. Conclusions The results demonstrate the effectiveness of the filter in capturing all relevant UK populations for the review. This suggests that well-planned search filters can be written for reviews that analyze imprecisely defined population groups. This filter could be used in topic areas of associated comorbidities, for rapid clinical searches, or for investigating hard-to-reach populations. © 2014 Elsevier Inc. All rights reserved.

Birkmeyer J.D.,University of Michigan | Reames B.N.,University of Michigan | Carr A.J.,University of Oxford | Campbell W.B.,National Institute for Health and Care Excellence (NICE) | Wennberg J.E.,Dartmouth College
The Lancet | Year: 2013

The use of common surgical procedures varies widely across regions. Differences in illness burden, diagnostic practices, and patient attitudes about medical intervention explain only a small degree of regional variation in surgery rates. Evidence suggests that surgical variation results mainly from differences in physician beliefs about the indications for surgery, and the extent to which patient preferences are incorporated into treatment decisions. These two components of clinical decision making help to explain the so-called surgical signatures of specific procedures, and why some consistently vary more than others. Variation in clinical decision making is, in turn, affected by broad environmental factors, including technology diffusion, supply of specialists, local training frameworks, financial incentives, and regulatory factors, which vary across countries. Better scientific evidence about the comparative effectiveness of surgical and non-surgical interventions could help to mitigate regional variation, but broader dissemination of shared decision aids will be essential to reduce variation in preference-sensitive disorders.

McCulloch P.,John Radcliffe Hospital | Nagendran M.,John Radcliffe Hospital | Campbell W.B.,National Institute for Health and Care Excellence (NICE) | Price A.,University of Oxford | And 3 more authors.
The Lancet | Year: 2013

Provision rates for surgery vary widely in relation to identifiable need, suggesting that reduction of this variation might be appropriate. The definition of unwarranted variation is difficult because the boundaries of acceptable practice are wide, and information about patient preference is lacking. Very little direct research evidence exists on the modification of variations in surgery rates, so inferences must be drawn from research on the alteration of overall rates. The available evidence has large gaps, which suggests that some proposed strategies produce only marginal change. Micro-level interventions target decision making that affects individuals, whereas macro-level interventions target health-care systems with the use of financial, regulatory, or incentivisation strategies. Financial and regulatory changes can have major effects on provision rates, but these effects are often complex and can include unintended adverse effects. The net effects of micro-level strategies (such as improvement of evidence and dissemination of evidence, and support for shared decision making) can be smaller, but better directed. Further research is needed to identify what level of variation in surgery rates is appropriate in a specific context, and how variation can be reduced where desirable.

Dillon A.,National Institute for Health and Care Excellence (NICE)
International Journal of Technology Assessment in Health Care | Year: 2015

Health systems around the world cope with the challenge of difficult economic times, and the value of health technology assessment (HTA) is increasing. Making the right choices, with limited resources, in the face of increasingly complex technologies requires decisions informed by data and analyses that help us to manage the risks involved. Those who undertake and use HTA can play a greater role in helping decision makers meet these challenges; they need to think how to define innovation and respond to it, how to communicate their analyses, and, critically, how to align their work with the ambitions of their health systems. HTA can become a key health system enabler without compromising its objectivity or independence. It can say that it is too early to determine the value of a new technology when the data simply will not support a safe decision. However, it can also be bold and recommend the managed introduction of new technologies, even when the when the data is immature, provided that the health system understands the risks and there is a plausible case for believing that further research will support the value proposition. The goal for HTA is to be able confidently to do both. Copyright © Cambridge University Press 2015.

George E.,National Institute for Health and Care Excellence (NICE)
Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen | Year: 2016

Most guidance developed by NICE is based on a value assessment using clearly articulated and published clinical and cost effectiveness criteria. In order to enable consistency and fairness across all decisions, NICE uses as a unit of health benefit the quality-adjusted life year (QALY). Both QALYs and costs for a technology are estimated by long-term disease modelling. This requires a variety of clinical input parameters, and often extrapolation beyond the trial period, and of intermediate or surrogate to final outcomes. RCT data will remain the main data source for the majority of appraisals, but because the data necessary for disease modelling is often not available from RCTs, particularly for the UK context, the use of non-RCT data is the norm in -Rfnet ICE technology appraisals. This does not only apply to data on resource use, service provision and HRQL data, but also to efficacy data. In some situations non-RCT data are more relevant to a decision context than the RCT data, and in some situations, as illustrated by 3 examples, it would be unreasonable, not to take account of existing non-RCT data. The use of non-RCT clinical evidence is most common for devices, interventions where RCTs are difficult, and in conditions with poor prognosis where single arm studies are often carried out. Therefore, a pragmatic approach to the available evidence is needed for many decision made by the NICE Appraisal Committees to come to a reasonable and defendable decision.

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