Research

The NICE ADHD health technology assessment: A review and critique

Michael Schlander^1,2,3

¹  Institute for Innovation & Valuation in Health Care (InnoVal^HC), Rathausplatz 12-14, D-65760 Eschborn, Germany

²  Department of Public Health, Social and Preventive Medicine, Mannheim Medical Faculty, University of Heidelberg, Ludolf-Krehl-Strasse 7-11, D-68167 Mannheim, Germany

³  University of Applied Economic Sciences Ludwigshafen, Ernst-Boehe-Strasse 4, D-67059 Ludwigshafen, Germany

author email corresponding author email

Child and Adolescent Psychiatry and Mental Health 2008, 2:1doi:10.1186/1753-2000-2-1

Published:	15 January 2008

Abstract

Background

Health technology assessments (HTAs) by the National Institute for Health and Clinical Excellence (NICE) enjoy high levels of international attention. The present analysis addresses NICE's appraisal of methylphenidate, atomoxetine and dexamphetamine for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents, published in March 2006.

Methods

A qualitative study of NICE Technology Appraisal No. 98 was done focusing on the >600-page technology assessment report, which aimed at evaluating ADHD treatment strategies by a clinical effectiveness review and an economic analysis using meta-analytical techniques and a cost-effectiveness model.

Results

The technology assessment was unable to differentiate between the various drugs in terms of efficacy, and its economic model was ultimately driven by cost differences. While the assessment concluded that the economic model "clearly identified an optimal treatment strategy" with first-line dexamphetamine, the NICE appraisal committee subsequently found it impossible to distinguish between the different strategies on grounds of cost-effectiveness. Analyzing the assessment reveals gaps and inconsistencies concerning data selection (ultimately relying on a small number of short-term studies only), data synthesis (pooling of heterogeneous study designs and clinical endpoints), and economic model structure (identifying double-counting of nonresponders as a likely source of bias, alongside further methodological anomalies).

Conclusion

Many conclusions of the NICE technology assessment rest on shaky grounds. There remains a need for a new, state-of-the-art systematic review of ADHD treatment strategies including economic evaluation, which ideally should address outcomes beyond children's health-related quality of life, such as long-term sequelae of the disorder and caregiver burden.