CINXE.COM

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML+RDFa 1.0//EN" "http://www.w3.org/MarkUp/DTD/xhtml-rdfa-1.dtd">     <html xml:lang="en" lang="en" dir="ltr" >    <head profile="http://www.w3.org/1999/xhtml/vocab"> <meta charset="utf-8"> <meta name="viewport" content="width=device-width, initial-scale=1.0"> <link rel=”apple-touch-icon-precomposed” href=”/sites/default/themes/bmj/the_bmj/img/icon.png”/> <meta http-equiv="X-UA-Compatible" content="IE=edge">  <link rel="dns-prefetch" href="//static.polldaddy.com" /> <link rel="dns-prefetch" href="//ajax.googleapis.com" /> <link rel="dns-prefetch" href="//crossmark-cdn.crossref.org" /> <link rel="dns-prefetch" href="//d1bxh8uas1mnw7.cloudfront.net" /> <link rel="dns-prefetch" href="//www.google.com" /> <link rel="dns-prefetch" href="//scholar.google.com" /> <meta http-equiv="Content-Type" content="text/html; charset=utf-8" /> <link rel="shortcut icon" href="https://www.bmj.com/sites/default/themes/bmj/the_bmj/favicon.ico" type="image/vnd.microsoft.icon" /> <link href="//netdna.bootstrapcdn.com/font-awesome/4.0.3/css/font-awesome.css" rel="stylesheet" media="all" type="text/css" /> <link rel="alternate" type="application/pdf" title="Full Text (PDF)" href="/content/388/bmj.q2868.full.pdf" /> <meta name="type" content="article" /> <meta name="category" content="editorial" /> <meta name="HW.identifier" content="/bmj/388/bmj.q2868.atom" /> <meta name="HW.pisa" content="bmj;388/jan09_5/q2868" /> <meta name="DC.Format" content="text/html" /> <meta name="DC.Language" content="en" /> <meta name="DC.Title" content="The cost of NICE appraisals … and other research" /> <meta name="DC.Identifier" content="10.1136/bmj.q2868" /> <meta name="DC.Date" content="2025-01-09" /> <meta name="DC.Publisher" content="British Medical Journal Publishing Group" /> <meta name="DC.Rights" content="Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions" /> <meta name="DC.AccessRights" content="restricted" /> <meta name="DC.Description" content="Tom Nolan reviews this week’s research Between 2000 and 2022 the National Institute for Health and Care Excellence (NICE) appraised 332 pharmaceuticals (with 83% getting positive recommendations). Had they rejected all of the drugs, England would have been £75.1 billion better off, and if that money had instead been spent on existing NHS services, England would have a healthier population: 1.25 million quality adjusted life years (QALYs) healthier. This is all according to a retrospective analysis published in the Lancet by a team of prominent health economists and policy experts. It estimated that new drugs generated 3.75 million QALYs across nearly 20 million patients, but 5 million additional QALYs would have been gained by spending the money on existing services. The authors call for NICE technology appraisal …" /> <meta name="DC.Contributor" content="Tom Nolan" /> <meta name="article:published_time" content="2025-01-09" /> <meta name="article:section" content="Opinion" /> <meta name="citation_title" content="The cost of NICE appraisals … and other research" /> <meta name="citation_abstract" lang="en" scheme="teaser" content="<p><b>Tom Nolan</b> reviews this week’s research</p>" /> <meta name="citation_journal_title" content="BMJ" /> <meta name="citation_publisher" content="British Medical Journal Publishing Group" /> <meta name="citation_publication_date" content="2025/01/09" /> <meta name="citation_mjid" content="bmj;388/jan09_5/q2868" /> <meta name="citation_id" content="388/jan09_5/q2868" /> <meta name="citation_public_url" content="https://www.bmj.com/content/388/bmj.q2868" /> <meta name="citation_abstract_html_url" content="https://www.bmj.com/content/388/bmj.q2868.abstract" /> <meta name="citation_full_html_url" content="https://www.bmj.com/content/388/bmj.q2868.full" /> <meta name="citation_pdf_url" content="https://www.bmj.com/content/bmj/388/bmj.q2868.full.pdf" /> <meta name="citation_issn" content="1756-1833" /> <meta name="citation_journal_abbrev" content="BMJ" /> <meta name="citation_doi" content="10.1136/bmj.q2868" /> <meta name="citation_pmid" content="39788617" /> <meta name="citation_volume" content="388" /> <meta name="citation_article_type" content="Editorial" /> <meta name="citation_section" content="Opinion" /> <meta name="citation_author" content="Tom Nolan" /> <meta name="citation_author_institution" content="The BMJ, London" /> <meta name="twitter:title" content="The cost of NICE appraisals … and other research" /> <meta name="twitter:card" content="summary" /> <meta name="twitter:description" content="Tom Nolan reviews this week’s research Between 2000 and 2022 the National Institute for Health and Care Excellence (NICE) appraised 332 pharmaceuticals (with 83% getting positive recommendations). Had they rejected all of the drugs, England would have been £75.1 billion better off, and if that money had instead been spent on existing NHS services, England would have a healthier population: 1.25 million quality adjusted life years (QALYs) healthier. This is all according to a retrospective analysis published in the Lancet by a team of prominent health economists and policy experts. It estimated that new drugs generated 3.75 million QALYs across nearly 20 million patients, but 5 million additional QALYs would have been gained by spending the money on existing services. The authors call for NICE technology appraisal …" /> <meta name="og-title" property="og:title" content="The cost of NICE appraisals … and other research" /> <meta name="og-url" property="og:url" content="https://www.bmj.com/content/388/bmj.q2868" /> <meta name="og-site-name" property="og:site_name" content="The BMJ" /> <meta name="og-description" property="og:description" content="Tom Nolan reviews this week’s research Between 2000 and 2022 the National Institute for Health and Care Excellence (NICE) appraised 332 pharmaceuticals (with 83% getting positive recommendations). Had they rejected all of the drugs, England would have been £75.1 billion better off, and if that money had instead been spent on existing NHS services, England would have a healthier population: 1.25 million quality adjusted life years (QALYs) healthier. This is all according to a retrospective analysis published in the Lancet by a team of prominent health economists and policy experts. It estimated that new drugs generated 3.75 million QALYs across nearly 20 million patients, but 5 million additional QALYs would have been gained by spending the money on existing services. The authors call for NICE technology appraisal …" /> <meta name="og-type" property="og:type" content="article" /> <meta name="og:image" property="og:image" content="https://www.bmj.com/sites/default/files/highwire/bmj/388/8457.cover-source.jpg"/> <meta name="twitter:card" content="summary_large_image"><meta name="twitter:image" property="twitter:image" content="https://www.bmj.com/sites/default/files/sites/defautl/files/attachments/bmj-article/2025/01/journals.png"><meta name="twitter:title" content="The cost of NICE appraisals … and other research" /><link rel="alternate" type="text/plain" title="Full Text (Plain)" href="/content/388/bmj.q2868.full.txt" /> <script>window.dataLayer = window.dataLayer || [];window.dataLayer.push({"page":{"hwTitle":"The cost of NICE appraisals \u2026 and other research","hwUrl":"https://www.bmj.com/content/388/bmj.q2868","hwPath":"/content/388/bmj.q2868","hwType":"journal page"},"user":{"hwMemberID":"","hwLoggedIntoInstitutionID":"","hwLoggedIntoInstitution":"","hwAccessUsageTerms":"guest","hwRegisteredUser":"no","hwHasFullTextAccess":"yes","hwEntitled":"no","mail":"e3b0c44298fc1c149afbf4c8996fb92427ae41e4649b934ca495991b7852b855"},"content":{"hwIssueDate":"2025-01-09","hwIssueDateTime":"2025-01-09 10:30:47","hwPublicationDate":"2025-01-09","hwPublicationDateTime":"2025-01-09 10:30:47","hwNlmArticleType":"editorial","hwDOI":"10.1136/bmj.q2868","hwAuthors":"Tom Nolan","hwContributors":"","hwIsEarlyRelease":"no","hwEissn":"1756-1833","hwPissn":"","hwVolume":"388","hwIssue":"","hwArticleType":"Opinion","hwTabView":"main_tab","hwViewType":"full","hwAccessType":"Free","hwOpenAccess":"no","hwFreeAccess":"yes","hwTaxonomy":"","hwCorpusCode":"bmj","hwType":"article","hwSubtitle":null,"hwOverline":null,"hwPisaId":"bmj;388/jan09_5/q2868","hwFirstPage":null,"hwLastPage":null,"hwIsLatestVersion":"yes","hwIsCurrentIssue":"no","hwIsOpenIssue":"no","hwHasFullText":"yes","hwHasPDF":"yes","hwParentTitle":"BMJ: 388","hwElectronicPubDate":"2025-01-09","hwElectronicPubDateTime":"2025-01-09 10:30:47"}}); //--><!]]></script> <meta name="generator" content="Drupal 7 (http://drupal.org)" /> <link rel="canonical" href="https://www.bmj.com/content/388/bmj.q2868" /> <link rel="shortlink" href="https://www.bmj.com/node/1105257" /> <meta name="twitter:card" content="summary" /> <meta name="twitter:url" content="https://www.bmj.com/content/388/bmj.q2868" /> <meta name="twitter:title" content="The cost of NICE appraisals … and other research" /> <title>The cost of NICE appraisals … and other research | The BMJ</title>   <link type="text/css" rel="stylesheet" href="https://www.bmj.com/sites/default/files/advagg_css/css__FiHqHoPUdv6CHw5dUEIfFV7jpYTgBb1JUncssjaxHyo__1sncCi_mkZlnZk1lpMbS0Ko6gldf3d0A0WKzvsoV5h4__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.css" media="all" /> <link type="text/css" rel="stylesheet" href="//cdn.jsdelivr.net/qtip2/2.2.1/jquery.qtip.min.css" media="all" /> <link type="text/css" rel="stylesheet" href="https://www.bmj.com/sites/default/files/advagg_css/css__Z9fgw99JqFKGwDuQuLtZOeq23E9uc0mK4qxQe7ZDZo8__ToVWhf1nLySNMRN6kHdMWHAxZT2jAPLuldI3WqOcr0g__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.css" media="all" /> <link type="text/css" rel="stylesheet" href="https://www.bmj.com/sites/default/files/advagg_css/css__hcEfBsSfdZ2na-rT9Jhk7K2mHyy5KBdPKm6ia_F7MYU__4716zpuGoj4DfVIEENbeOWgAOX_pf_t16EI4fvJGo7A__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.css" media="print" /> <link type="text/css" rel="stylesheet" href="https://www.bmj.com/sites/default/files/advagg_css/css__b-tWEqg3_twqP_ufdNXyA5V14StJgBdiIxG1UIi0LYc__3z5eyFP7TvyPE6DkwNj3xM94b3mZNfr4lSWEChDxsvU__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.css" media="screen" /> <link type="text/css" rel="stylesheet" href="https://www.bmj.com/sites/default/files/advagg_css/css__-BkZ71IF4pBXmZfP4vYyswWdIhuaKktrUUQ4i2vtUVo__0i_0YcYkMECNn0z7FdhNoJ8gLWleqnTtjnHRAmLijvc__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.css" media="all" /> <link href="/sites/default/themes/bmj/the_bmj/css/fonts.css" rel="stylesheet" media="all" type="text/css"> <style media="screen" type="text/css"> .page-news #latest-blogs h2.pane-title, .bootstrap-threecol-4-4-4 #latest-blogs h2.pane-title { width: 153px !important; } #navigation-wrapper #navigation .main-navigation .menu.nav>li.last { display: block !important; } </style>  <script src="https://cdn.cookielaw.org/consent/tcf.stub.js"" type="text/javascript" charset="UTF-8"></script>  <script src="https://cookie-cdn.cookiepro.com/scripttemplates/otSDKStub.js" type="text/javascript" charset="UTF-8" data-domain-script="565e50dd-f6e9-46d6-91cd-5c40a270264f"></script> <script type="text/javascript"> function OnetrustAdsConsent(){ if(googletag.apiReady){ //console.log("GoogleTag API ready") googletag.pubads().disableInitialLoad(); if(OptanonActiveGroups.match(/,4,/)){ googletag.pubads().setRequestNonPersonalizedAds(0); //googletag.pubads().refresh(); } else{ googletag.pubads().setRequestNonPersonalizedAds(1); // googletag.pubads().refresh(); } } else{ OnetrustAdsConsent(); } } function OptanonWrapper() { OnetrustAdsConsent(); } </script>  <script src="https://www.bmj.com/sites/default/files/advagg_js/js__wQYYWLUWErxls_q7a6fk-aoyATq9qiA4xZWj_nuQWIY__idPe4msTM3VewG9y-TVQn9f3_mIGnqFi2cuHIkTOFDs__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.js"></script> <script src="//cdn.jsdelivr.net/qtip2/2.2.1/jquery.qtip.min.js"></script> <script src="https://www.bmj.com/sites/default/files/advagg_js/js__0YTPIamlhRKP1C291geHzRxybsKbjQDTlsgtfmRDp-k___nGVJm_2vQH-OlkAZ4KJWyWRqF2DVgEgc5PAkG2TT7s__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.js"></script> <script src="https://www.google.com/recaptcha/api.js?hl=en&render=explicit&onload=drupalRecaptchaOnload"></script> <script src="https://www.bmj.com/sites/default/files/advagg_js/js__PgTqDXPxlq-HyomloHpN-WrBe9DkY3SNs9BDw85yP4I__rTeO0iPp3oLbE6MHxqppxss6-RxXMLj5_Q8F0SjcF1g__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.js"></script> <script src="https://www.bmj.com/sites/default/files/advagg_js/js__UUwMbpErCBHAQQqH_Cxzi20oSmMoxcbKeYV6qoD70qc__skFUSUohWkyaYdPjJ2LSEF0xKVUuQTqmOxG-9og_468__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.js"></script> <script src="https://www.bmj.com/sites/default/files/advagg_js/js__7tN13Z_jEtWpAlHc4vWZWrFePCNhuslRS59mkCehpG8__hIhm4v2jj35Ek3jyTBAduhmH_HOFYDYH-VH1JBUELWg__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.js"></script> <script>var _prum=[['id', '612e3f1b1733500011000061'], ['mark', 'firstbyte', (new Date()).getTime()]]; (function() { var s=document.getElementsByTagName('script')[0], p=document.createElement('script'); p.async='async'; p.src='//rum-static.pingdom.net/prum.min.js';s.parentNode.insertBefore(p,s);})();</script> <script>if(typeof window.MathJax === "undefined") window.MathJax = { menuSettings: { zoom: "Click" } };</script> <script async="async" src="https://scholar.google.com/scholar_js/casa.js"></script> <script>jQuery.extend(Drupal.settings,{"basePath":"\/","pathPrefix":"","ajaxPageState":{"theme":"the_bmj","theme_token":"38Z2YoXEKGJIAYBSVee0l6D3QG-xrPx1frPBIYkJ7Y4"},"colorbox":{"opacity":"0.85","current":"{current} of {total}","previous":"\u00ab Prev","next":"Next \u00bb","close":"Close","maxWidth":"98%","maxHeight":"98%","fixed":true,"mobiledetect":true,"mobiledevicewidth":"480px"},"highwire":{"nid":"1105257","apath":"\/bmj\/388\/bmj.q2868.atom","pisa":"bmj;388\/jan09_5\/q2868","ac":{"\/bmj\/388\/bmj.q2868.atom":{"access":{"full":true,"reprint":true},"pisa_id":"","apath":"\/bmj\/388\/bmj.q2868.atom","jcode":"bmj"},"bmj;388\/jan09_5\/q2868":{"access":{"full":true},"pisa_id":"bmj;388\/jan09_5\/q2868","apath":"","jcode":"bmj"}},"processed":["highwire_math"],"markup":[{"requested":"long","variant":"full-text","view":"full","pisa":"bmj;388\/jan09_5\/q2868"}],"trendmd":{"trendmd-suggestions":"{\u0022element\u0022:\u0022#trendmd-suggestions\u0022,\u0022track_id\u0022:\u002224814\u0022}"},"dataLayer":"{\u0022page\u0022:{\u0022hwTitle\u0022:\u0022The cost of NICE appraisals \\u2026 and other research\u0022,\u0022hwUrl\u0022:\u0022https:\\\/\\\/www.bmj.com\\\/content\\\/388\\\/bmj.q2868\u0022,\u0022hwPath\u0022:\u0022\\\/content\\\/388\\\/bmj.q2868\u0022,\u0022hwType\u0022:\u0022journal page\u0022},\u0022user\u0022:{\u0022hwMemberID\u0022:\u0022\u0022,\u0022hwLoggedIntoInstitutionID\u0022:\u0022\u0022,\u0022hwLoggedIntoInstitution\u0022:\u0022\u0022,\u0022hwAccessUsageTerms\u0022:\u0022guest\u0022,\u0022hwRegisteredUser\u0022:\u0022no\u0022,\u0022hwHasFullTextAccess\u0022:\u0022yes\u0022,\u0022hwEntitled\u0022:\u0022no\u0022,\u0022mail\u0022:\u0022e3b0c44298fc1c149afbf4c8996fb92427ae41e4649b934ca495991b7852b855\u0022},\u0022content\u0022:{\u0022hwIssueDate\u0022:\u00222025-01-09\u0022,\u0022hwIssueDateTime\u0022:\u00222025-01-09 10:30:47\u0022,\u0022hwPublicationDate\u0022:\u00222025-01-09\u0022,\u0022hwPublicationDateTime\u0022:\u00222025-01-09 10:30:47\u0022,\u0022hwNlmArticleType\u0022:\u0022editorial\u0022,\u0022hwDOI\u0022:\u002210.1136\\\/bmj.q2868\u0022,\u0022hwAuthors\u0022:\u0022Tom Nolan\u0022,\u0022hwContributors\u0022:\u0022\u0022,\u0022hwIsEarlyRelease\u0022:\u0022no\u0022,\u0022hwEissn\u0022:\u00221756-1833\u0022,\u0022hwPissn\u0022:\u0022\u0022,\u0022hwVolume\u0022:\u0022388\u0022,\u0022hwIssue\u0022:\u0022\u0022,\u0022hwArticleType\u0022:\u0022Opinion\u0022,\u0022hwTabView\u0022:\u0022main_tab\u0022,\u0022hwViewType\u0022:\u0022full\u0022,\u0022hwAccessType\u0022:\u0022Free\u0022,\u0022hwOpenAccess\u0022:\u0022no\u0022,\u0022hwFreeAccess\u0022:\u0022yes\u0022,\u0022hwTaxonomy\u0022:\u0022\u0022,\u0022hwCorpusCode\u0022:\u0022bmj\u0022,\u0022hwType\u0022:\u0022article\u0022,\u0022hwSubtitle\u0022:null,\u0022hwOverline\u0022:null,\u0022hwPisaId\u0022:\u0022bmj;388\\\/jan09_5\\\/q2868\u0022,\u0022hwFirstPage\u0022:null,\u0022hwLastPage\u0022:null,\u0022hwIsLatestVersion\u0022:\u0022yes\u0022,\u0022hwIsCurrentIssue\u0022:\u0022no\u0022,\u0022hwIsOpenIssue\u0022:\u0022no\u0022,\u0022hwHasFullText\u0022:\u0022yes\u0022,\u0022hwHasPDF\u0022:\u0022yes\u0022,\u0022hwParentTitle\u0022:\u0022BMJ: 388\u0022,\u0022hwElectronicPubDate\u0022:\u00222025-01-09\u0022,\u0022hwElectronicPubDateTime\u0022:\u00222025-01-09 10:30:47\u0022}}"},"jnl_bmj_infographic":{"infographic_tab":false},"custom_search":{"form_target":"_self","solr":1},"panel_ajax_tab":{"path":"sites\/all\/modules\/contrib\/panels_ajax_tab"},"instances":"{\u0022highwire_abstract_tooltip\u0022:{\u0022content\u0022:{\u0022text\u0022:\u0022\u0022},\u0022style\u0022:{\u0022tip\u0022:{\u0022width\u0022:20,\u0022height\u0022:20,\u0022border\u0022:1,\u0022offset\u0022:0,\u0022corner\u0022:true},\u0022classes\u0022:\u0022qtip-custom hw-tooltip hw-abstract-tooltip qtip-shadow qtip-rounded\u0022,\u0022classes_custom\u0022:\u0022hw-tooltip hw-abstract-tooltip\u0022},\u0022position\u0022:{\u0022at\u0022:\u0022right center\u0022,\u0022my\u0022:\u0022left center\u0022,\u0022viewport\u0022:true,\u0022adjust\u0022:{\u0022method\u0022:\u0022shift\u0022}},\u0022show\u0022:{\u0022event\u0022:\u0022mouseenter click \u0022,\u0022solo\u0022:true},\u0022hide\u0022:{\u0022event\u0022:\u0022mouseleave \u0022,\u0022fixed\u0022:1,\u0022delay\u0022:\u0022100\u0022}},\u0022highwire_author_tooltip\u0022:{\u0022content\u0022:{\u0022text\u0022:\u0022\u0022},\u0022style\u0022:{\u0022tip\u0022:{\u0022width\u0022:15,\u0022height\u0022:15,\u0022border\u0022:1,\u0022offset\u0022:0,\u0022corner\u0022:true},\u0022classes\u0022:\u0022qtip-custom hw-tooltip hw-author-tooltip qtip-shadow qtip-rounded\u0022,\u0022classes_custom\u0022:\u0022hw-tooltip hw-author-tooltip\u0022},\u0022position\u0022:{\u0022at\u0022:\u0022top center\u0022,\u0022my\u0022:\u0022bottom center\u0022,\u0022viewport\u0022:true,\u0022adjust\u0022:{\u0022method\u0022:\u0022\u0022}},\u0022show\u0022:{\u0022event\u0022:\u0022mouseenter \u0022,\u0022solo\u0022:true},\u0022hide\u0022:{\u0022event\u0022:\u0022mouseleave \u0022,\u0022fixed\u0022:1,\u0022delay\u0022:\u0022100\u0022}},\u0022highwire_reflinks_tooltip\u0022:{\u0022content\u0022:{\u0022text\u0022:\u0022\u0022},\u0022style\u0022:{\u0022tip\u0022:{\u0022width\u0022:15,\u0022height\u0022:15,\u0022border\u0022:1,\u0022mimic\u0022:\u0022top center\u0022,\u0022offset\u0022:0,\u0022corner\u0022:true},\u0022classes\u0022:\u0022qtip-custom hw-tooltip hw-ref-link-tooltip qtip-shadow qtip-rounded\u0022,\u0022classes_custom\u0022:\u0022hw-tooltip hw-ref-link-tooltip\u0022},\u0022position\u0022:{\u0022at\u0022:\u0022bottom left\u0022,\u0022my\u0022:\u0022top left\u0022,\u0022viewport\u0022:true,\u0022adjust\u0022:{\u0022method\u0022:\u0022flip\u0022}},\u0022show\u0022:{\u0022event\u0022:\u0022mouseenter \u0022,\u0022solo\u0022:true},\u0022hide\u0022:{\u0022event\u0022:\u0022mouseleave \u0022,\u0022fixed\u0022:1,\u0022delay\u0022:\u0022100\u0022}}}","qtipDebug":"{\u0022leaveElement\u0022:0}","ws_fl":{"width":100,"height":21},"jnl_bmj":{"container_id_share":"article-share-modal","container_id_response":"article-response-modal"},"urlIsAjaxTrusted":{"\/content\/388\/bmj.q2868?tab=article-alert":true,"\/content\/388\/bmj.q2868":true,"\/login":true},"orcidLogo":{"svg":"\/sites\/default\/themes\/bmj\/the_bmj\/img\/vector_iD_icon.svg"},"bootstrap":{"anchorsFix":"1","anchorsSmoothScrolling":"1","popoverEnabled":"1","popoverOptions":{"animation":1,"html":0,"placement":"right","selector":"","trigger":"click","title":"","content":"","delay":0,"container":"body"},"tooltipEnabled":"1","tooltipOptions":{"animation":1,"html":0,"placement":"auto left","selector":"","trigger":"hover focus","delay":0,"container":"body"}}});</script> <script type="text/javascript"> window.dataLayer = window.dataLayer || []; </script>  <script type="text/javascript">var DC = { Date : "", subject : "" };var ga_article_category = "Opinion";var ga_article_page_type = "editorial";var ga_article_pub_year = "2025";var ga_customer_number = "";var ga_user_type = "";DC.Date = "2025-01-09";DC.subject = "";</script>   <style>.async-hide { opacity: 0 !important} </style> <script>(function(a,s,y,n,c,h,i,d,e){s.className+=' '+y;h.start=1*new Date; h.end=i=function(){s.className=s.className.replace(RegExp(' ?'+y),'')}; (a[n]=a[n]||[]).hide=h;setTimeout(function(){i();h.end=null},c);h.timeout=c;})(window,document.documentElement,'async-hide','dataLayer',4000,{'GTM-NF7HCLL':true});</script>   <script>var googletag = window.googletag || {cmd: []};</script> <script async src="//securepubads.g.doubleclick.net/tag/js/gpt.js"></script> <script> var topBottomSizes = [ [970,250],[970,90],[728,90],[468,60],[300,50],[320,100] ]; var mpuSizes = [ [300,250],[300,600],[600,600], ]; //googletag.cmd.push(function() { googletag.display('div-gpt-ad-7326006-1'); }); googletag.cmd.push(function() { googletag.defineSlot('/21798771943/BMJ.com_HomePage_TOPBanner', topBottomSizes,'div-gpt-ad-7326006-1').addService(googletag.pubads()).setTargeting("pgid", "pubgrade_lib_disabled"); googletag.defineSlot('/21798771943/BMJ.com_HomePage_MPU1', mpuSizes, 'div-gpt-ad-7326006-2').addService(googletag.pubads()); googletag.defineSlot('/21798771943/BMJ.com_HomePage_MPU2', mpuSizes, 'div-gpt-ad-7326006-3').addService(googletag.pubads()); googletag.defineSlot('/21798771943/BMJ.com_HomePage_BOTTOM', topBottomSizes, 'div-gpt-ad-7326006-4').addService(googletag.pubads()); googletag.pubads().setTargeting('url', window.parent.location.pathname); // Some examples of ways to enable below. Normally, only one of these // methods should be used. // A) Enable with defaults. googletag.pubads().enableLazyLoad({ fetchMarginPercent: 0, // Fetch slots within 1 viewports. renderMarginPercent: 0, // Render slots within 1 viewports. mobileScaling: 2.0 // Double the above values on mobile. }); googletag.enableServices(); }); </script> <script> let cookies = parseCookies(); let bmj_uuid = cookies.bmj_uuid; let bmj_ppid = cookies.bmj_ppid; window.dataLayer = window.dataLayer || []; function checkUserLoginStatus(dataLayer) { const userMail = dataLayer.find((item) => item.user)?.user?.mail; if (!userMail) { return false; } return userMail !== anonMailId; } const anonMailId = 'e3b0c44298fc1c149afbf4c8996fb92427ae41e4649b934ca495991b7852b855'; let nonAnonMailId = ((dataLayer.find(item => item.user)?.user)?.mail) === anonMailId ? null : (dataLayer.find(item => item.user)?.user)?.mail; let userId = ((dataLayer.find(item => item.user)?.user)?.['data-ics']) ?? ((dataLayer.find(item => item.user)?.user)?.mail && nonAnonMailId) ?? bmj_ppid ?? bmj_uuid; document.cookie = 'bmj_ppid=' + userId + '; domain=.bmj.com; path=/; max-age=31622400; SameSite=None; Secure'; googletag.cmd.push(function() { googletag.pubads().setPublisherProvidedId(userId); googletag.pubads().setTargeting("islogged", checkUserLoginStatus(dataLayer) ? "true" : "false"); googletag.enableServices(); }); window.dataLayer.push({ 'bmj_uuid': bmj_uuid }); </script> </head>   <script type="text/javascript">(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-NF7HCLL');</script>  </head>  <body class="html not-front not-logged-in no-sidebars page-node page-node- page-node-1105257 node-type-highwire-article 1 Opinion" >  <noscript><iframe src="//www.googletagmanager.com/ns.html?id=GTM-NF7HCLL" height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript>  <div id="skip-link"> <a href="#main-content" class="element-invisible element-focusable">Skip to main content</a> </div> <div id="wrapper-outer"> <div id="wrapper"> <header> <div class="bmj-disclaimer"> <p>Intended for healthcare professionals</p> </div> <div class="ad-leaderboard"> <div id='div-gpt-ad-7326006-1'> <script> googletag.cmd.push(function() { googletag.display('div-gpt-ad-7326006-1'); }); </script> </div> </div>   <div id="top-nav" role="navigation" class="navbar navbar-static-top"> <div class="container"> <div id="userbar-status"> <ul id="status"> <li class="user-status-link user-status-subscribe phone-menu-item"> <a href="/us/subscribe">Subscribe</a> </li> <li class="user-status-myaccount phone-menu-item"> <div class="btn-group has-submenu"> <a class="btn dropdown-toggle" aria-expanded="false" aria-haspopup="true" data-toggle="dropdown" href="#" > My Account <span class="caret" aria-expanded="true"></span> </a> <ul class="jnl-bmj-user-my-account dropdown-menu"><li class="0 first last"><a href="//myaccount.bmj.com/myaccount/account/hw-registration.html">My email alerts</a></li> </ul></div> </li> <li class="user-status-bma phone-menu-item"> <a href="//bmjverification.bma.org.uk/validate/userdetails?url=https://www.bmj.com/content/388/bmj.q2868?sso=">BMA member login</a> </li> <div class="btn-group has-submenu"> <a class="btn dropdown-toggle" aria-expanded="false" aria-haspopup="true" data-toggle="dropdown" href="#" > Login <span class="caret" aria-expanded="true"></span> </a> <ul class="jnl-bmj-user-signin-popup dropdown-menu"><li class="0 first last"><span><form action="/login" method="post" id="jnl-bmj-user-login-form" accept-charset="UTF-8"><div><input type="hidden" name="form_build_id" value="form-Rh_ui95nKlF6NgCZULByGMS_jDFr-DXfGoJwg64Llkc" /> <input type="hidden" name="form_id" value="jnl_bmj_user_login_form" /> <div class="form-type-textfield form-item-name form-item form-group"> <label for="article-p-name">Username <span class="form-required" title="This field is required.">*</span></label> <input class="form-control form-text required" type="text" id="article-p-name" name="name" value="" size="15" maxlength="60" /> </div> <div class="form-type-password form-item-pass form-item form-group"> <label for="article-p-pass">Password <span class="form-required" title="This field is required.">*</span></label> <input class="form-control form-text required" type="password" id="article-p-pass" name="pass" size="15" maxlength="128" /> </div> <div class="link"><div id="edit-forgot" class="form-type-item form-item form-group"> <label for="edit-forgot"><a href="https://www.bmj.com/user/password" title="Retrieve your credentials.">Forgot your log in details?</a> </label> </div> </div><div class="link"><div id="edit-activate" class="form-type-item form-item form-group"> <label for="edit-activate"><a href="//journals.bmj.com/cgi/activate/basic">Need to activate</a> </label> </div> </div><input class="btn form-submit" type="submit" id="edit-submit--9" name="op" value="Login" /><div id="edit-message--3" class="form-type-item form-item form-group"> </div> <hr /><div id="edit-bma-members" class="form-type-item form-item form-group"> <label for="edit-bma-members"><a href="//bmjverification.bma.org.uk/validate/userdetails?url=https%3A//www.bmj.com/content/388/bmj.q2868%3Fsso%3D" title="Log in here if you are a BMA member.">BMA Member Log In</a> </label> </div> <div id="edit-athens" class="form-type-item form-item form-group"> <label for="edit-athens"><a href="https://openathens-sp.highwire.org/session/init?entityID=https%3A//idp.eduserv.org.uk/openathens&subcode=bmjjournals&hw-shib-return-uri=https%253A%252F%252Fwww.bmj.com%252Fcontent%252F388%252Fbmj.q2868">Log in via OpenAthens</a> </label> </div> <div id="edit-shibboleth" class="form-type-item form-item form-group"> <label for="edit-shibboleth"><a href="/login/shibboleth?uri=https%3A%2F%2Fwww.bmj.com%2Fcontent%2F388%2Fbmj.q2868&subcode=bmjjournals&env=prod">Log in via your institution</a> </label> </div> </div></form></span></li> </ul></div> </ul> <div id="userbar"> <div class="region region-userbar"> <section id="block-panels-mini-jnl-bmj-country-portal-switcher" class="block block-panels-mini clearfix"> <div class="panel-display panel-1col clearfix" id="mini-panel-jnl_bmj_country_portal_switcher"> <div class="panel-panel panel-col"> <div><div class="panel-pane pane-country-switcher" > <div class="pane-content"> <span class="country-label">Edition: </span> <div class="btn-group has-submenu"> <a class="btn dropdown-toggle" aria-expanded="false" aria-haspopup="true" data-toggle="dropdown" href="#" id=country-switcher> US <span class="caret" aria-expanded="true"></span> </a> <ul class="jnl-bmj-country-portal-country-switcher dropdown-menu"><li class="0 first"><a href="/bmj_countries/switch/uk?destination=node/1105257">UK</a></li> <li class="1"><a href="/bmj_countries/switch/india?destination=node/1105257">South Asia</a></li> <li class="2 last"><a href="/bmj_countries/switch/international?destination=node/1105257">International</a></li> </ul></div> </div> </div> </div> </div> </div> </section>  </div> </div> <div id="cmp-link"> <div class="pane-content"> <span class="country-label"><a href="/company?int_source=tbmj&int_medium=header&int_campaign=URLswitch">Our company</a></span> </div> </div> </div> </div> </div>  <div id="main-nav" data-spy="affix" data-offset-top="125"> <div class="primary-navigation-bar"> <div id="navigation-wrapper"> <div class="container">  <a href="#" id="btn-nav" class=""> <span class="sr-only">Toggle navigation</span> </a>  <a class="logo navbar-btn pull-left" href="/" title="Home">  <div class="bmj-logo">The BMJ logo</div> </a> <div class="ie6-site-map"><a href="/sitemap">Site map</a></div>  <div class="main-nav-search"> <div id="search">  <a href="#" class="dropdown-toggle" data-toggle="dropdown" title="Search"><div class="search"><em class="fa fa-search" alt="Search"></em><span class="search-label">Search</span></div></a> <div class="dropdown-menu"> <div class="header-search-form container"> <div class="searchbar"> <div class="region region-search-block"> <section id="block-search-form" class="block block-search clearfix"> <form class="search-form form-search content-search" action="/content/388/bmj.q2868" method="post" id="search-block-form" accept-charset="UTF-8"><div><div> <h2 class="element-invisible">Search form</h2> <div class="input-group"><input title="Enter the terms you wish to search for." class="container-inline input-append form-control form-text" placeholder="Search The BMJ" type="text" id="edit-search-block-form--2" name="search_block_form" value="" size="15" maxlength="128" /><span class="input-group-btn"><button type="submit" class="btn btn-default">Search</button></span></div><button class="element-invisible btn btn-primary btn btn-primary form-button" type="submit" id="edit-submit--4" name="op" value="Search">Search</button><input type="hidden" name="form_build_id" value="form-ScVHs8r43Ma_7OnVwHUUFTJHzvzF3JTYdGof0OdK8D4" /> <input type="hidden" name="form_id" value="search_block_form" /> <input type="hidden" name="custom_search_paths" value="search/advanced/[key]" /> </div> </div></form> </section>  </div> </div> <div class="advanced-search"> <ul class="list-inline"> <li><a href="/search/advanced" title="Advanced search">Advanced search</a></li> <li><a href="/rapid-responses" title="Search responses">Search responses</a></li> <li><a href="//blogs.bmj.com/bmj/" title="Search blogs">Search blogs</a></li> </ul> </div> </div> </div> </div> </div>  <a href="#" id="toggle-mobile-top-nav"> <span class="fa fa-cog"></span> <span class="sr-only">Toggle top menu</span> </a>  <div id="navigation" class="navigation">  <div class="main-navigation"> <nav role="navigation"> <ul class="menu nav navbar-nav"><li class="first leaf"><a href="/coronavirus">covid-19</a></li> <li class="expanded dropdown"><a href="/us/research" data-target="#" class="dropdown-toggle" data-toggle="dropdown">Research</a><ul class="dropdown-menu"><li class="first leaf"><a href="/us/research">At a glance</a></li> <li class="leaf"><a href="/us/research/research">Research papers</a></li> <li class="leaf"><a href="/us/research/research%20methods%20%26amp%3B%20reporting">Research methods and reporting</a></li> <li class="last leaf"><a href="/us/research/minerva">Minerva</a></li> </ul></li> <li class="expanded dropdown"><a href="/us/education" data-target="#" class="dropdown-toggle" data-toggle="dropdown">Education</a><ul class="dropdown-menu"><li class="first leaf"><a href="/us/education">At a glance</a></li> <li class="leaf"><a href="/us/education/clinical%20review">Clinical reviews</a></li> <li class="leaf"><a href="/us/education/practice">Practice</a></li> <li class="leaf"><a href="/us/education/minerva">Minerva</a></li> <li class="leaf"><a href="/us/education/endgames">Endgames</a></li> <li class="leaf"><a href="/specialties/state-art">State of the art</a></li> <li class="leaf"><a href="/specialties/what-your-patient-thinking">What your patient is thinking</a></li> <li class="leaf"><a href="/rapid-recommendations">Rapid recommendations</a></li> <li class="last leaf"><a href="/student">Student</a></li> </ul></li> <li class="expanded dropdown"><a href="/us/news" data-target="#" class="dropdown-toggle" data-toggle="dropdown">News & Views</a><ul class="dropdown-menu"><li class="first leaf"><a href="/us/news">At a glance</a></li> <li class="leaf"><a href="/us/news/news?category=News">News</a></li> <li class="leaf"><a href="/us/news/feature">Features</a></li> <li class="leaf"><a href="/us/news/editorial">Editorials</a></li> <li class="leaf"><a href="/us/news/analysis">Analysis</a></li> <li class="leaf"><a href="/news/opinion">Opinion</a></li> <li class="leaf"><a href="/us/news/head%20to%20head">Head to head</a></li> <li class="leaf"><a href="/us/news/editor%27s%20choice">Editor's choice</a></li> <li class="leaf"><a href="/us/news/letter">Letters</a></li> <li class="leaf"><a href="/us/news/obituary">Obituaries</a></li> <li class="leaf"><a href="/careers-articles">Careers</a></li> <li class="last leaf"><a href="/rapid-responses">Rapid responses</a></li> </ul></li> <li class="expanded dropdown"><a href="/campaigns" data-target="#" class="dropdown-toggle" data-toggle="dropdown">Campaigns</a><ul class="dropdown-menu"><li class="first leaf"><a href="/campaigns">At a glance</a></li> <li class="leaf"><a href="/better-evidence">Better evidence</a></li> <li class="leaf"><a href="/campaign/climate-emergency">Climate change</a></li> <li class="leaf"><a href="/divestment">Divestment from fossil fuels</a></li> <li class="leaf"><a href="/campaign/patient-partnership">Patient and public partnership</a></li> <li class="last leaf"><a href="/too-much-medicine">Too much medicine</a></li> </ul></li> <li class="last expanded dropdown"><a href="/careers" data-target="#" class="dropdown-toggle" data-toggle="dropdown">Jobs</a><ul class="dropdown-menu"><li class="first leaf"><a href="/careers">Doctor Jobs UK</a></li> <li class="leaf"><a href="/careers/jobs/hospital/">Hospital Jobs UK</a></li> <li class="leaf"><a href="/careers/jobs/general-practice/">GP Jobs UK</a></li> <li class="last leaf"><a href="/careers/jobs/international/">International Jobs</a></li> </ul></li> </ul>  <div class="second-navigation"> <ul class="secondary-nav" id=""> <li class="even"><a href="/archive" class="">Archive</a></li> <li class="odd"><a href="/about-bmj/resources-authors" class="">For authors</a></li> <li class="odd last"><a href="http://hosted.bmj.com" class="">Hosted</a></li> </ul> </div> </nav> </div> </div> </div> </div> </div> </div> </header> <div class="main-container container" id="page">   <div class="row"> <section class="col-sm-12" > <ol class="breadcrumb"><li class="first"><a href="/us/news">News & Views</a></li> <li>The cost of NICE...</li> <li class="active last">The cost of NICE appraisals … and other research</li> </ol> <a id="main-content"></a> <div class="region region-content"> <section id="block-system-main" class="block block-system clearfix"> <div class="panel-display" > <div class="hero"> <div class="hero-wrapper"> <div class="hero-content" style="position: relative; left: 0px; top: 35.5px;"> </div>  </div>  </div>  <div class="row"> <div class="left-content col-xs-12 col-sm-8 col-md-8 col-lg-8"> <article> <div class="panel-pane pane-highwire-article-citation" > <div class="pane-content"> <div class="highwire-article-citation highwire-citation-type-highwire-article node1105257" data-node-nid="1105257" id="node-1105257--2212570465" data-pisa="bmj;388/jan09_5/q2868" data-pisa-master="bmj;bmj.q2868" data-apath="/bmj/388/bmj.q2868.atom"><cite class='highwire-cite highwire-citation-bmj-article-top'> <span class='highwire-cite-article-type'>Opinion</span> <h1 class="highwire-cite-title" id="page-title">The cost of NICE appraisals … and other research</h1> <span class='highwire-cite-journal'>BMJ</span> <span class='highwire-cite-published-year'>2025</span>; <span class='highwire-cite-volume-issue'>388</span> <span class='highwire-cite-doi'> doi: <a href="https://doi.org/10.1136/bmj.q2868">https://doi.org/10.1136/bmj.q2868</a></span> <span class='highwire-cite-date'>(Published 09 January 2025)</span> <span class='highwire-cite-article-as'> Cite this as: <span class="italic">BMJ</span> 2025;388:q2868 </span> </cite> </div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-highwire-panel-tabs pane-panels-ajax-tab-tabs" > <div class="pane-content"> <ul class="tabs inline panels-ajax-tab"><li class="first"><a title="Article Tab - Article" href="/content/388/bmj.q2868" class="panels-ajax-tab-tab" data-panel-name="jnl_bmj_tab_art" data-target-id="highwire_article_tabs" data-entity-context="node:1105257" data-trigger="" data-url-enabled="1"><span>Article</span></a><a title="Article Tab - Article" href="/panels_ajax_tab/jnl_bmj_tab_art/node:1105257/1" rel="nofollow" style="display:none" class="js-crawler-link"></a></li> <li><a title="Article Tab - Related Articles" href="/content/388/bmj.q2868/related" class="panels-ajax-tab-tab" data-panel-name="jnl_bmj_tab_related_art" data-target-id="highwire_article_tabs" data-entity-context="node:1105257" data-trigger="related" data-url-enabled="1"><span>Related content</span></a><a title="Article Tab - Related Articles" href="/panels_ajax_tab/jnl_bmj_tab_related_art/node:1105257/1" rel="nofollow" style="display:none" class="js-crawler-link"></a></li> <li><a title="Article Tab - Info & Metrics" href="/content/388/bmj.q2868/article-info" class="panels-ajax-tab-tab" data-panel-name="jnl_bmj_tab_info" data-target-id="highwire_article_tabs" data-entity-context="node:1105257" data-trigger="article-info" data-url-enabled="1"><span>Metrics</span></a><a title="Article Tab - Info & Metrics" href="/panels_ajax_tab/jnl_bmj_tab_info/node:1105257/1" rel="nofollow" style="display:none" class="js-crawler-link"></a></li> <li><a title="BMJ Article Related Rapid Responses" href="/content/388/bmj.q2868/rapid-responses" class="panels-ajax-tab-tab" data-panel-name="bmj_related_rapid_responses" data-target-id="highwire_article_tabs" data-entity-context="node:1105257" data-trigger="rapid-responses" data-url-enabled="1"><span>Responses</span></a><a title="BMJ Article Related Rapid Responses" href="/panels_ajax_tab/bmj_related_rapid_responses/node:1105257/1" rel="nofollow" style="display:none" class="js-crawler-link"></a></li> <li><a title="Article Tab - Peer review" href="/content/388/bmj.q2868/peer-review" class="panels-ajax-tab-tab" data-panel-name="jnl_bmj_tab_peer_review" data-target-id="highwire_article_tabs" data-entity-context="node:1105257" data-trigger="peer-review" data-url-enabled="1"><span>Peer review</span></a><a title="Article Tab - Peer review" href="/panels_ajax_tab/jnl_bmj_tab_peer_review/node:1105257/1" rel="nofollow" style="display:none" class="js-crawler-link"></a></li> <li class="last"><a title="BMJ Rapid Responses Form" href="/content/388/bmj.q2868/submit-a-rapid-response" class="panels-ajax-tab-tab" data-panel-name="bmj_rapid_responses_form" data-target-id="highwire_article_tabs" data-entity-context="node:1105257" data-trigger="submit-a-rapid-response" data-url-enabled="1"><i class="fa fa-edit"></i></a><a title="BMJ Rapid Responses Form" href="/panels_ajax_tab/bmj_rapid_responses_form/node:1105257/1" rel="nofollow" style="display:none" class="js-crawler-link"></a></li> </ul> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-highwire-panel-tabs-container" > <div class="pane-content"> <div data-panels-ajax-tab-preloaded="jnl_bmj_tab_art" id="panels-ajax-tab-container-highwire_article_tabs" class="panels-ajax-tab-container"><div class="panels-ajax-tab-loading" style ="display:none"><img class="loading" src="https://www.bmj.com/sites/all/modules/contrib/panels_ajax_tab/images/loading.gif" alt="Loading" title="Loading" /></div><div class="panels-ajax-tab-wrap-jnl_bmj_tab_art"><div class="panel-display panel-1col clearfix" > <div class="panel-panel panel-col"> <div><div class="panel-pane pane-highwire-markup" > <div class="pane-content"> <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view "><span class="highwire-journal-article-marker-start"></span><div class="contributors"><ol class="contributor-list" id="contrib-group-1"><li class="last" id="contrib-1"><span class="name">Tom Nolan</span><span class="contrib-role">, clinical editor; sessional GP, Surrey</span></li></ol><ol class="affiliation-list"><li class="aff"><a id="aff-1" name="aff-1"></a><address><em>The BMJ</em>, London</address></li></ol></div><div class="teaser"><p id="p-1"><strong>Tom Nolan</strong> reviews this week’s research</p></div><div class="section other1" id="sec-1"><h2 class="">The cost of being NICE</h2><p id="p-2">Between 2000 and 2022 the National Institute for Health and Care Excellence (NICE) appraised 332 pharmaceuticals (with 83% getting positive recommendations). Had they rejected all of the drugs, England would have been £75.1 billion better off, and if that money had instead been spent on existing NHS services, England would have a healthier population: 1.25 million quality adjusted life years (QALYs) healthier. This is all according to a retrospective analysis published in the <em>Lancet</em> by a team of prominent health economists and policy experts. It estimated that new drugs generated 3.75 million QALYs across nearly 20 million patients, but 5 million additional QALYs would have been gained by spending the money on existing services. The authors call for NICE technology appraisal recommendations to be presented relative to the health opportunity costs to show the trade-offs in funding decisions.</p><p id="p-3"><em>Lancet</em> doi:<a href="/lookup/doi/10.1016/S0140-6736(24)02352-3">10.1016/S0140-6736(24)02352-3</a></p></div><div class="section other2" id="sec-2"><h2 class="">High flow nasal oxygen’s non-inferiority complex</h2><p id="p-4">The RENOVATE study has found high flow nasal oxygen to be non-inferior to non-invasive ventilation (NIV) in patients with acute respiratory failure. However, the clinical implications are more complicated. For instance, there may be broader clinical considerations than the primary outcome of endotracheal intubation or death at seven days, and the relatively low numbers recruited to the study with COPD exacerbations (79) and acute cardiogenic pulmonary oedema (274) leaves greater uncertainty in these presentations. The study also stopped recruiting people with immunocompromise and hypoxia early due to worse outcomes in those assigned to high flow nasal oxygen. The main clinical take home message, according to one of the two editorials accompanying the paper, is that “the results are best interpreted as indicating that initiating treatment with high-flow oxygen is generally not harmful.”</p><p id="p-5"><em>JAMA </em>doi:<a href="/lookup/doi/10.1001/jama.2024.26244">10.1001/jama.2024.26244</a></p></div><div class="section other3" id="sec-3"><h2 class="">Comparing types of medical assistance in dying</h2><p id="p-6">Now that MPs have voted through proposals to legalise assisted dying in England and Wales, the details will be thrashed out in parliament. One of the many unknowns is how many people are going to seek medical assistance in dying. A study of data from eight countries where medically assisted dying is legal offers some clues. Overall, it found that, between 1985 and 2023, medical assistance in dying occurred in 1.4% of all deaths. The highest rates were in the Netherlands at 3.2% of all deaths and 5.1% in the most recently reported year; the lowest rates (just 0.1% of all deaths) were in the US state of New Jersey and Washington, DC.</p><p id="p-7"><em>JAMA Intern Med </em>doi:<a href="/lookup/doi/10.1001/jamainternmed.2024.6643">10.1001/jamainternmed.2024.6643</a></p></div><div class="section other4" id="sec-4"><h2 class="">Rethinking sentinel nodes biopsy</h2><p id="p-8">Sentinel node biopsy has been an integral part of breast cancer treatment for the past two decades, but its value is less clear these days with advances in tumour biology and systemic therapy. A randomised trial compared omission of axillary surgery with sentinel lymph node biopsy in people with clinically node-negative stage T1 or T2 invasive breast cancer who were scheduled to undergo breast conserving surgery. The estimated five year invasive disease-free survival rate was similar in each group (91.7% in those who had a sentinel node biopsy and 91.9% in those who didn’t), but those who didn’t undergo axillary surgery had lower rates of lymphoedema and arm or shoulder pain.</p><p id="p-9"><em>N Engl J Med </em>doi:<a href="/lookup/doi/10.1056/NEJMoa2412063">10.1056/NEJMoa2412063</a></p></div><div class="section other5" id="sec-5"><h2 class="">How to help people with chronic pain reduce opioids</h2><p id="p-10">People stuck on long term opioid therapy for chronic pain can reduce the dose of opioid they take with support, according to a new study set in the US. It recruited 820 people taking regular opioids for moderate to severe chronic pain and allocated them to a 12 month intervention delivered through an integrated pain team or pharmacist-led collaborative management. Neither strategy had much effect on pain (around 15% of participants had a reduction in pain score of >30% in both groups), but a quarter of people in each group managed to reduce their opioid dose by half.</p><p id="p-11"><em>JAMA Intern Med </em>doi:<a href="/lookup/doi/10.1001/jamainternmed.2024.6683">10.1001/jamainternmed.2024.6683</a></p></div><div class="section fn-group" id="fn-group-1"><h2>Footnotes</h2><ul><li class="fn-conflict" id="fn-1"><p id="p-12">Competing interests: None declared.</p></li><li class="fn-other" id="fn-2"><p id="p-13">Provenance and peer review: Not commissioned; not peer reviewed.</p></li></ul></div><span class="highwire-journal-article-marker-end"></span></div><span id="related-urls"></span></div></div> </div> </div> </div> </div> </div> </div></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-highwire-article-trendmd" > <div class="pane-content"> <div id="trendmd-suggestions"></div> </div> </div> </article> </div> <div class="right-nav col-xs-12 col-sm-4 col-md-4 col-lg-4"> <aside> <div class="panel-pane pane-service-links" > <div class="pane-content"> <div class="service-links"><ul><li class="first"><a href="http://twitter.com/share?url=https%3A//www.bmj.com/content/388/bmj.q2868&count=horizontal&via=&text=The%20cost%20of%20NICE%20appraisals%20%E2%80%A6%20and%20other%20research&counturl=https%3A//www.bmj.com/content/388/bmj.q2868" class="twitter-share-button service-links-twitter-widget" id="twitter_widget" title="Tweet This" rel="nofollow"><span class="element-invisible">Tweet Widget</span></a></li> <li class="last"><a href="http://www.facebook.com/plugins/like.php?href=https%3A//www.bmj.com/content/388/bmj.q2868&layout=button_count&show_faces=false&action=like&colorscheme=light&width=100&height=21&font=&locale=" id="facebook_like" title="I Like it" class="service-links-facebook-like" rel="nofollow"><span class="element-invisible">Facebook Like</span></a></li> </ul></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-snippet" > <div class="pane-content"> <div class="oas-ad-middle-1" id="oas-ad-middle-1"> <div class="snippet-content"> <div id="div-gpt-ad-7326006-2"><script> googletag.cmd.push(function() { googletag.display('div-gpt-ad-7326006-2'); }); </script></div> </div> </div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-bmj-issue-link" > <div class="pane-content"> <a href="/content/388/8454" class="btn btn-primary" target="_blank">See other articles in issue 8454</a> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-bmj-article-buttons" > <h2 class="pane-title"> Article tools </h2> <div class="pane-content"> <a href="/content/388/bmj.q2868.full.pdf" title="PDF" class="pdf-link"><span class="icon"><em class="bmj-icon blue-icon fa fa-file-text"></em>PDF</span></a><a href="/content/388/bmj.q2868/rapid-responses" class="citation-rr-link"><em class="bmj-icon blue-icon fa fa-comment"></em>0 responses</a> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-panels-mini pane-jnl-bmj-art-tools" > <div class="pane-content"> <div class="panel-display panel-1col clearfix" id="mini-panel-jnl_bmj_art_tools"> <div class="panel-panel panel-col"> <div><ul><li class="first"><div class="panel-pane pane-custom pane-1" > <div class="pane-content"> <p><i class="bmj-icon fa fa-edit"></i><a href="/content/388/bmj.q2868/submit-a-rapid-response">Respond to this article</a></p> </div> </div> </li> <li><div class="panel-pane pane-bmj-variant-link" > <div class="pane-content"> <i class="bmj-icon fa fa-print"></i><a href="/content/388/bmj.q2868.full-text.print" data-font-icon="fa fa-print">Print</a> </div> </div> </li> <li><div class="panel-pane pane-bmj-minipanel-model-link pane-jnl-bmj-article-page-alerts" > <div class="pane-content"> <div class='minipanel-model-wrapper'><div class='minipanel-model-link-link'><i class="bmj-icon fa fa-bullhorn"></i><a href="/#mini-panel-jnl-bmj-article-page-alerts-1" data-toggle="collapse" role="button" data-font-icon="fa fa-bullhorn">Alerts & updates</a></div><div id="mini-panel-jnl-bmj-article-page-alerts-1" class="panel-collapse collapse"><div class="minipanel-header"><h4 class="minipanel-label">Article alerts</h4><div class="short-description"><div class="alerts-marketing">Please note: your email address is provided to the journal, which may use this information for marketing purposes.</div></div></div><div class="minipanel-body"><div class="panel-display row bootstrap-onecol" id="mini-panel-jnl_bmj_article_page_alerts"> <div class="panel-panel col-xs-12 col-sm-12 col-md-12 col-lg-12"> <div class="panel-pane pane-custom pane-2" > <div class="pane-content"> <h4 class="minipanel-label">Log in or register:</h4> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-alerts-login-form" > <div class="pane-content"> <form action="/content/388/bmj.q2868?tab=article-alert" method="post" id="user-login-form" accept-charset="UTF-8"><div><div class="form-type-textfield form-item-name form-item form-group"> <label for="edit-name">Username <span class="form-required" title="This field is required.">*</span></label> <input class="form-control form-text required" type="text" id="edit-name" name="name" value="" size="15" maxlength="60" /> </div> <div class="form-type-password form-item-pass form-item form-group"> <label for="edit-pass">Password <span class="form-required" title="This field is required.">*</span></label> <input class="form-control form-text required" type="password" id="edit-pass" name="pass" size="15" maxlength="128" /> </div> <input type="hidden" name="form_build_id" value="form-1pzSR_NyfJlZwOx49880AFyGHpl3YeG-Cvr6VPFekTo" /> <input type="hidden" name="form_id" value="highwire_alerts_user_login" /> <input class="btn form-submit" type="submit" id="edit-submit" name="op" value="Log in" /></div></form> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-custom pane-3" id="register-for-alerts" > <div class="pane-content"> <p><a class="btn register-button" href="//myaccount.bmj.com/myaccount/registration.html?regService=bmj-registration&fwdUrl=https://www.bmj.com/content/388/bmj.q2868?tab=article-alert&itemId=pr1906">Register for alerts</a><br /> <div class="alerts-email"><i class="fa fa-info-circle"></i> If you have registered for alerts, you should use your registered email address as your username</div> </div> </div> </div> </div> </div></div></div> </div> </div> </li> <li><div class="panel-pane pane-bmj-minipanel-model-link pane-article-page-citation-download" > <div class="pane-content"> <div class='minipanel-model-wrapper'><div class='minipanel-model-link-link'><i class="bmj-icon fa fa-globe"></i><a href="/#mini-panel-article-page-citation-download-1" data-toggle="collapse" role="button" data-font-icon="fa fa-globe">Citation tools</a></div><div id="mini-panel-article-page-citation-download-1" class="panel-collapse collapse"><div class="minipanel-header"><h4 class="minipanel-label">Download this article to citation manager</h4></div><div class="minipanel-body"><div class="panel-display row bootstrap-onecol" id="mini-panel-article_page_citation_download"> <div class="panel-panel col-xs-12 col-sm-12 col-md-12 col-lg-12"> <div class="panel-pane pane-bmj-citation-export" > <div class="pane-content"> <div> <div class="highwire-citation-info"> <div class="highwire-article-citation highwire-citation-type-highwire-article node1105257--3" data-node-nid="1105257" id="node-1105257--41141348813" data-pisa="bmj;388/jan09_5/q2868" data-pisa-master="bmj;bmj.q2868" data-apath="/bmj/388/bmj.q2868.atom"><div id="jnl_bmj_custom_authors" style="display: none;"><span data-delta="0"><span class="nlm-given-names">Tom</span> <span class="nlm-surname">Nolan</span> <span class="nlm-role">clinical editor; sessional GP, Surrey</span></span></div> <div class="highwire-cite highwire-cite-highwire-article highwire-citation-bmj-article-citation-export clearfix" > <span class="highwire-cite-authors" ><!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN" "http://www.w3.org/TR/REC-html40/loose.dtd"> <html><body><span data-delta="0"><span class="nlm-surname">Nolan</span> <span class="nlm-given-names">T</span></span>. </body></html> </span> <span class="highwire-cite-title article-title">The cost of NICE appraisals … and other research</span> <span class="highwire-cite-metadata" ><span class="highwire-cite-metadata-journal highwire-cite-metadata">BMJ </span><span class="highwire-cite-metadata-date highwire-cite-metadata">2025; </span><span class="highwire-cite-metadata-volume highwire-cite-metadata">388 </span><span class="highwire-cite-metadata-volume highwire-cite-metadata">:q2868 </span></span> <span class="article-doi" >doi:10.1136/bmj.q2868</span> </div> </div> </div> <div class="highwire-citation-formats"> <div class="highwire-citation-formats-links"> <span class="Z3988" title="ctx_ver=Z39.88-2004&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.spage&rft.epage&rft.atitle=The%20cost%20of%20NICE%20appraisals%20%E2%80%A6%20and%20other%20research&rft.volume=388&rft.issue&rft.date=2025-01-09%2010%3A30%3A47&rft.stitle&rft.jtitle=BMJ&rft.au=Nolan%2C+Tom"></span><h3></h3><ul class="bmj-citation-links"><li class="first">BibTeX (win & mac)<a href="/highwire/citation/1105257/bibtext" class="citation-link btn btn-primary pull-right">Download</a></li> <li>EndNote (tagged)<a href="/highwire/citation/1105257/endnote-tagged" class="citation-link btn btn-primary pull-right">Download</a></li> <li>EndNote 8 (xml)<a href="/highwire/citation/1105257/endnote-8-xml" class="citation-link btn btn-primary pull-right">Download</a></li> <li>RefWorks Tagged (win & mac)<a href="/highwire/citation/1105257/refworks-tagged" class="citation-link btn btn-primary pull-right">Download</a></li> <li>RIS (win only)<a href="/highwire/citation/1105257/ris" class="citation-link btn btn-primary pull-right">Download</a></li> <li class="last">Medlars<a href="/highwire/citation/1105257/medlars" class="citation-link btn btn-primary pull-right">Download</a></li> </ul> </div> </div> </div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-snippet" > <h2 class="pane-title"> Help </h2> <div class="pane-content"> <div class="jnl-bmj-citation-download-help" id="jnl-bmj-citation-download-help"> <div class="snippet-content"> <div class="citation-help"> <p class="citation-manager">If you are unable to import citations, please contact technical support for your product directly (links go to external sites):</p> <ul> <li><a href="http://www.endnote.com/support/ensupport.asp">EndNote</a></li> <li><a href="http://www.procite.com/support/pcsupport.asp">ProCite</a></li> <li><a href="http://www.refman.com/support/rmsupport.asp">Reference Manager</a></li> <li><a href= "http://www.refworks.com/content/products/content.asp">RefWorks</a></li> <li><a href="http://www.zotero.org/support">Zotero</a></li> </ul> </div> </div> </div> </div> </div> </div> </div> </div></div></div> </div> </div> </li> <li class="last"><div class="panel-pane pane-bmj-permission-link" > <div class="pane-content"> <i class="bmj-icon icon-copyright"></i><a href="https://s100.copyright.com/AppDispatchServlet?publisherName=BMJ&publication=bmj&title=The%20cost%20of%20NICE%20appraisals%20%E2%80%A6%20and%20other%20research&publicationDate=01/09/2025&author=Tom%20Nolan&contentID=10.1136/bmj.q2868&volumeNum=388&issueNum=&startPage=&endPage=&copyright=BMJ%20Publishing%20Group%20Ltd&oa=n&orderBeanReset=1&link_type=PERMISSIONDIRECT&atom=/bmj/388/bmj.q2868.atom" rel="external" class="bmj-permission-link request-permissions" target="_blank" data-font-icon="icon-copyright">Request permissions</a> </div> </div> </li> </ul></div> </div> </div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-panels-mini pane-bmj-article-share-modal" > <div class="pane-content"> <div class="panel-display row bootstrap-onecol" id="mini-panel-bmj_article_share_modal"> <div class="panel-panel col-xs-12 col-sm-12 col-md-12 col-lg-12"> <div class="panel-pane pane-bmj-article-links" > <div class="pane-content"> <div class="bmj-article-links minipanel-model-wrapper"><ul class="links"><li><div class="minipanel-model-link-link"><i class="bmj-icon fa fa-user"></i><a data-font-icon="fa fa-bullhorn" role="button" data-toggle="collapse" href="/#mini-panel-jnl-bmj-article-page-citation" class="collapsed">Author citation</a></div></li></ul><div style="height: 0px;" id="mini-panel-jnl-bmj-article-page-citation" class="panel-collapse collapse"><ul class="links"><li class="0 first last"><a href="//www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=Nolan%20Tom%5Bau%5D&dispmax=50" target="_blank">Articles by Tom Nolan</a></li> </ul></div></div><div class="bmj-article-links"><ul class="links"><li class="0 first last"><a href="//portfolio.bmj.com/portfolio/add-to-portfolio.html?t=The%20cost%20of%20NICE%20appraisals%20%E2%80%A6%20and%20other%20research&u=https%3A//www.bmj.com/content/388/bmj.q2868" target="_blank" id="add-to-bmj-portfolio" class="bmj-portfolio" rel="nofollow">Add article to BMJ Portfolio</a></li> </ul></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-bmj-minipanel-model-link pane-jnl-bmj-article-button-email-to" > <div class="pane-content"> <div class='minipanel-model-wrapper'><div class='minipanel-model-link-link'><i class="bmj-icon icon-email"></i><a href="/#mini-panel-jnl-bmj-article-button-email-to-1" data-toggle="collapse" role="button" data-font-icon="icon-email">Email to a friend</a></div><div id="mini-panel-jnl-bmj-article-button-email-to-1" class="panel-collapse collapse"><div class="minipanel-header"><h4 class="minipanel-label">Forward this page</h4></div><div class="minipanel-body"><div class="panel-display row bootstrap-onecol" id="mini-panel-jnl_bmj_article_button_email_to"> <div class="panel-panel col-xs-12 col-sm-12 col-md-12 col-lg-12"> <div class="panel-pane pane-block pane-forward-form" > <div class="pane-content"> <form action="/content/388/bmj.q2868" method="post" id="forward-form" accept-charset="UTF-8"><div><div id="edit-instructions" class="form-type-item form-item form-group"> <p>Thank you for your interest in spreading the word about The BMJ.</p><p>NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.</p> </div> <div class="form-type-textfield form-item-name form-item form-group"> <label for="edit-name--2">Username <span class="form-required" title="This field is required.">*</span></label> <input class="form-control form-text required" type="text" id="edit-name--2" name="name" value="" size="58" maxlength="256" /> </div> <div class="form-type-textfield form-item-email form-item form-group"> <label for="edit-email">Your Email <span class="form-required" title="This field is required.">*</span></label> <input class="form-control form-text required" type="text" id="edit-email" name="email" value="" size="58" maxlength="256" /> </div> <div class="form-type-textarea form-item-recipients form-item form-group"> <label for="edit-recipients">Send To <span class="form-required" title="This field is required.">*</span></label> <div class="form-textarea-wrapper"><textarea class="form-control form-textarea required" id="edit-recipients" name="recipients" cols="50" rows="3"></textarea></div> </div> <div id="edit-page" class="form-type-item form-item form-group"> <label for="edit-page">You are going to email the following </label> <a href="/content/388/bmj.q2868" class="active">The cost of NICE appraisals … and other research</a> </div> <div class="form-type-textarea form-item-message form-item form-group"> <label for="edit-message--2">Your Personal Message </label> <div class="form-textarea-wrapper"><textarea class="form-control form-textarea" id="edit-message--2" name="message" cols="50" rows="3"></textarea></div> </div> <input type="hidden" name="path" value="node/1105257" /> <input type="hidden" name="path_cid" value="" /> <input type="hidden" name="forward_footer" value=" " /> <input type="hidden" name="form_build_id" value="form-SFrBuUAQF9NHw2_jh4gpannc5KawyPqXKDdPAezwklU" /> <input type="hidden" name="form_id" value="forward_form" /> <fieldset class="captcha panel panel-default form-wrapper"> <legend class="panel-heading"> <div class="panel-title fieldset-legend"> CAPTCHA </div> </legend> <div class="panel-body"> <p class="help-block"> This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. </p> <input type="hidden" name="captcha_sid" value="383468361" /> <input type="hidden" name="captcha_token" value="90b16787e7fc2a7443e4e9db1d14bf98" /> <input type="hidden" name="captcha_response" value="Google no captcha" /> <div class="g-recaptcha" data-sitekey="6LfnJVIUAAAAAE-bUOMg0MJGki4lqSvDmhJp19fN" data-theme="light" data-type="image"></div> </div> </fieldset> <input class="btn form-submit" type="submit" id="edit-submit--2" name="op" value="Send" /></div></form> </div> </div> </div> </div> </div></div></div> </div> </div> </div> </div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-snippet" > <div class="pane-content"> <div class="altmertrics" id="altmertrics"> <div class="snippet-content">  <div id="altmetric"></div>  </div> </div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-snippet" > <div class="pane-content"> <div class="oas-ad-middle-2" id="oas-ad-middle-2"> <div class="snippet-content"> <div id="div-gpt-ad-7326006-3"><script> googletag.cmd.push(function() { googletag.display('div-gpt-ad-7326006-3'); }); </script></div> </div> </div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-custom pane-4" > <div class="pane-content"> <p><a data-target="crossmark"><img src="https://crossmark-cdn.crossref.org/widget/v2.0/logos/CROSSMARK_Color_horizontal.svg" width="150" /></a></p> <div id="crossmark-dialog" style="display: none;" title="Crossmark"> <iframe id="crossmark-dialog-frame" frameborder="0"></iframe></div>  </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-snippet pane-poll-international" id="poll-widget" > <h2 class="pane-title"> This week's poll </h2> <div class="pane-content"> <div class="poll-international" id="poll-international"> <div class="snippet-content"> <p><a class="anchor" id="this-weeks-poll"></a></p> <div id="PDI_container58250" class="PDS_Poll"></div> <div id="PD_superContainer"></div> <div class="poll-related"> <p><a href="https://www.bmj.com/content/385/bmj.q1429">Read</a> related article</p> <p><a href="/about-bmj/poll-archive">See</a> previous polls</p> </div> </div> </div> </div> </div> </aside> </div> </div>  <div class="row"> <div class="panel-panel page-bottom col-md-12 col-lg-12"> <div class="panel-pane pane-highwire-back-to-top" > <div class="pane-content"> <a href="#page" class="back-to-top"><span class="icon-chevron-up"></span> Back to top</a> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-snippet pane-oas-ad-bottom" > <div class="pane-content"> <div class="oas-ad-bottom" id="oas-ad-bottom"> <div class="snippet-content"> <div id="div-gpt-ad-7326006-4"><script> googletag.cmd.push(function() { googletag.display('div-gpt-ad-7326006-4'); }); </script></div> </div> </div> </div> </div> </div> </div>  </div>  </section>  </div> </section> </div> </div>  <div class="footer-wrapper"> <div class="container"> <footer id="footer"> <div class="region region-footer"> <section id="block-panels-mini-bmj-footer" class="block block-panels-mini clearfix"> <div class="panel-display bootstrap-footer" id="mini-panel-bmj_footer"> <div class="footer-top-row"> <div id="footer-social-media" class="footer-column panel-panel col-xs-12 col-sm-3 col-md-3 col-lg-3"> <div class="panel-pane pane-block pane-menu-block-2" > <h2 class="pane-title"> Follow us on </h2> <div class="pane-content"> <div class="menu-block-wrapper menu-block-2 menu-name-menu-footer parent-mlid-1298 menu-level-1"> <ul class="menu nav"><li class="first leaf menu-mlid-1299"><a href="http://twitter.com/bmj_latest" target="_blank">Twitter</a></li> <li class="leaf menu-mlid-1301"><a href="https://www.facebook.com/bmjdotcom" target="_blank">Facebook</a></li> <li class="leaf menu-mlid-1300"><a href="http://youtube.com/user/BMJmedia" target="_blank">YouTube</a></li> <li class="last leaf menu-mlid-1302"><a href="http://feeds.bmj.com/bmj/recent">RSS</a></li> </ul></div> </div> </div> </div> <div class="footer-content col-xs-12 col-sm-9 col-md-9 col-lg-9"> <div id="footer-top-row" class="row"> <div class="footer-column panel-panel col-xs-6 col-sm-4 col-md-4 col-lg-4"> <div class="panel-pane pane-block pane-menu-block-3" > <h2 class="pane-title"> Content links </h2> <div class="pane-content"> <div class="menu-block-wrapper menu-block-3 menu-name-menu-footer parent-mlid-1303 menu-level-1"> <ul class="menu nav"><li class="first leaf menu-mlid-125058"><a href="http://www.bmj.com/collections">Collections</a></li> <li class="leaf menu-mlid-125036"><a href="http://www.bmj.com/health-in-south-asia">Health in South Asia</a></li> <li class="leaf menu-mlid-125034"><a href="http://www.bmj.com/content/women%E2%80%99s-children%E2%80%99s-and-adolescents%E2%80%99-health-0">Women’s, children’s & adolescents’ health</a></li> <li class="leaf menu-mlid-17959"><a href="http://www.bmj.com/freezikaresources">Zika virus</a></li> <li class="leaf menu-mlid-1305"><a href="/us/research">Research</a></li> <li class="leaf menu-mlid-1306"><a href="/us/education">Education</a></li> <li class="leaf menu-mlid-6506"><a href="/us/news">News and views</a></li> <li class="leaf menu-mlid-1310"><a href="http://blogs.bmj.com/bmj/">BMJ Opinion</a></li> <li class="leaf menu-mlid-7612"><a href="/rapid-responses">Rapid responses</a></li> <li class="last leaf menu-mlid-1309"><a href="/archive">Archive</a></li> </ul></div> </div> </div> </div> <div class="footer-column panel-panel col-xs-6 col-sm-4 col-md-4 col-lg-4"> <div class="panel-pane pane-block pane-menu-block-4" > <h2 class="pane-title"> About us </h2> <div class="pane-content"> <div class="menu-block-wrapper menu-block-4 menu-name-menu-footer parent-mlid-1314 menu-level-1"> <ul class="menu nav"><li class="first leaf menu-mlid-6487"><a href="/about-bmj">About us</a></li> <li class="leaf menu-mlid-1316"><a href="/about-bmj/editorial-staff">Editorial staff</a></li> <li class="leaf menu-mlid-1317"><a href="/about-bmj/editorial-staff/bmj-united-states">BMJ in the USA</a></li> <li class="leaf menu-mlid-127585"><a href="/health-in-latin-america">BMJ in Latin America</a></li> <li class="leaf menu-mlid-1318"><a href="/about-bmj/editorial-staff/bmj-south-asia">BMJ in South Asia</a></li> <li class="leaf menu-mlid-1319"><a href="/about-bmj/advisory-panels">Advisers</a></li> <li class="leaf menu-mlid-1320"><a href="/about-bmj/resources-authors/forms-policies-and-checklists">Policies</a></li> <li class="last leaf menu-mlid-1323"><a href="http://mc.manuscriptcentral.com/bmj">Submit your paper</a></li> </ul></div> </div> </div> </div> <div class="footer-column panel-panel col-xs-6 col-sm-4 col-md-4 col-lg-4"> <div class="panel-pane pane-block pane-menu-block-5" > <h2 class="pane-title"> Resources </h2> <div class="pane-content"> <div class="menu-block-wrapper menu-block-5 menu-name-menu-footer parent-mlid-1324 menu-level-1"> <ul class="menu nav"><li class="first leaf menu-mlid-1325"><a href="/about-bmj/resources-authors">Authors</a></li> <li class="leaf menu-mlid-1326"><a href="/about-bmj/resources-reviewers">Reviewers</a></li> <li class="leaf menu-mlid-1327"><a href="/about-bmj/resources-bma-members">BMA members</a></li> <li class="leaf menu-mlid-1329"><a href="/about-bmj/resources-readers">Readers</a></li> <li class="leaf menu-mlid-1328"><a href="/about-bmj/resources-subscribers">Subscribers</a></li> <li class="leaf menu-mlid-1330"><a href="/about-bmj/resources-advertisers-and-sponsors">Advertisers and sponsors</a></li> <li class="leaf menu-mlid-1331"><a href="/about-bmj/resources-media">Media</a></li> <li class="last leaf menu-mlid-7610"><a href="https://recruiter.bmj.com/">Recruiters</a></li> </ul></div> </div> </div> </div> <div class="footer-column panel-panel col-xs-6 col-sm-4 col-md-4 col-lg-4"> <div class="panel-pane pane-block pane-menu-block-6" > <h2 class="pane-title"> Explore BMJ </h2> <div class="pane-content"> <div class="menu-block-wrapper menu-block-6 menu-name-menu-footer parent-mlid-1332 menu-level-1"> <ul class="menu nav"><li class="first leaf menu-mlid-7613"><a href="https://www.bmj.com/company/?int_source=tbmj&int_medium=footer&int_campaign=URLswitch">Our company</a></li> <li class="leaf menu-mlid-7421"><a href="https://jobs.bmj.com/">BMJ Careers</a></li> <li class="leaf menu-mlid-7423"><a href="http://learning.bmj.com/">BMJ Learning</a></li> <li class="leaf menu-mlid-7424"><a href="http://masterclasses.bmj.com">BMJ Masterclasses</a></li> <li class="leaf menu-mlid-7425"><a href="http://journals.bmj.com">BMJ Journals</a></li> <li class="leaf menu-mlid-7422"><a href="/student">BMJ Student</a></li> <li class="leaf menu-mlid-7426"><a href="http://www.bmj.com/about-bmj/resources-readers">Academic edition of The BMJ</a></li> <li class="leaf menu-mlid-7427"><a href="http://bestpractice.bmj.com/">BMJ Best Practice</a></li> <li class="last leaf menu-mlid-17958"><a href="http://thebmjawards.bmj.com/home">The BMJ Awards</a></li> </ul></div> </div> </div> </div> <div class="footer-column panel-panel col-xs-6 col-sm-4 col-md-4 col-lg-4"> <div class="panel-pane pane-block pane-menu-block-7" > <h2 class="pane-title"> My account </h2> <div class="pane-content"> <div class="menu-block-wrapper menu-block-7 menu-name-menu-footer parent-mlid-1343 menu-level-1"> <ul class="menu nav"><li class="first leaf menu-mlid-1344"><a href="http://myaccount.bmj.com/myaccount/account/hw-registration.html">Email alerts</a></li> <li class="last leaf menu-mlid-1345"><a href="http://journals.bmj.com/cgi/activate">Activate subscription</a></li> </ul></div> </div> </div> </div> <div class="footer-column panel-panel col-xs-6 col-sm-4 col-md-4 col-lg-4"> <div class="panel-pane pane-block pane-menu-block-8" > <h2 class="pane-title"> Information </h2> <div class="pane-content"> <div class="menu-block-wrapper menu-block-8 menu-name-menu-footer parent-mlid-1346 menu-level-1"> <ul class="menu nav"><li class="first leaf menu-mlid-1347"><a href="/about-bmj/contact-us">Contact us</a></li> <li class="last leaf menu-mlid-1321"><a href="/about-bmj/complaints-procedure">Complaints</a></li> </ul></div> </div> </div> </div> </div> </div> </div> <div id="footer-bottom-row" class="row"> <div class="panel-panel col-xs-12 col-sm-12 col-md-12 col-lg-12"> <div class="panel-pane pane-block pane-menu-block-9 hidden-phone" > <div class="pane-content"> <div class="menu-block-wrapper menu-block-9 menu-name-menu-footer parent-mlid-1349 menu-level-1"> <ul class="menu nav"><li class="first leaf menu-mlid-125888"><a id="ot-sdk-btn" class="ot-sdk-show-settings" clickable="false">Cookie settings</a></li> <li class="leaf menu-mlid-1350"><a href="https://www.bmj.com/company/your-privacy/cookies-policy/">Cookie Policy</a></li> <li class="leaf menu-mlid-125299"><a href="https://www.bmj.com/company/your-privacy/">Privacy policy</a></li> <li class="leaf menu-mlid-1351"><a href="http://www.bmj.com/company/legal-information/">Website T&Cs</a></li> <li class="leaf menu-mlid-1352"><a href="http://group.bmj.com/group/about/revenue-sources">Revenue Sources</a></li> <li class="leaf menu-mlid-1353"><a href="http://home.highwire.org/">HighWire Press</a></li> <li class="last leaf menu-mlid-8093"><a href="/sitemap">Sitemap</a></li> </ul></div> </div> </div> <div class="panel-separator"></div><div class="panel-pane pane-bmj-copy-right" > <div class="pane-content"> <div class="copyright">Copyright © 2025 BMJ Publishing Group Ltd</div> </div> </div> </div> </div> </div> </section>  </div> </footer>  </div> </div> </div>  </div>  <script src="https://www.bmj.com/sites/default/files/advagg_js/js__uW7NyUocxI-7E_sL-GP7L5FYvHrfi0D8UkwaFa_jFUQ__ITpTmydBN18ujP4Nq9igNKs2_uPvSa_MMIGZilNH7xo__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.js"></script> <script src="https://www.bmj.com/sites/default/files/advagg_js/js__L2RNsEq1_BwrvVr4-XqL6HCM3TrId8FewyOD-ifl56Y__xFUWwD-CmrvIMpj7PKKOzG6M0u5x4a4YsfZcc7fa3qg__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.js"></script> <script src="https://www.bmj.com/sites/default/files/advagg_js/js__ADNpAJRqEZQTdJr17qFcuXkfatW9ULGGExiAh_zWtxs__Xan4DQzBMVgws81Yi1i-_1Amp0wkg5IKAA2fCWPVSwI__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.js"></script> <script src="https://www.bmj.com/sites/default/files/advagg_js/js__wteGLiD1wamodYGt1CPf350dgG_dnSPaybjTJJ4V8O0__tHSi0oVxXVY1K8dKSadgniknKfq0JO39EkwFnl-Qx3k__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.js"></script> <script src="https://static.polldaddy.com/w/58250.js"></script> <script src="https://ajax.googleapis.com/ajax/libs/jqueryui/1.8.7/jquery-ui.min.js"></script> <script src="https://crossmark-cdn.crossref.org/widget/v2.0/widget.js"></script> <script src="https://d1bxh8uas1mnw7.cloudfront.net/assets/embed.js"></script> <script src="https://www.bmj.com/sites/default/files/advagg_js/js__SFoHIUTheqo0e4hxRINC0gFp_rO4LFMUUrC70xvOwtY__h5zRuwNt-m_fFPTyMKF2APwK7ArnJ2U3S4dW5Cp_p_o__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.js"></script> <script> setTimeout(function(){var a=document.createElement("script"); var b=document.getElementsByTagName("script")[0]; a.src=document.location.protocol+"//dnn506yrbagrg.cloudfront.net/pages/scripts/0014/4896.js?"+Math.floor(new Date().getTime()/3600000); a.async=true;a.type="text/javascript";b.parentNode.insertBefore(a,b)}, 1);</script> <script>jQuery(".page-search .pane-quick-search-results .search-snippet").text(function (_, old){ return old.replace(/\S+@\S+\.\S+/, "");});</script> <script type="text/javascript"> /* <![CDATA[ */ var google_conversion_id = 973817434; var google_custom_params = window.google_tag_params; var google_remarketing_only = true; /* ]]> */ </script> <script type="text/javascript" src="//www.googleadservices.com/pagead/conversion.js"> </script> <noscript> <div style="display:inline;"> <img height="1" width="1" style="border-style:none;" alt="" src="//googleads.g.doubleclick.net/pagead/viewthroughconversion/973817434/?value=0&guid=ON&script=0"/> </div> </noscript> <script async src="https://cdn.pbgrd.com/core-bmj.js"></script> </body> </html>