National Institute for Health and Care Excellence (NICE)
Full Text Guideline
Evidence Supporting the Recommendations
The type and quality of supporting evidence is identified and graded for each recommendation (see Appendix C of the original guideline document).
Implementation of the Guideline
National Institute for Health and Clinical Excellence (NICE) guidance can help:
- National Health Service (NHS) organisations meet the Department of Health (DH) standards for public health as set out in the seventh domain of 'Standards for better health' (updated in 2006). Performance against these standards is assessed by the Healthcare Commission, and forms part of the annual health check score awarded to local healthcare organisations.
- NHS organisations, social care and children's services meet the requirements of the DH's 'Operating framework for 2008/09' and 'Operational plans 2008/09–2010/11'.
- NHS organisations, social care and older people's services meet the requirements of the Department of Communities and Local Government's 'The new performance framework for local authorities and local authority partnerships'.
- National and local organisations within the public sector meet government indicators and targets to improve health and reduce health inequalities.
- Local authorities fulfil their remit to promote the economic, social and environmental wellbeing of communities.
- Local NHS organisations, local authorities and other local public sector partners benefit from any identified cost savings, disinvestment opportunities or opportunities for re-directing resources.
NICE has developed tools to help organisations implement this guidance. These are available on the NICE website at www.nice.org.uk/PH16. (See also the "Availability of Companion Documents" field).
Quick Reference Guides/Physician Guides
Benefits/Harms of Implementing the Guideline Recommendations
- Appropriate use of occupational therapy and physical therapy interventions to promote mental wellbeing in older persons
- Enabling of people who have physical, mental and/or social needs to achieve as much as they can to get the most out of life
- Improved mental wellbeing of older people in primary and residential care
Rating Scheme for the Strength of the Recommendations
The interventions were assessed for their applicability to the UK and the evidence statements were graded as follows:
- Likely to be applicable across a broad range of settings and populations
- Likely to be applicable across a broad range of settings and populations, assuming they are appropriately adapted
- Applicable only to settings or populations included in the studies – broader applicability is uncertain
- Applicable only to settings or populations included in the studies
- This guidance represents the views of the Institute and was arrived at after careful consideration of the evidence available. Those working in the NHS, local authorities, the wider public, voluntary and community sectors and the private sector should take it into account when carrying out their professional, managerial or voluntary duties.
- Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
- This guidance complements and supports, but does not replace, National Institute for Health and Clinical Excellence (NICE) guidance on supporting people with dementia and their carers in health and social care, managing depression in primary and secondary care, assessing and preventing falls in older people, obesity, commonly used methods to increase physical activity, physical activity and the environment, behaviour change and community engagement.
- Public Health Interventions Advisory Committee (PHIAC) noted that an intervention, policy or strategy in current practice not covered by this guidance should not be assumed to be ineffective and be discontinued. The recommendations in this document are based on the evidence from peer-reviewed literature available at the time of writing and PHIAC recognised that some interventions may not yet have been evaluated.
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Note from the National Guideline Clearinghouse (NGC): Key questions were established as part of the scope. They formed the starting point for the review of evidence and facilitated the development of recommendations by the Public Health Interventions Advisory Committee (PHIAC).
The overarching question was:
What are the most effective and cost effective ways for primary and residential care services to promote the mental wellbeing of older people? (Refer to Appendix B of the original guideline document for a list of the subsidiary questions).
A systematic search of the literature was conducted by the National Health Service Centre for Reviews and Dissemination at the University of York using the search strategy in Appendix A in the original guideline document.
A systematic search of 21 data bases and 11 websites sought evidence, published between January 1993 and February 2007, of the effectiveness or cost-effectiveness of interventions to promote mental well-being in later life. The search was restricted to the English language. In principle all study designs were considered for inclusion. In total 15,388 citation titles and abstracts were screened for relevance. By this process 248 articles were identified for further appraisal for inclusion in either review – 218 for effectiveness and 30 for cost-effectiveness. Application of inclusion criteria selected 97 papers for the review – 95 for effectiveness and two for cost-effectiveness. On completion of the review two further papers were identified during the consultation period and included in the effectiveness analyses. In total the 97 effectiveness papers described four meta-analyses, 14 trials of good quality (one of which generated two papers), 69 quantitative studies of poor quality (one of which generated two papers) and eight qualitative papers (including six of good quality). Refer to Appendix B of the original guideline document for a list of the searched databases and websites.
Inclusion and Exclusion Criteria
The reviews focus on interventions that promote mental well-being in older people, defined as those over 65. Studies were considered if they included older people, for example studies of 50-70 year olds, but only if they subdivided results by age groups.
Refer to the companion document "Public health interventions to promote mental well-being in people aged 65 and over: systematic review of effectiveness and cost-effectiveness" for details of the inclusion criteria (population, interventions, study designs, and outcomes) and exclusion criteria. (Refer to the "Availability of Companion Documents" field.)
To identify potentially eligible papers, two independent reviewers screened titles and abstracts for inclusion. Where there was disagreement the article was referred to a third reviewer. All papers that appeared to meet the inclusion criteria were retrieved for critical appraisal by a validated checklist, updated to include economic modelling as recommended by NICE. One researcher assessed quality and extracted data, and a second checked both.
The following databases were searched for the period from January 1993 to February 2007:
- Health Economic Evaluation Database (HEED)
- National Health Service Economic Evaluation Database (NHS EED)
The search strategies for these reviews were developed by National Institute for Health and Clinical Excellence (NICE) in collaboration with the Centre for Reviews and Dissemination at the University of York. Further detail can be found in the full reviews: www.nice.org.uk/PH16.
For the health economic and modelling review, studies were identified that included economic evaluation/analyses as well as health economics, cost benefit, cost containment, cost effectiveness, cost utility, cost allocation, socioeconomics, healthcare costs and healthcare finance.
The National Institute for Health and Care Excellence (NICE) undertook a review of this guideline in 2011 and determined that the information is current. See the NICE Web site for the review decision.
Of 220 papers identified for possible inclusion in this review, 97 were included, 95 for effectiveness and two for cost-effectiveness.
Weighting According to a Rating Scheme (Scheme Given)
- Meta-analyses, systematic reviews of randomized controlled trials (RCTs), or RCTs (including cluster RCTs)
- Systematic reviews of, or individual, non-randomised controlled trials, case-control studies, cohort studies, controlled before-and-after (CBA) studies, interrupted time series (ITS) studies, correlation studies
- Non-analytical studies (for example, case reports, case series)
- Expert opinion, formal consensus
++ All or most criteria have been fulfilled. Where they have not been fulfilled the conclusions are thought very unlikely to alter
+ Some criteria have been fulfilled. Those criteria that have not been fulfilled or not adequately described are thought unlikely to alter the conclusions
- Few or no criteria have been fulfilled. The conclusions of the study are thought likely or very likely to alter
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Included papers were assessed for methodological rigour and quality using the National Institute for Health and Clinical Excellence (NICE) methodology checklist, as set out in the NICE technical manual 'Methods for development of NICE public health guidance' (see Appendix E in the original guideline document). Each study was described by study type and graded (++, +, -) to reflect the risk of potential bias arising from its design and execution.
Summarising the Evidence and Making Evidence Statements
The review data were summarised in evidence tables (see full reviews). The findings from the review were synthesised and used as the basis for a number of evidence statements relating to the key question. The evidence statements reflect the strength (quantity, type and quality) of evidence and its applicability to the populations and settings in the scope.
Interventions identified in the effectiveness review that did not have supporting economic evidence were selected for inclusion in an economic model developed for the assessment of benefits (expressed in quality-adjusted life years; QALYs) relative to their respective costs. Algorithms were applied to the profile of scores covering physical and emotional health used in the identified studies, often measured by means of the SF-36 or SF-12 questionnaires, to derive SF-6D health state utility indices to enable the calculation of cost utility estimates. The results are reported in 'Public health interventions to promote mental well-being in people aged 65 and older: systematic review of effectiveness and cost-effectiveness'. They are available at www.nice.org.uk/PH16. (See also "Availability of Companion Documents" field.)
How Public Health Interventions Advisory Committee (PHIAC) Formulated the Recommendations
At its meetings in September 2007, November 2007, April 2008, and June 2008, PHIAC considered the evidence of effectiveness and cost effectiveness of interventions to promote the mental wellbeing of older people to determine:
- Whether there was sufficient evidence (in terms of quantity, quality and applicability) to form a judgement
- Whether, on balance, the evidence demonstrates that the intervention is effective or ineffective, or whether it is equivocal
- Where there is an effect, the typical size of the effect
PHIAC developed draft recommendations through informal consensus, based on the following criteria:
- Strength (quality and quantity) of evidence of effectiveness and its applicability to the populations/settings referred to in the scope.
- Effect size and potential impact on population health and/or reducing inequalities in health.
- Cost effectiveness (for the National Health Service [NHS] and other public sector organisations).
- Balance of risks and benefits.
- Ease of implementation and the anticipated extent of change in practice that would be required.
Where possible, recommendations were linked to an evidence statement(s) (see Appendix C of the original guideline document for details). Where a recommendation was inferred from the evidence this was indicated by the reference 'IDE' (inference derived from the evidence).
In general, community-based exercise programmes delivered by exercise professionals and activity counselling interventions delivered by primary care practice nurses were found to be cost effective with respect to mental wellbeing outcomes.
Two studies provided good evidence about the cost-effectiveness of interventions to improve the mental well-being of older people. The first study showed that a 2-hour group session of preventive advice from an occupational therapist per week is cost-effective in the USA with an incremental cost per quality-adjusted life year (QALY) of $10,700 (95% CI, $6,700 to $25,400). The second study showed that twice-weekly exercise classes led by qualified instructors are probably cost-effective in the UK with an incremental cost per QALY of 12,100 pounds sterling (95% CI, 5,800 pounds sterling to 61,400 pounds sterling). While both studies are sound, one cannot be entirely confident that such sparse findings will apply to similar populations (relatively healthy, living independently, and motivated to take advice and exercise) in similar community-based settings in the UK.
To complement these sparse data economic modelling based on the integration of existing studies of effectiveness and existing sources of data about patient utilities and resource costs was needed. The most cost-effective intervention was a thrice-weekly community-based walking programme, delivered to sedentary older people who are able to walk without assistance. Modelling yielded an incremental cost per QALY of £7400 after 6 months, which is comparable with the two published economic analyses. Modelling was also used to enhance three randomized controlled trials of advice about physical activity. Such advice had an estimated incremental cost per QALY of £26,200 when modelled from one group of investigators, who estimated the effects of the primary care 'green prescription' counselling programme in New Zealand. The estimated incremental cost per QALY rose to £45,600 when modelled from another group of investigators, who evaluated proactive health promotion by nurses in Canada in addition to usual home care for people over 75, and to £106,232 based on the modelling of a Norwegian physiotherapist-led exercise programme. However, yet another group of investigators reported decreased mental wellbeing in response to 20 minutes of individual advice on physical activity by an exercise specialist in general practice in Australia. Thus the advice was dominated by the control group to whom no advice was given.
Refer to Appendix C of the original guideline document and the companion document "Costing Report" (see "Availability of Companion Documents" field) for more information on cost-effectiveness analyses.
External Peer Review
Internal Peer Review
The draft guidance, including the recommendations, was released for consultation in February 2008. At its meetings in April 2008 and June 2008 Public Health Interventions Advisory Committee considered comments from stakeholders and the results from fieldwork and amended the guidance. The guidance was signed off by the NICE Guidance Executive in September 2008.
Identifying Information and Availability
National Institute for Health and Clinical Excellence (NICE). Occupational therapy interventions and physical activity interventions to promote the mental wellbeing of older people in primary care and residential care. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008 Oct. 50 p. (Public health guidance; no. 16). [23 references]
Not applicable: The guideline was not adapted from another source.
National Institute for Health and Clinical Excellence (NICE)
NICE Project Team
Public Health Interventions Advisory Committee (PHIAC)
NICE Project Team Members: Mike Kelly, CPHE Director; Tricia Younger, Associate Director; Linda Sheppard, Analyst; Clare Wohlgemuth, Analyst; Bhash Naidoo, Technical Adviser (Health Economics)
Public Health Interventions Advisory Committee (PHIAC) Members: Professor Sue Atkinson, CBE Independent Consultant and Visiting Professor, Department of Epidemiology and Public Health, University College London; Mr John F Barker, Associate Foundation Stage Regional Adviser for the Parents as Partners in Early Learning Project, DfES National Strategies; Professor Michael Bury, Emeritus Professor of Sociology, University of London, Honorary Professor of Sociology, University of Kent; Professor Simon Capewell, Chair of Clinical Epidemiology, University of Liverpool; Professor K K Cheng, Professor of Epidemiology, University of Birmingham; Ms Joanne Cooke, Director, Trent Research and Development Support Unit; Dr Richard Cookson, Senior Lecturer, Department of Social Policy and Social Work, University of York; Mr Philip Cutler, Forums Support Manager, Bradford Alliance on Community Care; Professor Brian Ferguson, Director, Yorkshire and Humber Public Health Observatory; Professor Ruth Hall, Regional Director, Health Protection Agency, South West; Ms Amanda Hoey, Director, Consumer Health Consulting Limited; Mr Alasdair J Hogarth, Head Teacher, Archbishops School, Canterbury; Mr Andrew Hopkin, Assistant Director, Local Environment, Derby City Council; Dr Ann Hoskins, Deputy Regional Director of Public Health/Medical Director, NHS North West; Ms Muriel James, Secretary, Northampton Healthy Communities Collaborative and the King Edward Road Surgery Patient Participation Group; Dr Matt Kearney, General Practitioner, Castlefields, Runcorn, GP Public Health Practitioner, Knowsley; Ms Valerie King, Designated Nurse for Looked After Children, Northampton PCT, Daventry and South Northants PCT and Northampton General Hospital, Public Health Skills Development Nurse, Northampton PCT; Professor Catherine Law, Professor of Public Health and Epidemiology, UCL Institute of Child Health, University College London; Ms Sharon McAteer, Public Health Development Manager, Halton and St Helens PCT; Mr David McDaid, Research Fellow, Department of Health and Social Care, London School of Economics and Political Science; Professor Klim McPherson, Visiting Professor of Public Health Epidemiology, Department of Obstetrics and Gynaecology, University of Oxford; Professor Susan Michie, Professor of Health Psychology, BPS Centre for Outcomes Research & Effectiveness, University College London; Dr Mike Owen, General Practitioner, William Budd Health Centre, Bristol; Ms Jane Putsey, Lay Representative, Chair of Trustees of the Breastfeeding Network; Dr Mike Rayner, Director, British Heart Foundation Health Promotion Research Group, Department of Public Health, University of Oxford; Mr Dale Robinson, Chief Environmental Health Officer, South Cambridgeshire District Council; Ms Joyce Rothschild, Children's Services Improvement Adviser, Solihull Metropolitan Borough Council; Dr Tracey Sach, Senior Lecturer in Health Economics, University of East Anglia; Professor Mark Sculpher, Professor of Health Economics, Centre for Economics (CHE), University of York; Dr David Sloan, Retired Director of Public Health; Dr Dagmar Zeuner Joint Director of Public Health, Hammersmith and Fulham PCT
All members of the Public Health Interventions Advisory Committee are required to make an oral declaration all potential conflicts of interest at the start of the consideration of each public health intervention appraisal. These declarations will be minuted and published on the National Institute for Health and Clinical Excellence (NICE) website.
Members are required to provide in writing an annual statement of current conflicts of interests, in accordance with the Institute's policy and procedures.
Potential members of the Public Health Programme Development Groups (PDG), and any individuals having direct input into the guidance (including expert peer reviewers), are required to provide a formal written declaration of personal interests. A standard form has been developed for this purpose which also includes the Institute's standard policy for declaring interests. This declaration of interest form should be completed before any decision about the involvement of an individual is taken.
Any changes to a Group member's declared conflicts of interests should also be recorded at the start of each PDG meeting. The PDG Chair should determine whether these interests are significant. If a member of the PDG has a possible conflict of interest with only a limited part of the guidance development or recommendations, that member may continue to be involved in the overall process but should withdraw from involvement in the area of possible conflict. This action should be documented and be open to external review. If it is considered that an interest is significant in that it could impair the individual's objectivity throughout the development of public health guidance, he or she should not be invited to join the group.
This is the current release of the guideline.
The National Institute for Health and Care Excellence (NICE) reaffirmed the currency of this guideline in 2011.
Electronic copies: Available in Portable Document Format (PDF) format from the National Institute for Health and Clinical Excellence (NICE) Web site.
The following is available:
- Mental wellbeing and older people. Quick reference guide. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008 Oct. 6 p. (Public Health Intervention Guidance 16). Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site.
- Costing report: mental wellbeing and older people. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008 Oct. 20 p. (Public Health Intervention Guidance 16). Available in Portable Document Format (PDF) from the NICE Web site.
- Slide set: mental wellbeing and older people. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008. 14 p. (Public Health Intervention Guidance 16). Available in Portable Document Format (PDF) from the NICE Web site.
- Public health interventions to promote mental well-being in people aged 65 and over: systematic review of effectiveness and cost-effectiveness. London (UK): National Institute for Health and Clinical Excellence (NICE); 2008 Mar. 144 p. (Public Health Intervention Guidance 16). Available in Portable Document Format (PDF) from the NICE Web site.
- Methods for development of NICE public health guidance. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Mar. 131 p. Available in Portable Document Format (PDF) from the NICE Archive Web site.
- The public health guidance development process. An overview for stakeholders including public health practitioners, policy makers and the public. London (UK): National Institute for Health and Clinical Excellence (NICE); 2006 Mar. 46 p. Available in Portable Document Format (PDF) from the NICE Archive Web site.
This summary was completed by ECRI Institute on February 3, 2009. The currency of the guideline was reaffirmed by the developer in 2011 and this summary was updated by ECRI Institute on October 30, 2013.
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
Assessment of Therapeutic Effectiveness
Physical Medicine and Rehabilitation
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Public Health Departments
To help National Health Service (NHS) organizations, local health and social care services promote mental health wellbeing of older people in primary and residential care
Older people (aged 65 and over) in England in primary and residential care and their carers
- Occupational therapy interventions that:
- Encourage older people to identify, construct, rehearse and carry out daily routines and activities that help to maintain or improve their health and wellbeing
- Increase older people's knowledge and awareness of where to get reliable information and advice on a broad range of topics
- Physical activity:
- Offer, promote and support tailored exercise and physical activity programmes in the community
- Walking schemes
- Offer, promote and support range of walking schemes of low to moderate intensity with a choice of local routes to suit different abilities
- Design and development of locally relevant training schemes for those working with older people
- Mental health and wellbeing (life satisfaction, optimism, self-esteem, mastery and feeling in control, having a purpose in life, sense of belonging and support)
- Physical health
- Ability to carry out daily routines
- Ability to be independent
- Quality of life
- Cost effectiveness
Occupational Therapy Interventions
Who is the target population?
Older people and their carers
Who should take action?
Occupational therapists or other professionals who provide support and care services for older people in community or residential settings and who have been trained to apply the principles and methods of occupational therapy
What action should they take?
- Offer regular group and/or individual sessions to encourage older people to identify, construct, rehearse and carry out daily routines and activities that help to maintain or improve their health and wellbeing. Sessions should:
- Involve older people as experts and partners in maintaining or improving their quality of life
- Pay particular attention to communication, physical access, length of session and informality to encourage the exchange of ideas and foster peer support
- Take place in a setting and style that best meet the needs of the older person or group
- Provide practical solutions to problem areas
- Increase older people's knowledge and awareness of where to get reliable information and advice on a broad range of topics, by providing information directly, inviting local advisers to give informal talks, or arranging trips and social activities. Topics covered should include:
- Meeting or maintaining healthcare needs (for example, eye, hearing and foot care)
- Nutrition (for example, healthy eating on a budget)
- Personal care (for example, shopping, laundry, keeping warm)
- Staying active and increasing daily mobility
- Getting information on accessing services and benefits
- Home and community safety
- Using local transport schemes
- Invite regular feedback from participants and use it to inform the content of the sessions and to gauge levels of motivation
Who is the target population?
Older people and their carers
Who should take action?
Physiotherapists, registered exercise professionals and fitness instructors and other health, social care, leisure services and voluntary sector staff who have the qualifications, skills and experience to deliver exercise programmes appropriate for older people.
What action should they take?
- In collaboration with older people and their carers, offer tailored exercise and physical activity programmes in the community, focusing on:
- A range of mixed exercise programmes of moderate intensity (for example, dancing, walking, swimming)
- Strength and resistance exercise, especially for frail older people
- Toning and stretching exercise
- Ensure that exercise programmes reflect the preferences of older people.
- Encourage older people to attend sessions at least once or twice a week by explaining the benefits of regular physical activity.
- Advise older people and their carers how to exercise safely for 30 minutes a day (which can be broken down into 10-minute bursts) on 5 days each week or more. Provide useful examples of activities in daily life that would help achieve this (for example, shopping, housework, gardening, cycling).
- Invite regular feedback from participants and use it to inform the content of the service and to gauge levels of motivation.
Who is the target population?
Older people and their carers
Who should take action?
General practitioners (GPs), community nurses, public health and health promotion specialists, 'Walking the way to health initiative' walk leaders, local authorities, leisure services, voluntary sector organisations, community development groups working with older people, carers and older people themselves.
What action should they take?
- In collaboration with older people and their carers, offer a range of walking schemes of low to moderate intensity with a choice of local routes to suit different abilities.
- Promote regular participation in local walking schemes as a way to improve mental wellbeing for older people and provide health advice and information on the benefits of walking.
- Encourage and support older people to participate fully according to health and mobility needs, and personal preference.
- Ensure that walking schemes:
- Are organised and led by trained workers or 'Walking the way to health initiative' volunteer walk leaders from the local community who have been trained in first aid and in creating suitable walking routes
- Incorporate a group meeting at the outset of a walking scheme that introduces the walk leader and participants
- Offer opportunities for local walks at least three times a week, with timing and location to be agreed with participants
- Last about 1 hour and include at least 30 to 40 minutes of walking plus stretching and warm-up/cool-down exercises (depending on older people's mobility and capacity)
- Invite regular feedback from participants and use it to inform the content of the service and to gauge levels of motivation
Who is the target population?
Health and social care professionals, domiciliary care staff, residential care home managers and staff, and support workers, including the voluntary sector
Who should take action?
- Professional bodies, skills councils and other organisations responsible for developing training programmes and setting competencies, standards and continuing professional development schemes.
- NHS and local authority senior managers, human resources and training providers and employers of residential and domiciliary care staff in the private and voluntary sector.
What action should they take?
- Involve occupational therapists in the design and development of locally relevant training schemes for those working with older people. Training schemes should include:
- Essential knowledge of (and application of) the principles and methods of occupational therapy and health and wellbeing promotion
- Effective communication skills to engage with older people and their carers (including group facilitation skills or a person-centred approach)
- Information on how to monitor and make the best use of service feedback to evaluate or redesign services to meet the needs of older people
- Ensure practitioners have the skills to:
- Communicate effectively with older people to encourage an exchange of ideas and foster peer support
- Encourage older people to identify, construct, rehearse and carry out daily routines and promote activities that help to maintain or improve health and wellbeing
- Improve, maintain and support older people's ability to carry out daily routines and promote independence
- Collect and use regular feedback from participants
Institute of Medicine (IOM) National Healthcare Quality Report Categories
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