Rheumatology Advance Access originally published online on December 5, 2007
Rheumatology 2008 47(2):222-223; doi:10.1093/rheumatology/kem282
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LETTERS TO THE EDITOR |
NICE guidance does not tally with clinical practice—a district general experience
University Hospitals of Morecambe Bay NHS Trust, Royal Lancaster Infirmary, Lancaster, UK
Correspondence to: M. Bukhari, University Hospitals of Morecambe Bay NHS Trust, Royal Lancaster Infirmary, Ashton Road, Lancaster LAI 4RP, UK. E-mail: marwan.bukhari{at}mbht.nhs.uk
SIR, We read with interest the articles about the High Court disagreeing with The National Institute for Health and Clinical Excellence (NICE) [1]. In rheumatology, we have had a similar experience with NICE guidance being at variance with patient and carer opinions [2]. This has been reflected to be due to rationing [3]. In 2005, NICE published the guidelines for the secondary prevention of osteoporosis in post-menopausal women [4]. These have included the advice that women over the age of 75 yrs who have sustained a fracture should be put on bisphosphonates without the need for a dual X-ray absorptiometry (DEXA) scan. We assume that this might have been due to the unequal provision of DEXA scanning nationally. We decided to audit the referrals to a district general DEXA service to ascertain whether osteoporosis (as defined by a T-score of less than –2.5 in the spine or hip) was as prevalent in this age group as NICE have implied.
Morecambe Bay has had a DEXA service since 1992 and since June 2004 has been recording fracture data. Since then, 1551 patients above the age of 75 yrs have been scanned, of whom 711 had experienced an osteoporotic fracture (hip, wrist, spine, pelvis, fibula/tibia, rib). Five hundred and seventy-seven of these patients were women with a mean age of 79.8 yrs (S.D. 3.86). The mean T-score was –2.4 (S.D. 1.29). The distribution of the T-score is shown in the given histogram (Fig. 1) and this indicates that although this population's scores are shifted to the left, their mean scores would preclude them from automatically being prescribed bisphosphonates. Two hundred and eighty-six (49.6%) of these patients had a T-score that put them outside the osteoporotic range and 63 (10.9%) were not even osteopenic. Although this might be an indicator that bone density is not the perfect surrogate for bone fracture, there is still significant room for misclassification and excessive treatment. This data agrees with recently published studies [5].
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This provides some evidence that NICE puts other considerations before issuing evidence-based guidelines. Perhaps commissioning research and surveys like our simple one would have prevented many unnecessary prescriptions and allowed resources to be used more appropriately; this would result in a better developed service to reduce the burden of osteoporotic fracture.
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The authors would like to thank the patients who attended the Royal Lancaster Infirmary for scans.
Disclosure statement: The authors have declared no conflicts of interest.
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TopAcknowledgementsReferences |
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- Clare D. NICE’s decision on dementia drugs was ‘irrational,’ High Court is told. Br Med J (2007) 334:1337.
[Free Full Text] - Mayor S. NICE reviews its guidance against sequential use of anti-TNF drugs for arthritis. Br Med J (2007) 334:1238–9.
[Free Full Text] - Walker S, Palmer S, Sculpher M. The role of NICE technology appraisal in NHS rationing. Br Med Bull (2007) 81–82:51–64.
- Clinical effectiveness and cost effectiveness of technologies for the secondary prevention of osteoporotic fractures in postmenopausal women. January 2005 TA87. http://guidance.nice.org.uk/TA87.
- Lashin H, Davie MW. DXA scanning in women over 50 years with distal forearm fracture shows osteoporosis is infrequent until age 65 years. Int J Clin Pract (2007) May 29; [Epub ahead of print].
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  S. Adimulam, C. Greenbank, J. Halsey, and M. Bukhari Comment on: NICE guidance does not tally with clinical practice--a district general experience: reply Rheumatology, November 1, 2008; 47(11): 1736 - 1736. [Full Text] [PDF]
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