NICE process and methods

6 Developing review questions and planning the evidence review

6 Developing review questions and planning the evidence review

The scope should identify key areas that the guidance will cover. There are various types of review question that may be considered for service guidance; for example, these may cover:

  • The content, configuration or integration of services, including the allocation of:

    • medical equipment or tools

    • staff, such as:

      • skills, mix and experience of staff

      • training requirements of staff

      • staffing levels (numbers and staff mix)

  • access to services for patients, including:

    • the availability of services

    • the uptake of services

  • timing and delivery of services, including:

    • diagnosis

    • treatment

    • transfer and referral

    • waiting times

  • location of services, in terms of:

    • setting for delivery

    • economies of scales

    • geographic variation

  • feasibility, with regard to:

    • resource constraints (including capacity, queues and waiting lists)

    • policy constraints.

The questions will compare possible service configurations, which may be existing variations to current services (national and international variations) or a proposed service configuration, with a current service configuration with respect to effectiveness and cost‑effectiveness.

Key outcomes of service delivery questions are likely to include measures of:

  • service effectiveness:

    • health outcomes, including health-related quality of life

    • process outcomes (both directly and indirectly linked to outcomes)

    • compliance rates of staff

    • system failures

  • service experience:

    • patient experience

    • family or carer experience

    • staff experience

  • service resource use:

    • staff

    • equipment

    • time

    • costs

  • service efficiency/optimisation:

    • cost effectiveness (cost–utility analysis)

    • cost consequence

    • cost saving

    • cost minimisations

  • service equity (including health and geographical inequalities).

A key difference for service guidance compared with clinical guidelines is that, to adequately address the question, it is necessary to explore the underlying health and/or service concern first, and then assess the effectiveness of the various health service interventions in addressing this underlying issue. This requires an iterative approach to developing the review questions. The first step is to develop questions to explore the underlying problem, followed by developing questions around potential solutions and service models.

These types of review questions will often require the consideration of supplementary methodological approaches to identifying, assessing, synthesising and interpreting the evidence to those normally used.

Evidence reviews will be iterative, with new searches and/or analysis being planned depending on the outcome of the initial reviews. For example, a search for studies exploring the effectiveness of a particular intervention may not produce any results. The next step would be to consider whether to search for evidence for a similar condition or another healthcare system. Alternatively, primary data may need to be identified or requested to inform recommendations. The Committee should be consulted on the suitability of different types of evidence for developing recommendations.