Intended for healthcare professionals


What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews

BMJ 2004; 329 doi: (Published 28 October 2004) Cite this as: BMJ 2004;329:999
  1. Trevor A Sheldon, professor (tas5{at},
  2. Nicky Cullum, professor1,
  3. Diane Dawson, senior research fellow2,
  4. Annette Lankshear, senior research fellow1,
  5. Karin Lowson, deputy director3,
  6. Ian Watt, professor1,
  7. Peter West, director3,
  8. Dianne Wright, research fellow3,
  9. John Wright, operations medical director4
  1. 1 Department of Health Sciences, University of York, York YO10 5DD
  2. 2 Centre for Health Economics, University of York
  3. 3 York Health Economics Consortium, University of York
  4. 4 Bradford Royal Infirmary, Bradford, BD9 6RJ.
  1. Correspondence to: T A Sheldon


    Objectives To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE).

    Design Interrupted time series analysis, review of case notes, survey, and interviews.

    Setting Acute and primary care trusts in England and Wales.

    Participants All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts.

    Main outcome measures Rates of prescribing and use of procedures and medical devices relative to evidence based guidance.

    Results 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P < 0.002) and orlistat for obesity (P < 0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer's disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued.

    Conclusions Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context.


    • Embedded Image The interview schedule for clinicians is on

    • Funding NHS R&D National Co-ordinating Centre for Research Methodology (NCCRM).

    • Competing interests NC was a member of the NICE Appraisals Committee between 1999 and 2002. KL, PW, DW, and JM work for York Health Economics Consortium, which undertakes work for a range of pharmaceutical companies, the Department of Health, and the NHS and has undertaken a cost-effectiveness study for Guidant, which manufactures implantable cardioverter defibrillators. This study was submitted to NICE as part of the assessment process.

    • Ethical approval North West Multicentre Research Ethics Committee.

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