NICE Physical Activity Collaborating Centre 2006 National Institute for Health and Clinical...

NICE Physical Activity Collaborating Centre 2006

National Institute for Health and Clinical Excellence (NICE)

Public Health Guidance:

Physical Activity


Outline Introduction to NICE

Brief overview of what counts as evidence

Review Process

Intervention Guidance

Implementation Advice

Audit Criteria

Questions / Discussion


NICE

Independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill-health.

Bring together knowledge and evidence on ways of promoting good health and treating ill-health


What does NICE do?What does NICE do?

GuidanceGuidance

Public HealthPublic Health

Health Health TechnologiesTechnologies

Clinical PracticeClinical Practice


Types of NICE Public Health Guidance

Intervention Guidance

Recommendations on clear types of activity (“interventions”), provided by local organisations, that help to reduce the risk of developing a disease or promote or maintain a healthy lifestyle.

Brief interventions

Pedometers

Exercise Referral

Walking and cycling schemes

Programme Guidance

Broader strategic activities for the promotion of good health and the prevention of ill-health. This guidance may focus on a topic or a particular setting:

a topic, such as smoking,

on a particular population, such as young people,

on a particular setting, for example, the workplace.


NICE Guidance focuses on..NICE Guidance focuses on..

EffectivenessEffectiveness

Cost-effectiveness - QALYCost-effectiveness - QALY

To do or not to do… and what are the To do or not to do… and what are the best ways to do it?best ways to do it?


What counts as evidence?What counts as evidence?

The message is clear: practitioners should be The message is clear: practitioners should be ensuring that people receive care based on the best ensuring that people receive care based on the best possible evidencepossible evidence

What works? Challenge: what counts as evidence? What works? Challenge: what counts as evidence?

Evidence-based Evidence-based practicepractice

Evidence-based Evidence-based guidelinesguidelines

Evidence-based Evidence-based policypolicy

Evidence-based Evidence-based decision-makingdecision-making


Evidence-based public health Evidence-based public health policy & practicepolicy & practice

public health policies and practices are interventions into people’s lives, therefore it is reasonable to require the same documentation of effects as one expects from clinical interventions aimed at individuals


What counts as evidence?What counts as evidence?

Evidence has been interpreted in relation to notions Evidence has been interpreted in relation to notions of proof and rationality – subject to rigorous scrutinyof proof and rationality – subject to rigorous scrutiny

Assumption in evidence-based medicine – that Assumption in evidence-based medicine – that research evidence, quantitative nature would provide research evidence, quantitative nature would provide watertight answerswatertight answers

Hierarchy of evidence – research evidence tends to Hierarchy of evidence – research evidence tends to be more highly valuedbe more highly valued

Relative neglect of other forms of evidenceRelative neglect of other forms of evidence


NICE Physical Activity Intervention Guidance

Effectiveness of :

1. Brief interventions in primary care

2. Exercise referral

3. Pedometers

4. Community-based walking and cycling schemes


Rapid Review Process

Define the intervention

Identify search terms / conduct search (‘hits’) Preliminary screen ‘In and out’ (using title/abstract) Data extraction (using standardized form) Study quality appraisal Summary report on findings

NICE PHIAC meeting – draft guidance / public consultation

NICE publishes Final Guidance


Effectiveness – Public Health Interventions?Effectiveness – Public Health Interventions?

Hierarchy of Evidence

1. Meta-analyses, systematic review of RCTs or RCTs

2. Systematic reviews of, or individual, non-RCTs, case-control studies, cohort studies, CBA, ITS, correlation studies

3. Non-analytic studies (for example, case reports, case series studies

4. Expert opinion, formal consensus


NICE Parameters for Rapid Review

Study year and type …. include search for interventions and evaluations and

also cohort, qualitative and survey studies for corroborative evidence.

….if sufficient high quality, up to date evidence is found for a specific question, older studies and/or those using weaker designs will not be examined.

Only English language papers will be included. Adults (>16 years) Minimum time period of 6 weeks between baseline and

repeat measures for interventions [review assessed outcomes at 6-12 week; >12-52 weeks; >1 year]


NICE guidance - what counts as NICE guidance - what counts as evidence?evidence?

Evidence used – depends on the extent to which it answers questions in the scope

Typical review:An evidence briefing (review of reviews)An evidence briefing (review of reviews)

A systematic review (of primary data)A systematic review (of primary data)

Existing (published) primary researchExisting (published) primary research

New primary researchNew primary research


In / Out Criteria

Aim of the study is to examine the effectiveness of …….? Does the study have a control or comparison group? Are the study’s participants all adults (16+ only)? Is the intervention plus follow-up a minimum of 6 weeks

or more? Is the main outcome a physical activity behaviour or

physical fitness measure? For the purpose of this review do you think that this study

should be (please circle):Included Excluded Not sure


Brief interventions in primary care

Definition: Any brief intervention involving verbal advice, encouragement, negotiation or discussion with the overall aim of increasing physical activity delivered in a primary care setting by a health or exercise professional, with or without written or other support or follow up


Brief interventions in primary careSearch Terms: Brief interventions, counselling, therapy AND primary care, general practice, physical activity, exercise, fitness AND controlled trial

1749 hits from databases

50 relevant

12 studies met criteria

for data extraction



Low quality scores due to:♦ Not randomised♦ Outcome assessment was

not independent and blind♦ Use of unvalidated PA

measures♦ No ‘intention–to-treat’

analysis♦ No adjustment for baseline

physical activity



Results showed:♦ Moderate increases in PA

♦ in ST (3 studies),♦ longer term (4 studies)♦ very long term (3 studies)

♦ Written ‘prescriptions’ may be useful adjunct♦ Follow up may be necessary for LT change


Pedometers

Definition: any intervention using pedometers as a tool to increase physical activity; used alone or in combination; were purchased by individual or provided (with or without advice) by health care team or another professional/agency.


Pedometers

Search Terms: Pedometers, Step counters


64 relevant

4 studies met criteria for data extraction


Pedometers

Main reasons for exclusions:

♦ no control or comparison group

♦ pedometers were used as a

monitoring tool

♦ not an intervention study

♦ no follow-up period of at least 6-weeks


Pedometers

Results showed:♦ At 12 weeks: equivocal ♦ 12-52 weeks: equivocal♦ >1 year: no studies

♦ Suggest that appropriate programme / support is required in addition to the pedometer

♦ Overall lack of evidence


Exercise referral

Definition: A scheme involving referral by an appropriate professional to a service where there is a formalised process of assessment of need, the development of tailored programme and monitoring of progress


Exercise referral


139 relevant

4 studies met criteria for data extraction

Search Terms: Exercise, physical activity AND referral, primary health care, prescription AND study, intervention, trial, control, controlled, comparison, comparator


Exercise referral

Low quality scores due to:♦ No ‘intention–to-treat’

analysis♦ No adjustment for

baseline physical activity

Main reasons for exclusions:♦ Not an intervention study♦ Not an exercise referral

scheme according to our definition

♦ No control or comparison group

♦ Not adult population group (<16 years)


Exercise referral

Results showed:♦ Moderate increases in PA in ST (2 studies)♦ Equivocal evidence of effectiveness in the

longer term (4 studies) and very long term (3 studies)

♦ Overall insufficient evidence and further research needed


Community-based walking and cycling schemes

Definition: Projects and groups with the aim of increasing participation in walking and cycling through involvement in organised (led) walks/rides.

Can include referral by a member of the primary care team of an individual as well as ‘self referral’ to such schemes, brought about by community workers, promotional flyers, media coverage, etc


Community-based walking and cycling schemes

Search Terms: walk, walking, bike, bicycling, bike riding, led walks, health walks, groups walks, pedal backs the years, rides, riding AND community intervention, project, programme, program, trial

16, 599 hits from databases

254 relevant

0 studies met criteria

Cycling Walking4 studies

met criteria

Grey literature


Community-based walking schemes

Low quality scores due to:♦ high loss to follow-up♦ use of unvalidated

measure of physical activity

♦ lack of use of intention to treat analysis

♦ lack of adjustment for baseline physical activity levels

Main reasons for exclusions:♦ Not led walks/rides

♦ Not intervention studies

♦ No pre-measures


Community-based walking schemes

Results showed:♦ 1 high quality RCT showed no effect ♦ 1 lower quality controlled study showed no effect♦ 1 high quality RCT showed +ve effect ♦ 1 lower quality RCT found +ve effect

♦ Overall evidence is equivocal


Community-based cycling schemes

♦ Database searches resulted in no evidence

(Note: organised rides only)

Grey literature:♦ Lack of pre-measures ♦ 1 lower quality

controlled study showed no effect


Economic Analysis

♦ Additional review process♦ Undertaken by Matrix Consultancy♦ Separate report available♦ Summary findings:

♦ Limited evidence for brief interventions♦ No evidence for walking and cycling♦ Some evidence for exercise referral♦ No evidence for pedometers


Guidance Development Process

♦ Synopsis (executive summary & evidence tables), full reviews, supplementary reviews & economic modelling submitted to Public Health

Interventions Advisory Committee (PHIAC)♦ PHIAC produces draft recommendations ♦ Draft recommendations published for consultation♦ Responses to consultation published♦ PHIAC amends recommendations ♦ Final guidance published on website


How PHIAC formulated recommendations

♦ Whether there was sufficient evidence (in terms of quantity, quality and applicability) to form a judgement

♦ Whether, on balance, the evidence demonstrates that the intervention is effective or ineffective, or whether it is equivocal

♦ Where there is an effect, the typical effect size


Brief Interventions in Primary Care: Recommendations

Recommendation 1 - Primary care practitioners should:

♦ Take the opportunity, whenever possible, to identify inactive adults and advise them to aim for 30 minutes of moderate activity on 5 days of the week (or more)

♦ Use their judgment to determine when this would be inappropriate

♦ Use a validated tool to identify inactive individuals

Brief interventions 1



Recommendation 2 - Primary care practitioners should:

♦ Take into account individual’s needs, preferences and circumstances when providing physical activity advice

♦ Agree goals with individuals♦ Provide written information about the benefits of

activity and the local opportunities to be active♦ Follow up at appropriate intervals 3-to-6 month

period




Recommendation 3 – Local policy makers, commissioners and managers together with primary care practitioners should:

♦ Monitor the effectiveness of local strategies and systems to promote physical activity

♦ Consider whether or not opportunistic advice is helping to increase the physical activity levels of people from disadvantaged groups, including those with disabilities

♦ Assess how effective professionals from a range of disciplines are at raising LT p.a. among these groups




Recommendation 4 – Local policy makers, commissioners and managers together with primary care practitioners should:

♦ Pay particular attention to the cultural needs of hard to reach and disadvantaged communities, including BME groups when developing service infrastructures to promote physical activity



Exercise Referral

PHIAC determined there was insufficient evidence to recommend the use of exercise referral schemes to promote physical activity other than as part of research studies where their effectiveness can be evaluated


Exercise Referral: Recommendation

Recommendation 5 – Practitioners, policy makers and commissioners should:

♦ Only endorse exercise referral schemes to promote p.a. that are part of a properly designed and controlled research study to determine effectiveness

♦ Measure intermediate outcomes such as knowledge, attitudes and skills, as well as measures of p.a.

♦ Only refer individuals to schemes that are part of such a study


Pedometers, walking and cycling schemes

PHIAC determined there was insufficient evidence to recommend the use of pedometers and walking and cycling schemes to promote physical activity other than as part of research studies where their effectiveness can be evaluated ……professionals should continue to promote walking and cycling as a means of incorporating p.a. into people’s daily lives


Pedometers, walking and cycling schemes: Recommendation

Recommendation 6: Practitioners, policy makers and commissioners should:

♦ Only endorse pedometers and walking and cycling schemes to promote p.a. that are part of a properly designed and controlled research study to determine effectiveness

♦ Measure intermediate outcomes such as knowledge, attitudes and skills, as well as measures of p.a.


In summary…

♦ SUPPORTED: ♦ Brief interventions in Primary

Care

♦ EVALUATE: ♦ Exercise referral ♦ Walking schemes ♦ Pedometers

♦ NICE Implementation Advice


D13: ‘effective programmes to improve health and reduce health inequalities, conforming to nationally agreed best practice, particularly as defined in NICE guidance and agreed national guidance on public health’


Responsibility for implementing this guidance rests with those responsible for commissioning and delivering public health services


Key areas for implementation

♦ Training♦ Communication♦ Monitoring local strategies and systems♦ Evaluation of existing and new

pedometer, exercise referral, walking and cycling schemes


http://www.nice.org.uk/page.aspx?o=PHI002&c=publichealthhttp://www.nice.org.uk/page.aspx?o=PHI002&c=publichealth

Implementation advice

Four commonly used methods to increase physical activity

Issue date: May 2006

Audit criteria

Four commonly used methods to increase physical activity

Issue date: May 2006


Forthcoming Programme Guidance: Physical activity and the Environment

To produce guidance for the Highways Agency, local authorities, the NHS, the independent sector and others, on the promotion and creation of built or natural physical environments that are conducive to and support increased levels of physical activity among local communities, to meet the physical activity recommendations of the Chief Medical Officer of England

Questions

What are the implications for practitioners?

NICE Physical Activity Collaborating Centre 2006 National Institute for Health and Clinical...

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