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Analysis of the Differences Between the ESVS 2019 and NICE 2020 Guidelines for Abdominal Aortic Aneurysm
Janet T Powell1, Anders Wanhainen2
1Vascular Surgery Research Group, Imperial College London, London, UK.
Insights
Differences in abdominal aortic aneurysm (AAA) guidelines from NICE and ESVS stem from varied methodologies and perspectives. Understanding these discrepancies is crucial for optimal patient care and future guideline development.
Area of Science:
- Vascular Surgery
- Clinical Guidelines
- Health Economics
Background:
- Two prominent guidelines for abdominal aortic aneurysm (AAA) management exist: NICE (2020) and ESVS (2019).
- These guidelines present discordant recommendations on key diagnostic and management aspects of AAA.
- Understanding the reasons behind these discrepancies is essential for clinical practice.
Purpose of the Study:
- To analyze the differing approaches, methodologies, and evidence bases of the NICE and ESVS guidelines.
- To identify the specific factors contributing to the discordant recommendations in AAA diagnosis and management.
Main Methods:
- Comparative review of the evidence appraisal and methodological frameworks used by NICE and ESVS guideline committees.
- Analysis of the types of evidence (e.g., RCTs, observational studies) and economic modeling employed by each guideline.
Main Results:
- NICE utilizes a multidisciplinary committee and rigorous RCT-based evidence with UK-centric economic modeling, resulting in 46 recommendations.
- ESVS employs an expert committee, less rigorous evidence assessment, and broader European applicability, yielding 125 recommendations.
- Discrepancies arise from differing evidence searches, consideration of sex-specific data, and reliance on economic modeling for treatment strategies (e.g., open vs. EVAR for ruptured AAA).
Conclusions:
- Divergent perspectives, methodologies, and quality assurance processes explain the differences between NICE and ESVS guidelines.
- Future ESVS guidelines could be enhanced by incorporating more multidisciplinary input and prospectively defined research questions.
- Clarifying these differences aids in the consistent and effective management of abdominal aortic aneurysms.
Objective:
The aim was to understand why two recently published guidelines for the diagnosis and management of patients with abdominal aortic aneurysm, the National Institute for Health and Care Excellence (NICE) 2020 guidelines and the European Society for Vascular Surgery (ESVS) 2019 guidelines, have discordant recommendations in several important areas.
Methods:
A review of the approach, methodology, and evidence used by the two guideline committees was carried out to understand potential reasons for their differing recommendations in their two final published guidelines.
Results:
NICE guidelines use a multidisciplinary committee to address a limited number of prospectively identified questions, using rigorous methods heavily reliant on evidence from randomised controlled trials (RCTs) supported by in house economic modelling, with the purpose of providing the best, cost-effective health care in the UK in 46 main recommendations. The ESVS guidelines use an expert committee to encourage clinical effectiveness across a range of European health economies. ESVS guideline topics, but not questions, are prospectively identified, assessment of evidence was less rigorous, and 125 recommendations were made. More up to date evidence searches by the ESVS committee partially underscore the differences in recommendations for screening women. The NICE committee did not consider sex specific analysis or evidence for thresholds for intervention but relied on sex specific modelling to support their advice to use endovascular repair (EVAR) for ruptures in women. Their recommendation to use open repair for ruptured abdominal aortic aneurysms (AAAs) in men aged < 71 years was based on in house economic modelling. NICE recommends an open first strategy for non-ruptured AAA mainly based on earlier RCTs and UK specific economic modelling, while the ESVS guidelines recommend an EVAR first strategy after consideration of modern, but lower quality, evidence from observational studies. Similar reasons explain differences in the recommended treatments of juxtarenal aneurysms.
Conclusion:
Differences between the NICE and ESVS guidelines can be explained, at least in part, by their differing perspectives, methodologies, and quality assurance. Future ESVS guidelines may benefit from more multidisciplinary input and prospectively identified questions.
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