Dr Nicky Welton
MRC methodology research fellow at the University of Bristol.
Dr Nicky Welton develops methods to help support decision making by organisations such as the National Institute for Health and Clinical Excellence (NICE).
Modelling strategies for how birds can survive the winter might not seem like it has much relevance for health services research, but Dr Nicky Welton says her PhD provided her with good experience of modelling decision making.
“Although it’s a totally different application area, the methods are not so distinct. I was trying to find the optimal strategy [for birds]; what’s the best thing to do to maximise benefits minus costs. That’s not too different to thinking about the optimal treatment strategy for patients,” she says.
Nicky completed her PhD at the University of Bristol and then spent the majority of the next few years lecturing in statistics at the University of the West of England. She returned to the University of Bristol in 2002 to what was then the MRC Health Services Research Collaboration (HSRC), beginning her Methodology Research Fellowship in 2009.
Decisions, decisions
Any new technology or treatment that’s going to be used in the NHS must be approved by NICE, and part of the approval process is a cost-benefit analysis based on submitted evidence. Nicky is involved in the mathematics ‘behind the scenes’ that synthesises this evidence of a treatment’s benefits and costs.
But the central area of her fellowship is developing the methods to work out how certain to be about those cost-benefit analyses, and whether there is a need to carry out new research studies.
The key question is, she says, “if this is cost effective based on what we know at the moment, is that enough to be able to say ‘right, let’s stop, let’s use this intervention’ or should we be saying ‘no, we’re really not that sure about the best treatment to offer to people with this particular condition and should carry out a new clinical trial to learn more’.”
Nicky is developing these ‘value of information’ analyses so that they can be carried out by statisticians and health economists as a routine part of preparing for clinical trials.
The information can then be submitted alongside all the other evidence so that NICE can decide whether to adopt a treatment in the NHS, or say it should be used only for research purposes.
Funders of clinical trials, such as the NIHR’s Health Technology Assessment programme (NIHR HTA), can also use the information to decide whether to fund a new trial.
In practice
There is no agreed treatment for severe sepsis, a deadly state in which the whole body has an inflammatory response against an infection. One potential — but expensive — treatment is intravenous immunoglobulin (IVIG).
There have been calls for a trial of IVIG for severe sepsis so the NIHR HTA commissioned a value of information analysis, which Nicky was involved in, to see whether it was appropriate for them to fund such a trial.
“We showed that there was value in running a trial but the quality of the evidence for IVIG is poor — we couldn’t say what the format of the trial should be because the science underlying IVIG as a treatment isn’t understood. Our conclusion was there’s a need for a trial but prior to that there really needs to be the basic, underlying research,” says Nicky.
The methods are pertinent at a time when resources are scarce, says Nicky, because the methods could focus resources on trials that are most needed, as well as stopping expensive treatments from being used until their cost-effectiveness has been proved.
Nicky is working on producing a set of step-by-step examples for those who will use the methods, covering a range of scenarios. “It’s also important to get the buy-in of clinicians so that these methods become accepted standard practice in trials,” she says.
Striking a balance
Nicky says she has struggled on occasion to balance her fellowship with the relatively senior stage that her career is at.
“I was already involved in quite a lot of staff management and lots of projects when I started,” she says, “I haven’t had a beautiful four-year stretch of time that I thought I’d have to focus on my fellowship work.”
But overall, this juggling is worth it, says Nicky. “I love maths and playing around with the algebra and writing the computer programs ... and I can go home at the end of the day and think ‘I did something that made a difference to people’s lives’. Not many people can say that.”
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Published February 2012