I think it would be better to do an RCT on NICE guidelines themselves!
Not sure how it would work.
Perhaps you could present doctors/nurses/managers with two sets of
guidelines for various conditions, all mocked up to look like NICE had
written them, but one had been written by a semi competent consultant in
a relevant specialty, not produced by a committee. Then ask them which
they think are the real ones. I bet they'd struggle to tell them apart.
Alternatively, just present NICE guidelines as they are, except you take
away the evidence level marker and ask people to fill in what they think
the evidence level is. Again, I bet a lot of people think the evidence
for what is being suggested/recommended/enforced is higher than it
actually is.
Simon
Cynical in South Yorkshire
-----Original Message-----
From: Rowley Cottingham [mailto:[log in to unmask]]
Sent: 19 September 2006 00:07
To: [log in to unmask]
Subject: NICE guidelines - who needs them? Let's do an RCT.
Excellent BASICS conference at the weekend at which I discovered (among
a few other things) that someone slipped out some NICE guidelines for
the management of AF a while back without telling me.
http://www.nice.org.uk/page.aspx?o=cg36 if you must know.
I thought this would be wonderful, as we seem to have a different
treatment each week for the LOLs who turn up in AF after going a bit
wobbly while watching Des Lynam/eating fish/staring out of window or
some other stressful event. I had a very good result digitalising a
rather sweet 86 year old last week.
But it's useless. Rate control or rhythm control? Ooh, sit on hands.
"1.6.1 Acute AF in haemodynamically unstable patients
1.6.1.1 In patients with a life-threatening deterioration in
haemodynamic stability following the onset of AF, emergency electrical
cardioversion should be performed, irrespective of the duration of the
AF. D
1.6.1.2 In patients with non-life-threatening haemodynamic instability
following the onset of AF:
* electrical cardioversion should be performed D
* where there is a delay in organising electrical cardioversion,
intravenous amiodarone should be used D
* for those with known Wolff-Parkinson-White
syndrome: D(GPP)
- flecainide may be used as an alternative for attempting
pharmacological cardioversion
- atrioventricular node-blocking agents (such as diltiazem,
verapamil
or digoxin) should not be used.
1.6.1.4 Where urgent pharmacological rate-control is indicated,
intravenous treatment should be with one of the following: D
* beta-blockers or rate-limiting calcium antagonists
* amiodarone, where beta-blockers or calcium antagonists are
contraindicated or ineffective.
So the first recommended course of action is to shock them! Flecainide
(dirty stuff, and you have to be REALLY sure the heart is OK - see the
CAST trial) for WPP or amiodarone (mess up everything for 3 months)
otherwise.
I'm sorry, but I really don't think that is appropriate for my 86 year
old. She did fine on iv digoxin - which doesn't even rate a mention.
Notice the evidence base is all level D, which is really just their
opinions. Can acad-ae-med do better than NICE? Can't we put together an
RCT?
Something like: "In patients aged over 65 with onset of symptoms
suggesting new AF in the previous 48 hours who are found to be in AF on
ECG, is electrical cardioversion (followed by?), diltiazem, intravenous
digitalisation or amiodarone superior for control of symptoms at one
hour, return to sinus rhythm, relief of symptoms at 1 month and patient
acceptance?"
Blinding may be tricky. We need to think about how many stroke out,
whether or when to anticoagulate (about the only really positive finding
from AFFIRM but that is a different patient population) and how many we
need (probably 1000 per group or thereabouts) but it should be easy
enough to do countrywide.
/Rowley./
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