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Relevance of NICE guidelines to GPs ‘as low as 2%’

Fewer than a quarter of NICE recommendations for GPs are based on studies that are relevant to primary care, concludes an independent investigation into the institute’s methods.

Researchers looked at all the guidelines issued by NICE over two years and found only 39% of the studies used to develop recommendations for GPs were relevant to primary care, with the relevance of some guidelines as low as 2%.

The study – independently funded by the National Institute for Health Research – uncovers the evidence base behind the decisions taken by NICE from January 2010 and December 2011.

The research – led by RCGP honorary secretary Professor Amanda Howe and clinical senior lecturer at the University of East Anglia and GP Dr Nicholas Steel – looked at 32 primary care-relevant guidelines.

Two independent GPs reviewed each guideline and identified the evidence base for each recommendation aimed at primary care. Of the 555 recommendations, they found 292 specific to primary care, and 21% of these were based on evidence that was directly relevant to primary care.

The researchers cited guidelines, such as those for heart failure that extrapolated evidence from severe disease and applied it to the mild and moderate disease commonly treated in primary care.

Presenting the study at the Society for Academic Primary Care Conference in Glasgow earlier this month, they concluded: ‘The important new finding of this research is that the evidence is often simply not assessed for relevance to its intended audience, in this case primary care. In some guidelines the link between recommendations and any evidence base is not clear.’

Dr Steel told Pulse the research was being supported by NICE, and they hoped to develop tools that the institute can use to improve the relevance of their guidelines for GPs.

He said: ‘The project is on-going, and the next two stages of the project will involve GPs in telling us what they think is important in guidelines, and then working with NICE to develop recommendations for future guideline development.

‘We hope that greater clarity about the relevance of guideline evidence to primary care will lead to better care for patients.’

Dr Bill Beeby, chair of the GPC clinical and prescribing subcommittee and a GP in Middlesbrough, said the kind of research needed was ‘thin on the ground’ and there was not enough GP input into NICE committees.

‘Many working groups do not have adequate representation from primary care because the significant commitment if GPs participate is unremunerated (except for face to face meetings).

‘So we have strange results that creep in such as ignoring amitriptyline for pain management and recomending pregabalin as first line.’

Professor Martin Roland, chair of health services research at the University of Cambridge, said the research suggested NICE needed to indicate more clearly where a recommendation for GPs was made despite a paucity of relevant evidence.

He said: ‘Where possible, NICE guidance should be based on studies of general practice patients.

‘The problem is that evidence often doesn’t exist, with many of the major trials done on people seen in secondary care. That doesn’t mean they should necessarily be ignored, but it is a weakness of guidelines.’

Professor Mark Baker, director of the Centre for Clinical Practice at NICE, said they would be examining the evidence ‘in detail’.

He added: ‘The lack of evidence generated in primary care is a challenge for the primary care and research funders to take on – guideline developers can play their part by making relevant research recommendations.’