Doctors prescribe more drugs recommended by NICE than predictedBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3737 (Published 11 September 2009) Cite this as: BMJ 2009;339:b3737
All rapid responses
The celebrations reported in the News item “Doctors prescribe more
drugs recommended by NICE than predicted” (1) may be a little premature
for the Technology Appraisals (TAs) relating to osteoporosis documented in
the recent Health and Social Care Information Centre (HSCIC) report (2).
The authors make it quite clear that it is an experimental approach and as
such should be interpreted with caution.
National clinical audit (3) and a study commissioned by the HSIC
itself (4) have indicated that the overwhelming majority of patients fail
to receive interventions recommended in TA 161 (previously 87) for the
secondary prevention of osteoporotic fractures and that the NHS is not
organized in a way that assures the delivery of appropriate care for those
at risk (5).
This discrepancy, amounting to an 80% under-performance rather than a
20% over-performance, would appear to have a number of causes, principally
the denominator target population of 586,100 deemed eligible in the report
for treatment under the combined TAs 160 (primary prevention) and 161
(secondary prevention). The HSIC also adopts a 63.18% attenuation of the
prior fracture population from the legacy TA87 even though the relevant
guidance (TA161) which was to all intents and purposes operational at the
time of the data capture would advise 100% eligibility. Even allowing for
that, the figure of 586,100 seems not to be credible. The Department of
Health estimates in its Commissioning Framework a combined incident and
prevalent population of women over 50 with a prior fragility fracture of
approximately 1.3 million to which needs to be added the eligible primary
prevention cohort. This is much nearer the 1.08 million eligible from the
NICE Costing Template, to which of course needs to be added another
250,000 eligible for primary prevention under TA160.
It also is not clear from the report whether the prescribing days
have been adjusted for the 16% of bone-sparing agents issued to men for
whom these TAs are not applicable. Finally, the issue of a prescription
is not of course a guarantee that it is appropriately issued. As the
previously cited HSCIC report found, 50% of patients receiving bone-
sparing agents have no record of a diagnosis of osteoporosis, a
requirement in both TAs.
Information is vital to evaluate standards of care but it has got to
reflect what is known from patient level studies. Organisations such as
NICE would do well to be more cautious about congratulating themselves
when a wealth of more valid metrics tell a very different story.
1. Mooney H (2009) Doctors prescribe more drugs recommended by NICE
than predicted. 339:b3737.
2. Health and Social Care Information Centre. Prescribing Support
Unit (2009) Use of NICE-appraised medicines in the NHS in England -
3. The Clinical Effectiveness and Evaluation Unit: Royal College of
Physicians’ London (2007) National Clinical Audit of Falls and Bone
Health: Available from http://www.rcplondon.ac.uk/clinical-
standards/ceeu/Documents/fbhop-nationalreport.pdf [Accessed 15 May 2009].
4. Hippisley-Cox J, Bayly J, Potter J, Fenty J, Parker C (2007)
Evaluation of standards of care for osteoporosis and falls in primary
care. The Health and Social Care Information Centre.
5. The Clinical Effectiveness and Evaluation Unit: Royal College of
Physicians’ London (2009) National Audit of the Organisation of Services
for Falls and Bone Health of Older People. Available from
March-2009.pdf [Accessed 18 May 2009].
Jonathan Bayly has received honoraria, travel and subsistence expenses from a number of companies with an interest in falls and bone health (Procter & Gamble, Roche, Novartis, Shire, Amgen, Pfizer, Strakan, Servier, Menarini)
Competing interests: No competing interests