NICE guidance should consider lifestyle only if it influences effectiveness

NICE guidance should consider lifestyle only if it influences interventions’ effectiveness

London

Susan Mayor

Age and lifestyle factors that may have caused disease should not influence guidance on the use of healthcare interventions unless they are likely to affect the effectiveness of the intervention. This is a conclusion of a report published last week by the National Institute for Health and Clinical Excellence (NICE), which advises on the use of treatments in the NHS in England and Wales.

The report clarifies how social value judgments—defined as ethical principles, preferences, culture, and aspirations—should be used by NICE in conjunction with clinical judgments in deciding what interventions the NHS should provide.

It recommends that NICE’s clinical guidance should limit the use of a therapeutic or preventive intervention to a particular age group only when there is clear evidence of differences in clinical effectiveness in different age groups.

Michael Rawlins, chairman of NICE, said: “Our advisory groups should not make recommendations that depend on people’s ages when they are considering the use of a particular treatment, unless there is clear evidence of a difference in its effectiveness for particular age groups. Even then, age should only be mentioned when it provides the only practical ‘marker’ of risk or benefit.”

The charity Help the Aged said that the report represented a change in policy, overturning previous recommendations that the charity considered discriminated against elderly people. Jonathan Ellis, policy manager at Help the Aged said: “This is a real U-turn for NICE, who previously, and rather carelessly, suggested that chronological age, rather than individual need, should be used to determine a person’s treatment.”

The report also recommends that NICE guidance should not deny care to patients with conditions that are or may be self inflicted. However, it argues that it may be appropriate to take lifestyle factors into account if their continuation is likely to influence the clinical or cost effectiveness of a particular treatment. But only in the most exceptional circumstances would it would be acceptable to deny treatment because of lifestyle factors. Professor Rawlins said, “Almost invariably we do not expect people to take that sort of thing into account.”

The report says that sexual orientation and social factors, such as income and class, should not be taken into account in developing guidance on use of treatments.

Acknowledging the need for NICE guidance to take cost into consideration, the report argues that cost-utility analysis should be included in the economic evaluation of particular interventions but should not be the sole basis for decisions on cost effectiveness. The report suggests that NICE should, generally, accept interventions with a cost-effectiveness ratio of less than £20000 per quality adjusted life year (QALY), and should only accept interventions with a cost-effectiveness ratio of over £30 000 per QALY in exceptional circumstances. NICE guidance should provide explicit reasons if it recommended interventions with a cost effectiveness ratio between £20 000 and £30 000 per QALY.

The report’s recommendations are designed to be used by NICE and its advisory committees in developing guidance, not by doctors treating individual patients. The recommendations were developed after public consultation on a draft report that was based on a review of relevant published literature, reports from NICE’s Citizens Council (30 people who reflect the age, sex, socioeconomic status, and ethnicity of the population in England and Wales), and a survey of 1010 members of the public (BMJ 2005;330:1102).

Social Value Judgements: Principles for the Development of NICE Guidance is available at www.nice.org.uk