Public Health Interventions Advisory Committee (PHIAC)

Transcription

1 Public Health Interventions Advisory Committee (PHIAC) Minutes of meeting 3, 28 th February 2006 Smoking Cessation and Physical Activity Interventions Attendees Members Catherine Law (Chair), Cheryll Adams, Ron Akehurst, Sue Atkinson, Michael Bury, Simon Capewell, K K Cheng, Philip Cutler, Brian Ferguson, Ruth Hall, Ann Hoskins, Matthew Kearney, Klim McPherson, Susan Michie, Jane Putsey, Mike Rayner, Dale Robinson, David Sloan, Dagmar Zeuner NICE Mike Kelly, Antony Morgan, Simon Ellis, Lesley Owen, Patti White, Bhash Naidoo, Margit Physant, Hugo Crombie, Thara Raj, Amanda Killoran, Victoria Thomas, Consortium Ann McNeill Physical Activity Collaborating Centre Charlie Foster Observers Chair of Smoking Cessation PDG Alexander Macara Gisela Abbam, Tricia Younger, Andrew Dillon, NICE Authors File Ref Amanda Killoran, Lesley Owen and Gisela Abbam PHIAC Minutes Version Audience Members of PHIAC, NICE Smoking Cessation Intervention and Programme teams, Consortium on Smoking Cessation, Health economics contractors, NICE publishing and implementation teams Page 1 of 12

2 Agenda Item Minutes Action 1 Welcome and introductions (Chair) 2 Apologies Chair welcomed Members to the third meeting. All attendees introduced themselves Apologies received from Amanda Hoey, Andrew Hopkin, Sharon McAteer, Michael Varnam, David Jones 3 Declaration of Interest (All) Declaration of conflicts of interest in relation to both Smoking Cessation and Physical Activity Interventions were requested. Members indicated that they may benefit in the future from research funding on these topics: These were: Catherine Law, Simon Capewell, Klim Mcpherson, KK Cheng, Susan Mitchie, Ron Akehurst, Michael Bury and Brian Ferguson. Members who may receive a service payment for implementing some of the services that the Committee may recommend were: Matt Kearney and Phil Culter All Members 4 Presentation of the Evidence on Smoking Cessation 4.1 Presentation on the views of lay experts Victoria Thomas from the Patient and Public Involvement Programme (PPIP) outlined the views of lay experts on the draft Smoking Cessation intervention guidance. A questionnaire was sent to all registered stakeholders for the Smoking Cessation Intervention and also posted on the website. Two lay experts came forward. Both of the respondents had received advice from health professional and others and self help materials from an internet site. Both received treatment and follow up. Both had received NRT and one had also been given supportive help to change her behaviour. Their views elicited in discussion with NICE PPIP were noted by the Committee. PPIP, NICE Page 2 of 12

3 4.2a Presentation on the main issues raised by stakeholders comments on the draft recommendations consultations Lesley Owen, the Technical Lead presented the stakeholder consultation comments on the draft guidance. The main issues raised by stakeholders in response to the consultation on the draft recommendations were highlighted.. The consultation took place between 25 th January and 21 st February. More than 140 comments were received from 22 external organisations and 3 departments within NICE. Most of the comments received focused on the content of a brief intervention and training needs. External organisations included health bodies (eg. PCTs), various networks (eg. smoking and pregnancy network), voluntary agencies (eg. ASH), professional bodies (eg. RCGP) and pharmaceutical and research agencies and a local authority. There was a concern that current wording would result in more prescribing and fewer referrals and so diminish the greater potential impact of combined NRT and behavioural support. On the other hand there was a concern that blanket referral would result in a waste of resources because smokers who were not ready or willing to stop would be taking up the referrals. The order in which the individual components of a brief intervention should be delivered was also questioned. Stakeholders were keen to have more information on how to assess motivation to quit and the nature of the advice that should be given. Stakeholders also queried how smokers who have not been seen by a health professional within a year be treated. Should they be sent letters or be seen face-toface There was a consensus that health professionals should be trained to deliver brief interventions, that the training should be mandatory and accredited. It was also suggested that health professionals should be remunerated for undertaking the training. Stakeholders suggested that all health professionals should have knowledge of their local stop smoking services and the support that is provided by them. On the subject of referrals some stakeholders queried whether referrals should be restricted to the NHS stop smoking services. Several suggestions were received for highlighting CPHE drafting team Page 3 of 12

4 particular professions and sub-groups of smokers. Queries were raised regarding who should be responsible for monitoring and audit and the wording of the recommendations was thought by some to create problems for audit. Members of PHIAC were advised that the number of research recommendations would need to be limited to around 5 and that a steer should be provided on important aspects of the process. 4.2b Presentation on Incremental cost analysis 5 The Process (Mike Kelly) The presentation on incremental cost analysis was by the Health Economist from NICE. The increase in the Quality Adjusted Life Years (QALY) was plotted against the increase in cost. In the original analysis, a brief intervention compared with do nothing gave a QALY of 1,510. A brief intervention compared with a brief intervention plus NRT gave a QALY of 5,876. Because the evidence was weak, the original analyses did not include brief interventions plus self help and telephone helplines. However, based on the evidence that was available the costs per QALY for brief interventions and self-help materials compared with do nothing was 763 and for brief interventions plus telephone helpline compared with brief intervention plus self help materials was 839. The process was explained by Mike Kelly, the Centre Director. More than 140 comments were submitted by stakeholders and the NICE process requires that each comment is responded too. The responses to stakeholder comments in addition to their comments would be made publicly available on the website on the day of the publication of the guidance. The next stage is for the Committee to go through the recommendations picking up key points raised by stakeholders. The responses to the stakeholder comments are NICE not PHIAC s responses. Mike Kelly clarified that manufacturers and pro-smoking pressure groups like FOREST had been invited to become stakeholders but had declined the invitation. CPHE drafting team Mike Kelly 6 Discussion on the draft recommendations Recommendation one This is a recommendation in relation to GPs. There was All members Page 4 of 12

5 (All) lengthy discussion about what constitutes brief advice and whether it could/should be distinguished from prescribing NRT or referring to the services. The latter two cases would inevitably involve some brief advice. The Committee agreed that this intervention should be offered to all smokers if appropriate. It should not, for instance, be limited to people who are already suffering from smoking related illnesses. The committee also agreed that the recommendation should be clear that only under exceptional circumstances would it be deemed inappropriate to offer such advice. PHIAC indicated that the guidance should include a rationale for recommending referral to the services when the evidence of effectiveness for these had not been included as part of this work. Some members felt that it was not necessary to specify the services as the evidence seemed to suggest that it was intensive support that is important and helps. How the intensive support is delivered was less relevant. The Committee deliberated on and then agreed a stepdown approach as a recommendation to practitioners for whom there was little or weak evidence of effectiveness in delivering brief interventions. The approach entails offering first the best available combination of support through referrals to services. If the person is unwilling, then the person is offered a prescription or another form of support. Members agreed that the provision of NRT should be contingent on the smoker agreeing to set a quit date and having a level of commitment to try and make it work. Given the differential effectiveness of different elements of brief interventions and potential for different treatment pathways it was suggested that research be undertaken to determine whether the step-down approach is more effective than a step-up approach. Members of PHIAC felt the evidence base for the incremental analyses which favoured brief interventions plus self help materials and telephone helplines was too weak to use it to decide on a particular pathway. Frequency of contact with smokers It was agreed that the advice to smokers should also be opportunistic and undertaken at least once a year. Members of the committee stressed the importance of Page 5 of 12

6 setting the delivery of brief interventions in both a broader cessation and tobacco control context. Technology Appraisal for NRT and bupropion It was re-iterated that whilst waiting for the updating of the NICE Technology appraisal for NRT and bupropion, the current guidance stands as it is. Also it was explained that technology appraisal that included evidence on pharmacotherapies that were used in isolation (ie. not part of a brief intervention) would be updated as part of the programme guidance. Priority groups for treatment Members of PHIAC stressed the importance of being clear about whether there is no evidence or evidence that something is ineffective. With regard to priority groups it was clarified that those specified were identified on the basis of the evidence. It was further clarified that there was level 1 evidence which detected no effect for pregnant women and hospital inpatients.. Priority groups were identified as pregnant smokers and disadvantaged groups. PHIAC reiterated that such groups should be the focus of recommendations regarding equitable service. Moreover, every effort should be made to ensure that wording of recommendations will not add to the widening of inequalities. The importance of using consistent terminology to avoid confusion was raised, members agreed that brief interventions rather than brief advice should be adopted throughout the guidance. It was also noted that where there was no evidence or weak evidence of no effect the recommendations would need to be carefully worded so as not to create the impression that intervention was not worthwhile. Who will deliver the intervention The Committee deliberated on this. There was a tension between what the evidence base would suggest (which was based to a large extent on doctors and GPs) and the pragmatic view that at the very least no harm would be caused by the other health professionals offering advice. Given the changing nature of the health professions and the increasing involvement of non-healthcare professionals in delivering health promoting interventions, members felt that the competencies required to deliver interventions were at least as important as the nature of the profession. PHIAC agreed that all health professionals should deliver interventions and that GPs and nurses Page 6 of 12

7 would be specified. Pharmacists and Dentists would also be mentioned because of changes to their contracts and their potential reach. Training for professionals delivering the interventions It was agreed that all health professionals and workers should be trained to deliver interventions. It was not deemed necessary to make a specific recommendation on training as 1. it is assumed that for interventions recommended by NICE practitioners should be appropriately trained and 2. it will be covered in the implementation advice. Research Recommendations The Committee after deliberating the gaps identified in the evidence base decided that the research priorities were looking for evidence on : the most effective and cost effective brief interventions for hard-to-reach groups brief interventions delivered in a wider range of settings characteristics of effective brief interventions The outcomes if possible of all the above should be biochemically validated. Also, it was agreed that Recommendation 13 should be rephrased as a set of research questions. Members wanted the guidance to be clear about what evidence had and had not been considered, particularly in relation to referrals as the recommendations focus on evidence of effectiveness of brief interventions and not referral even though the latter was included in the original brief. Finally, it was agreed that further iterations of all the recommendations would be refined by the CPHE drafting team and circulated to members for further discussions by 10 March Page 7 of 12

8 7 Schedule of meetings for the rest of the year (Catherine Law) 8 Physical Activity: Consideration of stakeholder comments The next meeting is on 5 May This will be to consider the synopsis of evidence from Preventing Sexually Transmitted Infections (STI s) and Teenage Conceptions. The away days will be in June. The dates have now been confirmed and are 27 and 28 June The 4 th and 5 th of September 2006 are meetings to discuss Substance misuse and Preventing Sexually Transmitted Infections (STI s) and Teenage Conceptions respectively. On the 5 th of December, 2006 a meeting will be held to discuss Substance misuse. Victoria Thomas of PPIP outlined the views of lay experts on the draft physical activity intervention guidance. Hugo Crombie presented the stakeholder consultation comments on the draft guidance. Chair PPIP, NICE 8a Physical Activity: Consideration of stakeholder comments and discussion of the Recommendations Members discussed the following general issues that were raised by the stakeholder comments. Context Members shared concerns about the narrow scope of guidance and recommendations. It was agreed that the recommendations should be presented within the broader context of the evidence and national policy concerned with promoting physical activity. Evidence for starting and stopping an intervention There was a need to clarify the quality (and quantity) of evidence that was required to decide whether to start doing something or stop doing something and whether different thresholds were appropriate. Overall, members agreed that in principle the same level of evidence was required to start or stop an intervention. However it was noted that this might be difficult in practice. Promotion physical activity Members shared concerns about the overall tone of the guidance. It was agreed that the guidance should strongly encourage the development locally of innovative ways of promoting physical activity to counter any perceived Page 8 of 12

9 negative aspects. The Committee discussed each of the four specific interventions covered by the guidance. Brief interventions Members discussed the following four specific questions raised in the stakeholder consultation with respect to brief interventions: It was noted that the DH had been developing a tool for practitioners to use in primary care to assess physical activity levels of individuals. It was agreed that NICE should discuss with the DH whether this tool would be available and its use should be recommended in the guidance. It was agreed that the guidance should state that:.brief advice should be provided opportunistically by health personnel working in a primary care context to all those who are inactive. And that..practitioners should ensure equity of access to this brief advice, and that more vulnerable and hard to reach groups were able to benefit.. And When providing verbal advice: Goals should be discussed and agreed taking account of individuals needs, preferences and circumstances The statement follow up at appropriate intervals over a 3 to 6 months period was agreed. It was agreed that the recommendation on brief interventions applied only to primary care, although a range of professionals might be involved, and this should be made clear in the guidance. It was noted that health trainers were likely to have a role in offering brief advice. Members judged that no recommendation about the frequency that brief intervention should be offered should be made, as the evidence did not address this aspect. Walking and cycling It was agreed that no practice recommendation should be made with respect to organised walking and cycling schemes, as there was insufficient evidence. However the guidance should acknowledge the potential social value of such schemes. It should highlight the importance of walking and cycling (and that of other physical activity) in a wider context and the need to promote physical activity in Page 9 of 12

10 ways which people would find accessible and enjoyable. It was agreed that further research should be recommended. Pedometers Similarly the Committee agreed that no practice recommendation should be made with respect to pedometers. Exercise referral There was considerable discussion about the recommendations relating to exercise referral schemes. Comments were made concerning the limited and variable quality of the evidence, and it was agreed that further research was needed and that a strong research recommendation should be made. The Committee considered whether a research only recommendation should be made. This would mean that any new schemes (and also existing schemes) should only operate within a framework of evaluative research. Two related issues were raised. It was noted that such a recommendation was likely to result in the closure of many existing schemes. It was therefore important that the evidence justified this decision. It was also noted that an evaluation trial of exercise referral schemes was due to report, and the findings were likely to have bearing on the recommendations. However, after discussion, members judged that the findings of this trial should not be privileged at this stage, but should be considered in due course. It was therefore agreed to recommend that exercise referral schemes should only be recommended within the context of a rigorous research of their effectiveness. Outcome measures should include mediators of change, as well as measures of change in physical activity levels. Furthermore, the Medical Research Council should be asked to ensure that a programme of evaluation of physical activity interventions was established and this should include the evaluation of exercise referral schemes. The Committee requested that the Physical Activity Technical team revise the draft guidance in line with the above discussions of the four intervention areas. Page 10 of 12

11 9 Issues Paper presented by Associate Directors for Smoking Cessation and Physical Activity An issues paper was presented by Antony Morgan and Simon Ellis. (PHIAC 3.7) The paper highlighted the process and methodological issues that have arisen from the PHIAC meetings so far. The issues paper will however be discussed in detail at the PHIAC Away day in June. It was also agreed that one or two topics should be selected for discussion at the Away day and a proposal to develop some medium to long term pieces of work with sub groups should be considered. Antony Morgan / Simon Ellis, NICE 9 Minutes and matters arising from minutes of PHIAC Minutes and matters arising from PHIAC The following amendments to the previous minutes of 16 December were agreed: Page 2 : potential conflict of interest related both to current and possible future receipt of research awards. Page 10: confirmed that two draft statements were to be prepared in line with one statement saying there was insufficient evidence and the other stating there was sufficient evidence. However, it was confirmed that the drafting of two statements proved unnecessary. Page 3: it was agreed that GPs, for example would see most patients for less than 10 minutes not 5 minutes as the PHIAC 2 minutes stated. Page 8: Health professional s roles had expanded to include some tasks traditionally undertaken by GPs. A discussion ensued about the extent to which economic models should be evidence or service driven. All 10 AOB Members were informed that the webboard, that is Intranet communication and information for members would be set up before the next meeting. Members were reminded that the Committee has the power to co-opt people with special expertise and they could be either professionals, practitioners, researchers or lay people. Members were invited to suggest co-optees for the Committee. Members raised the need for a more systematic approach to getting and accessing qualitative work. Members raised the need for an integrated approach between PHIAC and the Programme Development Groups (PDGs). NICE NICE Page 11 of 12

12 A member raised the issue of consultation with stakeholders and said several consultations sometimes happened simultaneously, which puts extra pressure on the stakeholder organisations. The need for PHIAC to input into scopes for future work was raised and agreed by the Committee. 11 Date of next meeting and programme of future work Mike Kelly) The next meeting is on 5 May This will be to consider the synopsis of evidence from Preventing Sexually Transmitted Infections (STI s) and Teenage Conceptions. NICE Page 12 of 12