This form is intended for use by specialist advisers who have been invited to submit advice about specific interventional procedures.

All other people who wish to comment on a new interventional procedure are asked to e-mail ip@nice.org.uk or write to

Interventional Procedures Manager,
National Institute for Health and Clinical Excellence,
MidCity Place,
71 High Holborn,
London WC1V 6NA.

Please note: Before you complete this questionnaire, please read Conflicts of Interest for Specialist Advisers. If you have a personal specific pecuniary interest (see section 2) or a personal family specific interest (see section 3) in this procedure, this excludes you from offering advice to the Committee on the procedure and you should not proceed any further with the questionnaire. However, please return the questionnaire to us incomplete for our records.

Please enter the number and name of the procedure you are commenting on:

1. Knowledge of this procedure

1. Do you have adequate knowledge of this procedure to provide advice?

1.1 Does the title used above describe the procedure adequately?

2. Your involvement in this procedure

2.1 Is this procedure relevant to your specialty?

The next two questions are about whether you carry out the procedure, or refer patients for it. If you are in a specialty that normally carries out the procedure please answer question 2.2.1. If you are in a specialty that normally selects or refers patients for the procedure please answer question 2.2.2.

2.2.1 If you are in a specialty which does this procedure, please indicate your experience with it.

2.2.2 If your specialty is involved in patient selection or referral to another specialty for this procedure, please indicate your experience with it:

2.3 Please indicate your research experience relating to this procedure (please choose one or more if relevant):

3. Status of this procedure

3.1 Which of the following best describes the procedure (choose one):

3.2 What would be the comparator (standard practice) to this procedure?

3.3 Please estimate the proportion of doctors in your specialty who are performing this procedure (choose one):

4. Safety and efficacy

4.1 What are the adverse effects of the procedure?

Please list under each heading the likely adverse events and major risks (even if uncommon). If possible, estimate their incidence.

4.2 What are the key efficacy outcomes for this procedure?

4.3 Are there uncertainties or concerns about the efficacy of this procedure? If so, what are they?

4.4 What training and facilities are required to undertake this procedure safely?

4.5 Are there any major trials or registries of this procedure currently in progress? If so, please list.

4.6 Are you aware of any abstracts that have been recently presented/published on this procedure that may not be listed in a standard literature search, e.g. PUBMED? (This can include your own work). If yes, please list.

Please note that NICE will do a literature search: we are only asking you for any very recent or potentially obscure abstracts and papers. Please do not feel the need to supply a comprehensive reference list (but you may proffer any which you regard as particularly important if you wish).

4.7 Is there controversy, or important uncertainty, about any aspect of the way in which this procedure is currently being done or disseminated?

5. Audit criteria

Please suggest a minimum data set of criteria by which this procedure could be audited.

5.1 Outcome measures of benefit (including commonly used clinical outcomes - both short and long-term; and quality of life measures):

5.2 Adverse outcomes (including potential early and late complications):

6. Trajectory of this procedure

6.1 In your opinion, what is the likely speed of diffusion of this procedure?

6.2 This procedure, if safe and efficious, is likely to be carried out in (choose one):

6.3 The potential impact of this procedure on the NHS, in terms of numbers of patients eligible for treatment and use of resources, is:

7. Other information

7.1 Is there any other information about this procedure that might assist NICE in assessing the possible need to investigate its use?

8. Data protection and conflicts of interest

8.1 Data protection statement

The Institute is committed to transparency. As part of this commitment your name and specialist society will be placed in the public domain, in future publications and on our website and therefore viewable worldwide. This information may be passed to third parties connected with the work on interventional procedures.

A copy of the completed Specialist Adviser advice will be sent to the Specialist Society who nominated the Specialist Adviser.

Specialist Advisers should be aware that full implementation of the Freedom of Information Act 2000 may oblige us to release Specialist Advice from 2005. The Freedom of Information Act 2000 favours the disclosure of information however requests will be considered on a case by case basis. If information is made available, personal information will be removed in accordance with the Data Protection Act 1998. In light of this please ensure that you have not named or identified individuals in your comments.

8.2 Declarations of interest by Specialist Advisers advising the NICE Interventional Procedures Advisory Committee

Please state any potential conflicts of interest, or any involvements in disputes or complaints, relevant to this procedure. Please use the Conflicts of Interest for Specialist Advisers code of practice available as a guide.

Thank you very much for your help.

Professor Bruce Campbell
Chair
Interventional Procedures Advisory Commmittee

Dr. Carole Longson
Director
Interventional Procedures Programme