Modelling clinical narrative as computable knowledge: The NICE computable implementation guidance project.

Introduction: Translating narrative clinical guidelines to computable knowledge is a long-standing challenge that has seen a diverse range of approaches. The UK National Institute for Health and Care Excellence (NICE) Content Advisory Board (CAB) aims ultimately to (1) guide clinical decision support and other software developers to increase traceability, fidelity and consistency in supporting clinical use of NICE recommendations, (2) guide local practice audit and intervention to reduce unwarranted variation, (3) provide feedback to NICE on how future recommendations should be developed. Objectives: The first phase of work was to explore a range of technical approaches to transition NICE toward the production of natively digital content. Methods: Following an initial 'collaborathon' in November 2022, the NICE Computable Implementation Guidance project (NCIG) was established. We held a series of workstream calls approximately fortnightly, focusing on (1) user stories and trigger events, (2) information model and definitions, (3) horizon-scanning and output format. A second collaborathon was held in March 2023 to consolidate progress across the workstreams and agree residual actions to complete. Results: While we initially focussed on technical implementation standards, we decided that an intermediate logical model was a more achievable first step in the journey from narrative to fully computable representation. NCIG adopted the WHO Digital Adaptation Kit (DAK) as a technology-agnostic method to model user scenarios, personae, processes and workflow, core data elements and decision-support logic. Further work will address indicators, such as prescribing compliance, and implementation in document templates for primary care patient record systems. Conclusions: The project has shown that the WHO DAK, with some modification, is a promising approach to build technology-neutral logical specifications of NICE recommendations. Implementation of concurrent computable modelling by multidisciplinary teams during guideline development poses methodological and cultural questions that are complex but tractable given suitable will and leadership.

Comparison of howRU and EQ-5D measures of health-related quality of life in an outpatient clinic.

This paper reports on a head-to-head study of howRU and EQ-5D on patients with cardiovascular disease. howRU is a short generic measure of health-related quality of life comprising 39 words, designed for routine use, which we compare with EQ-5D (230 words). Patients attending a clinic completed both instruments. Completed data were available for 116 patients, 51% female, mean age 56 and SD 20. howRU is shorter, has better readability statistics, a higher completion rate, a wider range of states used and a smaller ceiling effect than EQ-5D. The correlations of howRU with EQ-5D are similar to those of EQ-5D with other validated instruments.

Evaluation of a new short generic measure of health status: howRu.

BACKGROUND: Quality of life is paramount for patients and clinicians, but existing measures of health were not developed for routine use. OBJECTIVES: This paper describes the development and testing of a new generic tool for measuring health related quality of life (HRQoL) with direct comparison to the SF-12 Health Survey. METHODS: The new tool (howRu) has four items (discomfort, distress, disability and dependence), rated using four levels (none, a little, quite a lot and extreme), providing 256 possible states (4(4)); it has an aggregate scoring scheme with a range from 0 (worst) to 12 (best). Psychometric properties were examined in a telephone survey, which also recorded SF-12. RESULTS: The howRu script is shorter than SF-12 (45 words vs 294 words) and has better readability statistics. 2751 subjects, all with long-term conditions (average age 62, female 62.8%), completed the survey; 21.7% were at the ceiling (no reported problems on any dimension); 0.9% at the floor. Inter-item correlations, Cronbach's alpha and principal factor analysis suggest that a single summary score is appropriate. Correlations between the physical and mental components of both howRu and SF-12 were as expected. Across all patients the howRu score was correlated with PCS-12 (r=0.74), MCS-12 (r=0.49) and the sum of PCS-12 and MCS-12 (r=0.81). Subjects were classified by howRu score, primary condition, the number of conditions suffered, age group, duration of illness and area of residence. Across all six classifications, the correlation of the mean howRu score with the mean PCS-12 for each class was r=0.91, with MCS-12, r=0.45 and with the sum of PCS-12 and MCS-12, r=0.97. CONCLUSIONS: howRu is a new short generic measure of HRQoL, with good psychometric properties. It generates similar aggregate results to SF-12. It could provide a quick and easy way for practitioners to monitor the health of patients with long-term conditions.

Comparing outcomes of cataract surgery: challenges and opportunities.

BACKGROUND: There is an increasing demand for routine assessment of surgical outcomes. However, for assessments to be valid, it is essential to understand the influence of patient characteristics on outcomes. The VF-14 visual function instrument offers a possible means of monitoring outcomes of cataract surgery. This article examines lessons learned in the course of an attempt to do this. METHODS: One thousand and ninety-eight patients (41 per cent male and 59 per cent female) undergoing cataract extraction in 29 private hospitals within the British United Provident Association (BUPA) chain in the United Kingdom completed the VF-14 before and at 4 months following surgery. Outcome was measured in terms of absolute post-operative score achieved. The demographic factors associated with post-operative VF-14 score were examined using multivariate analysis, adjusting for baseline score. RESULTS: Women undergoing cataract extraction had worse pre-operative visual function than men. Post-operative VF-14 score was stable as the age of the patient increased, until age 85, after which it declined. The reduction in final outcome in older people was explained in part by their worse post-operative scores but also was associated with increasing age independent of pre-operative score. CONCLUSION: First, although many patients undergoing cataract extraction at an advanced age will achieve excellent results, older age does reduce the outcome that can be expected. Consequently, comparisons of performance of units or surgeons undertaking cataract surgery must take account of the age spectrum being treated. It is not enough simply to add a health status measure to an existing administrative database. Further research is needed to understand the reasons for the poorer outcomes at older ages, in particular the role of co-existing eye disease and development of data systems must take account of the additional information required to make appropriate adjustments.