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Rapid Responses: Rapid Responses published:
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Thiazide diuretics and hypertension
- Tom P Marshall (26 November 2004)
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Utility of Guidelines
- Deepak Kejariwal (29 November 2004)
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NICE and BHS guidelines on hypertension
- Peter Littlejohns, Leng G, Sutcliffe A (9 December 2004)
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Tom P Marshall, Senior Lecturer University of Birmingham B15 2TT
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Professor Poulter correctly takes issue with a number of aspects of the NICE hypertension guidance. In particular, drug treatment should not be substituted with lifestyle modification because the latter has not been shown to be effective. However, the insistence that drugs other than thiazides should be used as first line treatment is only one interpretation of the evidence. The evidence from systematic review of all drug-drug comparisons (including the ALLHAT study) is consistent with the view that acheived blood pressure reduction predicts reduction in risk. [1] Differences between the effects of different drugs on blood pressure are small. [2] Those who advocate calcium channel blockers (or any other drug class) offer significant advantages over thiazides should state the magnitude of these claimed benefits. Benefits can then be evaluated in relation to cost differences: £168 per year separates amlodipine from bendrofluazide. [3] Assuming amlodipine is 25% more effective, over ten years a patient at 15% ten-year CVD risk gains an incremental 0.3% reduction in risk at an incremental cost of £1677 - £467,000 per CVD event prevented. More importantly, the same patient could reduce his risk by more (2.2% over ten -years) at lower cost (£795 over ten-years) by adding metoprolol and enalapril to his bendrofluazide. References 1. Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of different blood-pressure-lowering regimens on major cardiovascular events: results of prospectively-designed overviews of randomised trials. Lancet 2003;362:1527-35. 2. Law M.R., Wald N.J., Morris J.K., Jordan R.E. Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials British Medical Journal 2003;326:1427-1432. 3. http://www.bnf.org/bnf/ [Last accessed 26th November 2004] Competing interests: None declared |
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Deepak Kejariwal, SpR James Paget Hospital, Gorleston, Norfolk, UK
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Prof. Poulters letter forces us to revisit the issue of clinical guidelines and its utility. Evidently clinical guidelines summarise the current state of knowledge and hence help physicians make the best decision about healthcare. Mere existence of guidelines doesnt mean doctors will know about them or know enough to implement them. There are many barriers to the implementation of clinical practice guidelines. Presence of multiple guidelines doesnt help matters. Its surprising to see two premier health organisations of the country coming out with their own guidelines in the same year. Further, it is a colossal waste of scarce resources. I do hope that better sense prevails in future. We would be served better, if efforts are directed towards dissemination and implementation of existing guidelines rather than producing another one. Multiplicity of guidelines on the same subject do not help anybody least of all, the physicians. Competing interests: None declared |
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Peter Littlejohns, Professor National Institute for Clinical Excellence, MidCity Place, 71 High Holborn , London WC1V 6NA, Leng G, Sutcliffe A
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Dear Sir Many national and international clinical guidelines on the management of hypertension have been published over the last few years. While their recommendations for clinical practice have often varied, they have had two features in common. They have all generated controversy and have been poorly implemented. Judging by the recent correspondence in the British Medical Journal following the publication of hypertension clinical guidelines by the National Institute for Clinical Excellence (NICE)1 and the British Hypertension Society (BHS)2, the first phenomenon is continuing to happen, can the second be prevented ? A number of developments suggests that it can. Firstly there is now widespread agreement on how guidelines should be developed. An international research collaboration has produced a quality template (the Appraising Guidelines for Research and Evaluation - AGREE instrument)3 that has been endorsed by the European Union, the Council of Europe, the World Health Organisation, and many national programmes (including NICE). These organisations require that guidelines produced under their aegis adhere to the AGREE principles. The instrument draws attention to methods to reduce bias in the development of recommendations, emphasising the importance of the independence of the guideline developers. It encourages guideline developers to seek acceptance of their recommendations through addressing the views and beliefs of their target professionals and patients as well as taking into account the impact of the guidelines and health economic considerations. These issues formed the substance of the concerns over the BHS guidelines expressed by general practitioners 2. NICE clinical guidelines are developed in a transparent, robust, multidisciplinary way and take into account evidence of cost- effectiveness as well as clinical effectiveness. For these reasons, as well as the scope of the NICE hypertension guideline being different from the BHS guideline, it is not surprising that some differences and points of emphasis exist. However the recommendations are not as dissimilar as Poulter suggests1. Indeed it would have been surprising if they were substantially different, mindful of the fact that the chairman of the BHS guideline development group was also a member of the NICE guideline development group. Secondly the complexity of implementing guidelines is being increasingly recognised and the challenge now is to establish multiple, diverse approaches to reducing the barriers to implementation and encouraging the development of facilitatory mechanisms. The establishment of the Implementation Systems Support Programme at NICE and the inclusion of NICE guidance in the national standards against which the HealthCare Commission will assess and monitor quality in the NHS are important steps in the right direction4. Reducing confusion and controversy by limiting the number of national guidelines is worth exploring and the joint working between NICE and the British Thoracic Society in updating their Chronic Obstructive Pulmonary Disease Guideline as a NICE guideline5 is a model that should be used for future hypertension guidelines References 1. NICE and BHS guidelines on hypertension differ importantly. Poulter NR. BMJ 2004 ;329:12892004 2.Guidelines from the British Hypertension Society: is hypertension really a disease?; numbers are missing: life in the real world may not allow recommendations to be implemented: NHS is set to bankrupt NHS: authors reply. Sackin PA, Davies P, Green PN, Duerden MG, Bryan Williams. BMJ 2004;329:569-570 3. Development and Validation of an international appraisal instrument for assessing the quality of clinical practice guidelines:the AGREE project. The AGREE Collaboration. Quality and Safety in Health Care 2003:12;18-23 5 Guidelines for chronic obstructive pulmonary disease. William MacNee BMJ, Aug 2004; 329: 361 - 363. Competing interests: Pl , GL and AS are employed by NICE Pl was coordinator of the AGREE Project 1998-9 and is a founding Trustee of the AGREE Research Trust |
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