Intended for healthcare professionals

Feature Essay

Balancing the evidence for guidelines: lessons from the NICE abdominal aortic aneurysm guidance—an essay by Bruce Campbell

BMJ 2020; 370 doi: (Published 24 September 2020) Cite this as: BMJ 2020;370:m3480
  1. Bruce Campbell, honorary vascular consultant and honorary professor12
  1. 1Royal Devon and Exeter Hospital, Exeter, UK
  2. 2University of Exeter Medical School, Exeter EX2 5DW, UK

The saga of the National Institute for Health and Care Excellence’s abdominal aortic aneurysm guideline was a long and uncomfortable chapter in NICE history. But the conflict provides insights into balancing disparate types of evidence, writes Bruce Campbell

The National Institute for Health and Care Excellence recently published a guideline on the diagnosis and management of abdominal aortic aneurysms.1 This was the culmination of a long, uncomfortable period of conflict with much of the vascular community and indeed with its own advisory committee. Typically, the disagreement was about one very small but important element of the draft. NICE revised the committee’s recommendation in line with stakeholder feedback but has been criticised for doing so.2

This episode provides some useful insights into the challenges facing NICE and what is involved in producing “evidence based” guidance for health services.

A brief history of the NICE aortic aneurysm guidance

The conflict was about the use of endovascular aneurysm repair (EVAR), which has become more popular worldwide for treating abdominal aneurysms than open surgery.3 EVAR has much lower perioperative risk and quicker recovery, but it requires long term follow-up with imaging and many more re-interventions than open surgical repair. Prevention of rupture is the main reason for elective aneurysm repair, but large, well designed randomised controlled trials (RCTs) have shown that, in the long term, the survival of patients who have had EVAR might be lower than that of those who have had surgical repair.4 RCTs have also shown that the survival of patients unfit for open repair is no greater overall after EVAR than after no intervention.5

NICE’s guideline committee reviewed all these data and also considered extensive economic modelling, which showed that there were no circumstances in which EVAR was as cost effective as open surgery in the long term (up to 15 years). Based on …

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