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Impact of NICE guidance on rates of haemorrhage after tonsillectomy: an evaluation of guidance issued during an ongoing national tonsillectomy audit
  1. National Prospective Tonsillectomy Audit
  1. Dr D Cromwell, London School of Hygiene and Tropical Medicine, Public Health and Policy, Keppel St, London WC1E 7HT, UK; david.cromwell{at}


Background: The National Institute for Health and Clinical Excellence (NICE) issued guidance on surgical techniques for tonsillectomy during a national audit of surgical practice and postoperative complications.

Objective: To assess the impact of the guidance on tonsillectomy practice and outcomes.

Design: An interrupted time-series analysis of routinely collected Hospital Episodes Statistics data, and an analysis of longitudinal trends in surgical technique using data from the National Prospective Tonsillectomy Audit.

Participants: Patients undergoing tonsillectomy in English NHS hospitals between January 2002 and December 2004.

Main outcome measure: Postoperative haemorrhage within 28 days.

Results: The rate of haemorrhage increased by 0.5% per year from 2002, reaching 6.4% when the guidance was published. After publication, the rate of haemorrhage fell immediately to 5.7% (difference 0.7%: 95% CI −1.3% to 0.0%) and the rate of increase appeared to have stopped. Data from the National Prospective Tonsillectomy Audit showed that the fall coincided with a shift in surgical techniques, which was consistent with the guidance.

Conclusion: NICE guidance influenced surgical tonsillectomy technique and in turn produced an immediate fall in postoperative haemorrhage. The ongoing national audit and strong support from the surgical specialist association may have aided its implementation.

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  • This Audit was carried out by the Comparative Audit Group of the British Association of Otorhinolaryngologists—Head and Neck Surgeons and the Clinical Effectiveness Unit of The Royal College of Surgeons of England—London School of Hygiene and Tropical Medicine.

    Project Team: P Brown, Milton Keynes General NHS Trust, Milton Keynes; R Ryan, Northwick Park Hospital, London; M Yung, Ipswich Hospital NHS Trust, Ipswich; J Brown, L Copley, D Cromwell, J Horrocks, J Lewsey, D Lowe, A Luton, J van der Meulen (chair), Clinical Effectiveness Unit, The Royal College of Surgeons of England and London School of Hygiene and Tropical Medicine, London, UK.

    Steering Group: R T. Ramsden (chair), B Bingham, N Black, S Dixon/L Shurlock, L Flood, M Haggard, S Ludgate/J Hopper, J Oates, J Shotton, A Tomkinson, J Toner, J van der Meulen, G Weiner and P Woods.

    P Brown, R Ryan and M Yung initiated the Audit; J van der Meulen, J Browne, P Brown, R Ryan and M Yung developed the protocol for the Audit; D Lowe coordinated the data collection supported by L Copley and J Horrocks; J Lewsey, D Cromwell and L Copley analysed the data, supported by D Lowe and J van der Meulen; D Cromwell and J van der Meulen wrote the manuscript with contributions from all Project Team members; the Chair of the Steering Group and N Black commented on the penultimate draft.

  • Funding: The Audit was funded by the Department of Health (England) and the Department of Health, Social Services and Public Safety (No rthern Ireland). Both departments had no role in study design, data collection, data analysis and interpretation, the writing of the report, or the decision to submit the paper other than by being represented in the steering group. J van der Meulen is supported by a National Public Health Career Scientist Award, Department of Health—NHS R&D Programme UK.

  • Competing interests: None.

  • Ethics approval: The Audit was approved by the Northern and Yorkshire Multi-Centre Research Ethics Committee.

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