NICE to HELP: Operationalizing National Institute for Health and Clinical Excellence Guidelines to Improve Clinical Practice

The National Institute for Health and Clinical Excellence (NICE) in the United Kingdom developed guidelines for the diagnosis, prevention, and management of delirium in July 2010 that included 10 recommendations for delirium prevention. The Hospital Elder Life Program (HELP) is a targeted multicomponent strategy that has proven effective and cost‐effective at preventing functional and cognitive decline in hospitalized older persons. HELP provided much of the basis for seven of the NICE recommendations. Given interest by new HELP sites to meet NICE guidelines, three new protocols addressing hypoxia, infection, and pain that were not previously included in the HELP program were developed. In addition, the NICE dehydration guideline included constipation, which was not specifically addressed in the HELP protocols. This project describes the systematic development of three new protocols (hypoxia, infection, pain) and the expansion of an existing HELP protocol (constipation and dehydration) to achieve alignment between the HELP protocols and NICE guidelines. Following the Institute of Medicine recommendations for developing trustworthy guidelines, an interdisciplinary group of experts conducted a systematic review of current literature, rated the quality of the evidence, developed intervention protocols based on the highest‐quality evidence, and submitted the protocols first to internal review and then to external review by an interdisciplinary panel of experts. The protocols were revised based on the review process and incorporated into the HELP materials. Inclusion of these protocols enhances the scope of the HELP program and allows fulfillment of NICE guideline recommendations for delirium prevention. The rigorous process applied may provide a useful example for updating existing guidelines or protocols that may be applicable to a broad range of clinical applications.     

Secondary prevention for patients following a myocardial infarction: summary of NICE guidance

Mortality from coronary heart disease has been falling in the UK since the 1970s, but remains higher than in most other Western countries. Most patients receive some treatment for secondary prevention after myocardial infarction, but not all patients are offered the most effective secondary prevention package. The recently published NICE guideline for secondary prevention in patients after myocardial infarction, summarised in this article, makes clear recommendations for management of patients after myocardial infarction, based on best available evidence. The guidelines update the 2001 NICE guideline, and have expanded and emphasised the recommendations for physical activity, dietary and other lifestyle changes, and cardiac rehabilitation, and updated the recommendations for drug therapy.     

The impact of implementing national hypertension guidelines on prevalence and workload in primary care: a population-based survey of older people

Recently revised UK and US hypertension guidelines have reduced thresholds for both diagnosis and treatment and differ in their recommendations. We have used data from a random, stratified community-based sample of 4784 people aged 65 years and over to compare the prevalence of treatable hypertension and the potential impact on patients and primary care from using current guidelines. BHS, NICE and JNC7 guidelines were applied to blood pressures obtained from primary care medical records (94%) or measured at a screening clinic (6%). Risk factors were obtained by questionnaire and from medical records, supplemented by epidemiological data. Workload was estimated for a representative practice population of 10 000 patients. Blood pressures were obtained on 4514 patients (94%). Prevalence of treatable hypertension was over 67%. Compared to BHS4, prevalence estimates using NICE guidelines were comparable for men but significantly lower for women (P<0.05). They were significantly higher using JNC7 compared with BHS4 and NICE guidance (P<0.05). A general practice of 10 000 patients could expect 1287 older hypertensive patients using BHS4 guidelines and 1231 patients using NICE guidelines. Under BHS4, an extra 94 patients will require annual, rather than 5-yearly review compared with that using the previous guideline. In conclusion, implementation of BHS4 guidelines, with their revised thresholds for diagnosis, will not add materially to the prevalence of treatable hypertension compared to previous BHS3 guidelines but will have a major impact on practice workload. Use of NICE guidelines in preference to BHS4 will result in GPs treating fewer patients and reviewing untreated patients less often.     

The development of global consensus guidelines on the management and prevention of the diabetic foot 2011

Diabetic foot ulcers are the source of major suffering and very large costs for both the patient and the health-care system, and every 30 s, a leg is lost somewhere in the world. Investing in a diabetic foot care guideline can therefore be one of the most cost-effective forms of health-care expenditure, provided the guideline is goal focused and properly implemented. The objective of the International Working Group on the Diabetic Foot (IWGDF) is to develop guidelines that will reduce the effect of diabetic foot disease through cost-effective and quality health care, based on the principles of evidence-based medicine. These guidelines are produced by working groups of experts in the field and are endorsed by the more than 100 country representatives of the IWGDF. In 2009, the IWGDF invited again three working groups to write consensus guidelines on peripheral arterial disease, infection, and wound healing. New texts were produced according to a systematic review of the literature in order to inform protocols for routine care and to highlight areas that should be considered for further study. During a meeting of the members of the IWGDF in May 2011, the new set of guidelines was approved and is published in this journal.     

Routine screening during prenatal care: a systematic comparison of the do not do recommendations of the National Institute for Health and Care Excellence with North American evidence-based guidelines

BackgroundPopulation-wide screening measures during pregnancy might cause more harm than good in terms of health benefits. Therefore, the National Institute for Health and Care Excellence (NICE) formulated 14 do not do recommendations relating to 18 screening measures during pregnancy in the antenatal care guideline published in 2008. We aimed to compare do not do recommendations with evidence-based guidelines from developed countries other than the UK.MethodsWe systematically searched for corresponding recommendations in the guideline databases Guidelines International Network and National Guideline Clearinghouse applying a broad search strategy by using the keyword “screening”. Additionally, we searched websites of guideline development groups using disease-specific keywords. We included evidence-based guidelines published in English from Jan 1, 2007, to Dec 31, 2012, that dealt with routine screening during pregnancy. Guidelines had to fulfil predefined methodological quality criteria (ie, they needed to be based on a systematic literature search in at least two databases and needed to formulate recommendations explicitly linked to the underlying evidence).FindingsWe identified 13 relevant clinical practice guidelines from the USA and Canada covering 13 out of 18 do not do recommendations. The systematic guideline comparison showed that for seven screening measures recommendations were consistent. Differences across countries were observed for six screening measures: two of these screening measures not routinely recommended by NICE are explicitly recommended by North American clinical practice guidelines (chlamydia and streptococcus group B). Four of the six screening recommendations differed in terms of screening methods or the timing. For the remaining five of the 18 screening measures, we did not identify recommendations from the USA or Canada.InterpretationSeven of 18 prenatal screening recommendations from North American guidelines are in line with NICE do not do recommendations. The differences in six screening recommendations might be explained by specific contextual factors related to national health-care systems such as organisational aspects or disease prevalence. The comparison of international evidence-based guidelines can facilitate the re-evaluation of national public health programmes and can be a starting point for the appraisal of interventions in the national context.FundingThe Ludwig Boltzmann Institute for Health Technology Assessment is funded by national research funds (The Ludwig Boltzmann Gesellschaft) and by partner institutions (eg, the Federation of Austrian Social Insurance Institutions and the Austrian Ministry of Health). This in-depth comparison of screening recommendations was carried out within a larger project aiming at the reorientation of the Austrian parent-child preventive care programme on behalf of the Austrian Ministry of Health.     

Diagnosis and management of pancreatic cancer in adults: A summary of guidelines from the UK National Institute for Health and Care Excellence

To enable standardisation of care of pancreatic cancer patients and facilitate improvement in outcome, the United Kingdom's National Institute for Health and Care Excellence (NICE) developed a clinical guideline for the diagnosis and management of pancreatic cancer in adults. Systematic literature searches, systematic review and meta-analyses were undertaken. Recommendations were drafted on the basis of the group's interpretation of the best available evidence of clinical and cost effectiveness. There was patient involvement and public consultation. Recommendations were made on: diagnosis; staging; monitoring of inherited high risk; psychological support; pain; nutrition management; and the specific management of people with resectable-, borderline-resectable- and unresectable-pancreatic cancer. The guideline committee also made recommendations for future research into neoadjuvant therapy, cachexia interventions, minimally invasive pancreatectomy, pain management and psychological support needs. These NICE guidelines aim to promote best current practice and support and stimulate research and innovation in pancreatic cancer.     

Guidelines to Practice Gap in the Use of Glycoprotein IIb/IIIa Inhibitors: From ISAR‐REACT to Overreact?

Adjunctive use of glycoprotein IIb/IIIa inhibitors (GPI) is associated with favorable outcomes following percutaneous coronary intervention (PCI). Guidelines for use of GPI have been published by various national societies including National Institute of Clinical Excellence (NICE), United Kingdom. The latter has not been updated since publication. The impact of contemporary trials such as ISAR-REACT (which showed no benefit of abciximab and 600 mg of clopidogrel compared with 600 mg of clopidogrel alone, in elective patients) on adherence to NICE guidelines is unknown.
Methods: We audited use of GPI against NICE guidelines following publication in May 2002. Data were collected from 1,685 patients between September and November in years 2002, 2003, 2004, and 2007.
Results: In 2002 and 2003, only 10.2% and 11.8%, respectively, of patients were noncompliant to NICE guidelines. Over time, there was an increase in patients not given GPI despite meeting NICE criteria. After publication of ISAR-REACT, the comparative figures for noncompliance in 2004 and 2007 were 40.0% and 44.5%. A similar pattern was seen in patients with diabetes; in 2002 and 2003 noncompliance was 16.7% and 11.1%, respectively, and in 2004 and 2007 noncompliance was 38.0% and 44.7%, respectively. Qualitatively, similar findings were recorded in patients with NSTE-ACS. The overall noncompliance to NICE guidelines increased from 11.0% to 42.1% (P < 0.0001) after the ISAR-REACT study.
Conclusions: We found a decline in compliance to NICE guidelines on GPI usage during PCI. This was likely influenced by contemporary trials demonstrating little or no benefit of GPI in patients undergoing elective PCI who are adequately pretreated with clopidogrel. Our findings suggest the need for a mechanism whereby regular updates to guidelines can be disseminated following new trial evidence.     

中国2型糖尿病防治指南（2013年版）更新要点的解读

近日,由中华医学会糖尿病学分会制定的《中国2型糖尿病防治指南（2013年版）》（下称“新版指南”）正式发布.该指南是继2010年版指南之后的新版指南,其内容强调需符合我国国情和疾病变迁特征,反映了我国糖尿病相关研究和防治策略的进展.新版指南在汇集国内证据和参考国外证据的基础上编撰而成,并对前一版指南的内容进行了丰富,更加关注T2DM防治的临床和应用.本文着重从T2DM的更新要点进行解读,并与国外指南及循证证据进行对比.     

Guidelines for chronic obstructive pulmonary disease treatment and issues of implementation

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Treatment advances over the last decade, although limited, have precipitated the development of clinical practice guidelines, with the aim of improving the quality of care received by patients through fostering evidence-based decision making and accelerating the application of new advances to everyday practice. Of the COPD guidelines that have been developed, those developed through the Global Initiative for Chronic Obstructive Lung Disease (GOLD), initially a joint activity between the U.S. National Heart, Lung, and Blood Institute and the World Health Organization, and the National Institute of Clinical Excellence (NICE) in the United Kingdom have both published their methods for evaluation of evidence. These comprehensive guidelines cover all aspects of the disease, with the aim of providing the basis for local care pathways. The guideline development process includes evaluation of the evidence, development of the guideline, and dissemination of the findings. Efforts to enhance guideline effectiveness have focused on improving the methods and approaches to implementation, which requires an appreciation of the issues that stop translation of guideline definitions of best practice into improved patient care. A variety of questions remain unanswered in the clinical management of COPD, including the definition of outcome measures that move beyond lung function, the potential application of multidimensional grading systems that assess respiratory and systemic expressions of COPD and that could possibly better categorize and predict outcome in these patients, and the impact of new clinical trial findings. Large ongoing outcome studies may also have an effect on defining best practice within future guideline recommendations.     

Adherence of published diabetes mellitus practice guidelines to methodologic standards of guideline development.

There are multiple practice guidelines published pertaining to diabetes care. Experts have formulated methodologic standards of guideline formulation. To determine whether practice guidelines pertaining to diabetes and published in peer-reviewed publications and the Internet adhered to established methodologic standards of guideline development. We identified all guidelines pertaining to diabetes care published between 1980 and 2000 using a computerized search of Medline, the Practice Guidelines Clearinghouse, the Institute for Clinical Systems Improvement Web site, and a global internet search engine. We used a previously validated 25-item assessment tool to determine guideline adherence to methodologic standards in three categories: guideline development and format, identification and summary of evidence, and formulation of recommendations. We conducted a multivariable regression analysis to determine the influence of guideline author, publishing medium, year of publication, and guidelines length on adherence to methodologic standards of guideline development. We evaluated 43 guidelines: 33% published on the Internet, 66% in peer-reviewed journals; 51% published by organizations, and 49% by individual experts. Of a maximum of 25 methodologic standards, the number of standards adhered by a guideline was 9 (range, 2 to 19). Mean proportion (SD) of guidelines that adhered to methodologic standards on guideline development and format was 48% (28); on identification and summary of evidence, 21% (22); and on the formulation of recommendations, 36% (27). Longer guidelines had greater adherence to methodologic standards (P < 0.0001). Guidelines pertaining to diabetes care published on the internet and in peer-reviewed publications do not meet most methodologic standards of guideline development.     

New guidelines for the management of adult community-acquired pneumonia

PURPOSE OF REVIEW: Community-acquired pneumonia is a major cause of morbidity and mortality, and is the leading cause of death from an infectious disease. International societies have published and revised guidelines aiming to improve the management of adult community-acquired pneumonia, based on the best available evidence. The aim of this review is to compare the current guideline recommendations. RECENT FINDINGS: Aspects of guidelines differ based on local factors including resources and antimicrobial factors, as well as the differences in interpretation of existing evidence. SUMMARY: The lack of robust evidence behind aspects of guideline recommendations as well as the lack of adherence to published guidelines both need to be addressed if the management of community-acquired pneumonia is to be improved.     

Clopidogrel in non-ST segment elevation acute coronary syndromes: an overview of the submission by the British Cardiac Society and the Royal College of Physicians of London to the National Institute for Clinical Excellence, and beyond

A comprehensive appraisal was undertaken on behalf of the British Cardiac Society and the Royal College of Physicians of London to assess the use of clopidogrel in acute coronary syndromes. The appraisal was submitted to the National Institute for Clinical Excellence (NICE) in August 2003 and contributed to the development of the recently published guidelines for the use of clopidogrel in acute coronary syndromes. The submission to NICE and more recent publications evaluating the use of clopidogrel are reviewed.     

The updated BSR guidelines for anti‐TNF in adults with RA: What has changed and why?

In 2001 the British Society for Rheumatology (BSR) published guidelines for prescribing TNF-alphablockers in adults with rheumatoid arthritis (RA). In an unusual move, the National Institute of Clinical Excellence (NICE) accepted the BSR guidelines and published them unchanged and included them in their own Technology Appraisal (National Institute of Clinical Excellence, 2002). The field of anti-TNF in RA is rapidly changing, and the BSR Standards, Guidelines and Audit Working Group decided in 2004 to update the guidelines. These were published in February 2005 (Ledingham and Deighton, 2005). This article summarizes the key changes, and attempts to justify them, using further data that has emerged since the updated guidelines were produced, and audit data from the Derby Rheumatology department.     

Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA).

This is part of the series of practice guidelines commissioned by the Infectious Diseases Society of America (IDSA) through its Practice Guidelines Committee. The purpose of this guideline is to provide assistance to clinicians in the diagnosis and treatment of two specific types of urinary tract infections (UTIs): uncomplicated, acute, symptomatic bacterial cystitis and acute pyelonephritis in women. The guideline does not contain recommendations for asymptomatic bacteriuria, complicated UTIs, Foley catheter-associated infections, UTIs in men or children, or prostatitis. The targeted providers are internists and family practitioners. The targeted groups are immunocompetent women. Criteria are specified for determining whether the inpatient or outpatient setting is appropriate for treatment. Differences from other guidelines written on this topic include use of laboratory criteria for diagnosis and approach to antimicrobial therapy. Panel members represented experts in adult infectious diseases and urology. The guidelines are evidence-based. A standard ranking system is used for the strength of the recommendation and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council, the sponsor and supporter of the guideline. The American Urologic Association and the European Society of Clinical Microbiology and Infectious Diseases have endorsed it. An executive summary and tables highlight the major recommendations. Performance measures are described to aid in monitoring compliance with the guideline. The guideline will be listed on the IDSA home page at http://www.idsociety.org It will be evaluated for updating in 2 years.     

Principles and methodology of K/DOQI clinical guidelines

NKF (National Kidney Foundation) launched the Dialysis Outcomes Quality Initiatives (DOQI) in 1995 and reported first guideline on dialysis therapy in Autumn of 1997. In 1999, DOQI was further developed into the Kidney Disease Outcomes Initiatives (K/DOQI), in which the target of clinical practice has included the entire phase of chronic kidney diseases (CKD). K/DOQI revised first guideline by DOQI in 2002 and also published the "Chronic Kidney Disease:Evaluation, Classification, and Stratification" in 2002 and "Proteinuria and Other Markers of Chronic Kidney Disease "in 2003, and then "Bone Metabolism and Disease in Chronic Kidney Disease" in the fall of 2003. These guidelines were prepared by working group and review team. For instance, the review team first searched 4,233 literatures and finally 467 relevant literatures was selected for citation as the basis of evidence. Based on the summary table of these literatures, working group prepared a draft guideline. Finally, the present guideline consists of 201 pages totally and reflects a dedicated effort by the team. K/DOQI has now started the effort to develop their guideline into truly a global one.     

Stroke Prevention,Evaluation of Bleeding Risk,and Anticoagulant Treatment Management in Atrial Fibrillation Contemporary International Guidelines

In recent years the management of atrial fibrillation patients has progressively and substantially changed because of the introduction of new treatments and the availability of new data regarding the epidemiology and clinical management of these patients. In the past 2 years alone, there have been 7 new guidelines or guideline updates that have been published, which have introduced new recommendations and significantly revised previously published ones. Two updates for Canadian guidelines were published in 2016 and 2018, whereas guidelines from the European Society of Cardiology in 2016, Asia Pacific Heart Rhythm Society were published in 2017, National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand, American College of Chest Physicians, and Korean Heart Rhythm Society have been published in 2018. In this narrative review we provide a comparison of these contemporary international guidelines, with particular attention on the evaluation of thromboembolic and bleeding risks and management of oral anticoagulant therapy. From the analysis of contemporary guidelines on the management of atrial fibrillation, a general agreement is evident about the baseline evaluation of thromboembolic and bleeding risk, as well as a preference for the use of non-vitamin K antagonist oral anticoagulants. Also, regarding the concomitant use of oral anticoagulant and antiplatelet drugs in patients with acute coronary syndromes, undergoing elective percutaneous coronary intervention, catheter ablation, and cardioversion procedures, all of the guidelines agree on the general principles and are supported by evidence. More data are still needed to better substantiate recommendations for specific atrial fibrillation subpopulations. The need for an integrated approach and holistic management is highlighted in the more recently published guidelines.     

Diabetes UK evidence‐based nutrition guidelines for the prevention and management of diabetes

A summary of the latest evidence‐based nutrition guidelines for the prevention and management of diabetes is presented. These guidelines are based on existing recommendations last published in 2011, and were formulated by an expert panel of specialist dietitians after a literature review of recent evidence. Recommendations have been made in terms of foods rather than nutrients wherever possible. Guidelines for education and care delivery, prevention of Type 2 diabetes, glycaemic control for Type 1 and Type 2 diabetes, cardiovascular disease risk management, management of diabetes‐related complications, other considerations including comorbidities, nutrition support, pregnancy and lactation, eating disorders, micronutrients, food supplements, functional foods, commercial diabetic foods and nutritive and non‐nutritive sweeteners are included. The sections on pregnancy and prevention of Type 2 diabetes have been enlarged and the weight management section modified to include considerations of remission of Type 2 diabetes. A section evaluating detailed considerations in ethnic minorities has been included as a new topic. The guidelines were graded using adapted ‘GRADE’ methodology and, where strong evidence was lacking, grading was not allocated. These 2018 guidelines emphasize a flexible, individualized approach to diabetes management and weight loss and highlight the emerging evidence for remission of Type 2 diabetes. The full guideline document is available at www.diabetes.org.uk/nutrition-guidelines .     

Balancing vision with pragmatism: The geriatric emergency department guidelines-realistic expectations from emergency medicine and geriatric medicine

In 2014 the Geriatric Emergency Department (GED) Guidelines were published and endorsed by four major medical organizations. The multidisciplinary GED Guidelines characterize the complex needs of the older emergency department (ED) patient and current best practices with the goal of promoting more cost-effective and patient-centered care. The recommendations are extensive and the vast majority of EDs then and now do not have either the resources nor hospital administrative support to provide this additional service. At the 2021 American Academy of Emergency Medicine's Scientific Assembly, a panel of emergency medicine physicians and geriatricians discussed the GED Guidelines and the current realities of EDs' capacity to provide best practice and guideline recommended care of GED patients. This article is a synthesis of the panel's presentation and discussion. With the substantial challenges in providing guideline recommended care in EDs, this article will explore three high impact GED clinical conditions to highlight guideline recommendations, challenges and opportunities, and discuss realistically achievable expectations for non-Geriatric ED accredited institutions. In 2014 the Geriatric Emergency Department Guidelines were published describing the current best practices for geriatric ED patients. Unfortunately, the vast majority of EDs worldwide do not provide the level of service recommended by the GED guidelines. The GED Guidelines can best be termed aspirational for U.S. EDs at the present time.     

Severe acute pancreatitis: pathogenesis,diagnosis and surgical management

BACKGROUND: Severe acute pancreatitis is a subtype of acute pancreatitis, associated with multiple organ failure and systemic inflammatory response syndrome. In this qualitative review we looked at the principles of pathogenesis, classification and surgical management of severe acute pancreatitis. We also looked at the current shift in paradigm in the management of severe acute pancreatitis since the guideline developed by the British Society of Gastroenterology.DATA SOURCES: Studies published between 1st January 1991 and 31st December 2015 were identified with Pub Med, MEDLINE, EMBASE and Google Scholar online search engines using the following Medical Subject Headings: "acute pancreatitis, necrosis, mortality, pathogenesis, incidence" and the terms "open necrosectomy and minimally invasive necrosectomy".The National Institute of Clinical Excellence(NICE) Guidelines were also included in our study. Inclusion criteria for our clinical review included established guidelines, randomized controlled trials and non-randomized controlled trials with a follow-up duration of more than 6 weeks.RESULTS: The incidence of severe acute pancreatitis within the UK is significantly rising and pathogenetic theories are still controversial. In developed countries, the most common cause is biliary calculi. The British Society of Gastroenterology,acknowledges the Revised Atlanta criteria for prediction of severity. A newer Determinant-based system has been developed.The principle of surgical management of acute necrotizing pancreatitis requires intensive care management, identifying infection and if indicated, debridement of any infected necrotic area. The current procedures opted for include standard surgical open necrosectomy, endoscopic necrosectomy and minimally invasive necrosectomy. The current paradigm is shifting towards a step-up approach.CONCLUSIONS: Severe acute pancreatitis is still a subject of grey areas in its surgical management even though new studies have been recorded since the origin of the latest UK guidelines for management of severe acute pancreatitis.     

The use of plain radiography in diagnosing osteoarthritis: A systematic review and time trend analysis

Introduction

The National Institute for Health and Care Excellence (NICE) suggest there is no role for routine radiography in the diagnosis of osteoarthritis (OA). It is not known how consistent this recommendation is across international guidelines, or the impact of UK guidance on domestic OA X-ray request rates.

Methods

A systematic search identified guideline recommendations on the role of radiography in OA diagnosis. Full texts underwent dual screening and appraisal using the AGREE II tool. A narrative synthesis was performed. Consultation data were extracted from a UK primary care database: the Consultations in Primary Care Archives (CiPCA). The annual proportion of X-ray requests per 100 OA consulters from 2000 to 2012 were calculated. Joinpoint regression analysis examined if there were changes in the trend of X-ray request rates and compared these with the publication dates of UK guidelines.

Results

Eighteen evidence-based OA guidelines were included in the review. Eleven recommended a clinical diagnosis of OA without radiographic confirmation. Seven recommended routine radiography; these guidelines were predominantly for radiologists. A mean of 17.3 X-rays per 100 patients were requested in patients consulting for OA per year between 2000 and 2012. A statistically significant reduction in X-ray request rates was seen in 2003.

Conclusion

Recommendations on the role of radiography in OA vary between medical specialty and countries. UK guidelines appear to have had a limited impact on X-ray request rates in OA.