When does NICE recommend the use of health technologies within a programme of evidence development?

This article is made available through the Brunel Open Access Publishing Fund. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.This article has been made available through the Brunel Open Access Publishing Fund.Background: There is growing interest internationally in linking reimbursement decisions with recommendations for further research. In the UK, the National Institute for Health and Clinical Excellence (NICE) can issue guidance to approve the routine use of a health intervention, reject routine use or recommend use within a research programme. These latter recommendations have restricted use to ‘only in research’ (OIR) or have recommended further research alongside routine use (‘approval with research’ or AWR). However, it is not currently clear when such recommendations are likely to be made. Objectives: This study aims to identify NICE technology appraisals where OIR or AWR recommendations were made and to examine the key considerations that led to those decisions. Methods: Draft and final guidance including OIR/AWR recommendations were identified. The documents were reviewed to establish the characteristics of the technology appraisal, the cost effectiveness of the technologies, the key considerations that led to the recommendations and the types of research required. Results: In total, 29 final and 31 draft guidance documents included OIR/AWR recommendations up to January 2010. Overall, 86 % of final guidance included OIR recommendations. Of these, the majority were for technologies considered to be cost ineffective (83 %) and the majority of final guidance (66 %) specified the need for further evidence on relative effectiveness. The use of OIR/AWR recommendations is decreasing over time and they have rarely been used in appraisals conducted through the single technology appraisal process. Conclusion: NICE has used its ability to recommend technologies within research programmes, although predominantly within the multiple technology appraisal process. OIR recommendations have been most frequently issued for technologies considered cost ineffective and the most frequently cited consideration is uncertainty related to relative effectiveness. Key considerations cited for most AWR recommendations and some OIR recommendations included a need for further evidence on long-term outcomes and adverse effects of treatment.Medical Research Counci

Acute kidney injury: an acceptable risk of treatment with renin-angiotensin system blockade in primary care?

Background: Use of renin-angiotensin system (RAS) blockade has become increasingly widespread driven by evidence-based guidance. There is concern about the role of these agents in the genesis of avoidable acute kidney injury (AKI). Objectives: To investigate the association between AKI and use of RAS blockade. Design: Multilevel hierarchical analysis of a large cohort of patients registered with UK general practitioners. Setting: Primary care practices in East and West Kent, United Kingdom. Patients: 244,715 patients from 27 practices. Measurements: Demographic, clinical, biochemical and prescription data. Methods: Analyses of data acquired between 02/3/2004 and 17/04/2012 using multilevel logistic regression to determine the relationship between AKI and use of RAS blockade; further analysed by indication for treatment with RAS blockade. Results: Sufficient serum creatinine data were available to define AKI in 63,735 patients with 208,275 blood test instances. In 95,569 instances the patient was prescribed a RAS antagonist of which 5.4% fulfilled criteria for AKI. The unadjusted odds ratio (OR) for AKI in those prescribed RAS blockade was 1.93 (1.81-2.06, 95%CI) falling to 1.11 (1.02-1.20, 95%CI) when adjusted for age, gender, co-morbidity, GFR category, proteinuria, systolic blood pressure and diuretic therapy. In patients with an evidence-based indication there was no difference in absolute risk of AKI. However, prescription of RAS blockade in the absence of indication appeared to be associated with greater risk of AKI. When analysis was repeated with AKIN2/AKIN3 as the outcome, although risk of AKI remained significant when unadjusted (OR 1.73, 95%CI 1.42-2.11, p<0.001), after full adjustment there was no increased risk (OR 0.83, 95%CI 0.63-1.09) in those taking RAS antagonists. However, when analysed by indication AKIN2/AKIN3 was significantly more likely in those prescribed RAS antagonists without indication (OR 2.04, 95%CI 1.41-2.94, p<0.001). Limitations: Observational database study. No information concerning hospitalisation. Prescribing assumptions and potential inaccurate coding. Potential survival bias; patients surviving longer will contribute more data. Conclusions: Use of RAS antagonists increased the risk of AKI, independent of common confounding variables. After correction for confounders the risk fell away and became non-significant for moderate and severe AKI. However, where there was no evidence-based indication for RAS antagonists the risk of AKI, whether mild, moderate or severe, remained greater

Age and employment: a picture of the East Midlands

This report draws together information from a range of existing sources to assist stakeholders in the East Midlands to consider the Later Life agenda when developing strategy and policy

Recommended Practices: Protecting Temporary Workers

[Excerpt] Workers employed through staffing agencies are generally called temporary or supplied workers. For the purposes of these recommended practices, “temporary workers” are those supplied to a host employer and paid by a staffing agency, whether or not the job is actually temporary. Whether temporary or permanent, all workers always have a right to a safe and healthy workplace. The staffing agency and the staffing agency’s client (the host employer) are joint employers of temporary workers and, therefore, both are responsible for providing and maintaining a safe work environment for those workers. The staffing agency and the host employer must work together to ensure that the Occupational Safety and Health Act of 1970 (the OSH Act) requirements are fully met. See 29 U.S.C. § 651. The extent of the obligations of each employer will vary depending on workplace conditions and should therefore be described in the agreement or contract between the employers. Their safety and health responsibilities will sometimes overlap. Either the staffing agency or the host employer may be better suited to ensure compliance with a particular requirement, and may assume primary responsibility for it. The joint employment structure requires effective communication and a common understanding of the division of responsibilities for safety and health. Ideally, these will be set forth in a written contract. OSHA and NIOSH recommend the following practices to staffing agencies and host employers so that they may better protect temporary workers through mutual cooperation and collaboration. Unless otherwise legally required, these recommendations are for the purpose of guidance and in some cases represent best practices

Categorical methods in graded ring theory

Let G be a group, R a G-graded ring and X a right G-set . We study functors between categories of modules graded by G-sets, continuing the work of [M]. As an application we obtain generalizations of Cohen-Montgomery Duality Theorems by categorical methods. Then we study when some functors introduced in [M] (which generalize some functors ocurring in [D1], [D2] and [NRV]) are separable. Finally we obtain an application to the study of the weak dimension of a group graded ring

NATIONAL EYE INSTITUTE- NIH Comprehensive Strategic Plan and Budget To Reduce and Ultimately Eliminate Heath Disparities

The National Eye Institute’s latest strategic plan, Vision Research-A National Plan: 1999-2003, was developed under the auspices of the National Advisory Eye Council. Over 100 experts from all fields of vision research were assembled to make recommendations on research priorities over the period covered by the plan. Among the priorities identified by these experts were several related to health disparities. These priorities included research on glaucoma, diabetic retinopathy, myopia, and health services delivery and use. Recommendations were also made regarding training and attracting minority scientists into vision research. During the review of the strategic plan, the draft was sent to over 50 professional, scientific, or advocacy organizations that support vision research. They were asked to consider whether any important areas of research or specific issues of importance to vision research had been overlooked. The final document reflects the comments and input received during that process.http://www.ncmhd.nih.gov/strategicmock/our_programs/strategic/pubs/NEI-rev.pd

An RBC model with non-Ricardian households: lessons for Bulgaria (1999–2018)

Purpose: We introduce non-Ricardian ("hand-to-mouth") myopic agents into an other- wise standard real-business-cycle (RBC) setup augmented with a detailed government sector.We investigate the quantitative importance of the presence of non-optimizing households for cyclical fluctuations in Bulgaria. Design Methodology/approach: We calibrate the RBC model to Bulgarian data for the period following the introduction of the currency board arrangement (1999-2018). Findings: We find that the inclusion of such non-Ricardian households improves model performance along several dimensions and generally provides a better match vis-a-vis data, as compared to the standard model populated with Ricardian agents only. Originality/value: This is a novel finding in the macroeconomic studies on Bulgaria using modern quantitative methods

End-of-life care: questions and answers

6 pages.Answers typical questions that a terminally ill patient or their caregivers may have

NATIONAL INSTITUTE ON AGING NIH STRATEGIC PLAN TO REDUCE AND ULTIMATELY ELIMINATE HEALTH DISPARITIES

The NIA maintains a year-round scientific planning process that draws upon interactions with scientists throughout the world, members of Congress, the Institute's National Advisory Council on Aging (NACA) and other advisory committees, constituency groups, and the public. These interactions stimulate internal consideration of potential new research strategies and provide a broad perspective for refining plans. Emphasis is given to novel proposals and collaborative projects that promise to stimulate activities with other research organizations