Construction and assumptions of models should be explicit
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39185.472743.3A (Published 19 April 2007) Cite this as: BMJ 2007;334:814
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Tom Fahey questions the transparency of the model used in the 2006
update of the NICE (National Institute for Health and Clinical Excellence)
hypertension guideline and of the process of stakeholder consultation to
which he contributed [1]. Sadly, both criticisms are inaccurate.
The 2006 NICE hypertension guideline brought together NICE and the
British Hypertension Society in developing a single guideline, using
robust methods to consider both clinical and cost effectiveness [2].
The fact that Fahey was able to contribute detailed, constructive
criticism of the guideline model’s assumptions illustrates the
transparency with which the model was laid bare for public consultation.
His comments on behalf of the Royal College of General Practitioners were
considered by the guideline development group, along with many others, and
influenced the final model and recommendations. For example, many
stakeholders asked that heart failure was given more prominence as an
adverse outcome in the model, and this was done. All comments from
registered stakeholders are available, together with the developers’
responses, in a 126 page document available on NICE’s website at
http://guidance.nice.org.uk/page.aspx?o=394279. We are unclear why Fahey
should contrast NICE with SIGN’s (Scottish Intercollegiate Guidelines
Network) methods as SIGN do not routinely undertake economic modelling.
Fahey’s criticisms of the transparency of arrangements for
stakeholder involvement is in contrast to the view expressed by the World
Health Organization when they reviewed NICE’s clinical guidelines
programme in 2006. Their independent report [3] states that “Collaboration
with stakeholders in the development of the guidelines through the
consultation and feedback mechanisms available was in general very
effective”.
References
[1] Fahey, T. Transparency in NICE: Construction and assumptions of
models should be explicit. BMJ 2007;334:814,
doi:10.1136/bmj.39185.472743.3A
[2] National Institute for Health and Clinical Excellence (April
2007) The Guidelines manual. London: National Institute for Health and
Clinical Excellence. Available from: www.nice.org.uk
[3] World Health Organization. The Clinical Guideline Programme of
the National Institute for Health and Clinical Excellence (NICE): a review
by the World Health Organization May 2006. Copenhagen: WHO, 2007. 2007
(EUR/05/5063284)
Competing interests:
None declared
Competing interests: No competing interests
Re: Transparency of NICE hypertension guideline
Editor,
I thank Phil Alderson and colleagues at NICE for responding to my
letter. I would like to respond to their comments:
Firstly, I would like to apologize for not correctly locating the
stakeholders comments on the NICE website. Prior to posting my letter I
did look carefully for stakeholders comments in response to the updated
hypertension guidelines. I was only able to locate the stakeholders
comments to the initial set of hypertension guidelines. These were
entitled "Hypertension, first consultation- stakeholders comments".
Unfortunately, I did not locate stakeholders comments to the updated
hypertension guidelines as they are called "Hypertension update-
consultation table". My apologies to the NICE group but would ask if the
stakeholders comments could be more clealy marked in the future.
Secondly, the main issue concerning transparency of the Makov
modelling, the point made by Maynard in the orginal editorial remains.[1]
When we published a Markov model of hypertension treatment, we were asked
for and provided the full model, as well as the estimates concerning
probabilities, utilities and costs.[2] This explicit approach is
consistent with the approach recommended by peer-review journals, so that
transparency and reproducility is acheived.[3]
As Maynard observes, conflict between stakeholders is inevitable.[1]
Surely the best way to address this issue is to publish rather than
withold the Markov model on which clincial guidelines are based?
Tom Fahey
References
1. Maynard A. Transparency in health technology assessments: should
NICE have the right to refuse access to its modelling data? BMJ
2007;334:594-5.
2. Montgomery A, Fahey T, Harding J, Ben Shlomo Y. The influence of
absolute cardiovascular risk, patient utilities and costs on the decision
to treat hypertension: A Markov Decision Analysis. Journal of Hypertension
2003; 21: 1753-59
3. Laine C, Goodman SN, Griswold ME, Sox HC. Reproducible research:
moving toward research the public can really trust. Ann Intern Med
2007;146:450-453.
Competing interests:
None declared
Competing interests: No competing interests