Session 4 Flashcards
What is evidence? How should health service be delivered? What is important with regards to evidence?
The available body of facts/information indicating whether a belief/proposition is true or valid.
-Health service: should be based on best available evidence - has to been effective (drugs/practice/interventions) and cost-effective (in a system with finite resources, where should money be spent to gain max utility?)
What is a systematic review?
Review of literature on a particular intervention –> reviews do higher level analysis, weighting different research/work for reliability, in order to get a big overarching conclusion on whether that intervention works or not (meta-analysis)
What are practices (negatively) influenced by?
Professional opinion
Clinical fashion
Historical practice/precedent
Organisational and social culture
What is a randomised control trial?
Answer later
What does evidence based practice involve?
•Evidence-based practice involves the integration of individual clinical expertise WITH the best available external clinical evidence from systematic research
Why are systematic reviews needed?
-Traditional, “narrative” literature reviews may be biased
and subjective
• Not easy to see how studies were identified for review
• Quality of studies reviewed variable and sometimes poor
• Systematic reviews are useful - can help address clinical
uncertainty
• Systematic reviews can also highlight gaps in
research/poor quality research
What can systematic reviews help clinicians achieve?
• They can help to prevent biased decisions being
made
• They can be relatively easily converted into
guidelines and recommendations
• However, doctors need to be able to access
systematic reviews and to appraise them to be
satisfied about the quality of the evidence
What gaps/mistakes do systematic reviews help to avoid?
• They can help to prevent biased decisions being
made
• They can be relatively easily converted into guidelines and recommendations
• However, doctors need to be able to access systematic reviews and to appraise them to be satisfied about the quality of the evidence
What are critiques of the evidence-based practice movement?
- ‘Practical criticisms’: around the possibility of evidence- based practice
- ‘Philosophical criticisms’: around the desirability of evidence-based practice
What are practical limitations for evidence-based practice research?
• May be an impossible task to create and maintain systematic reviews across all specialities
• May be challenging and expensive to disseminate and
implement findings
• RCTs are seen as the gold standard but not always feasible or
even necessary/desirable (e.g. due to ethical considerations)
• Choice of outcomes often very biomedical, which may limit
which interventions are trialled, and therefore which are funded
(e.g. NICE guidance)
• Requires ‘good faith’ on the part of pharmaceutical companies
What are philosophical cliques of evidence based practice?
• ‘Does not align with (most) doctors’ modes of reasoning
(probabilistic versus deterministic causality)
• Aggregate, population-level outcomes don’t mean that an
intervention will work for an individual
• Potential of EBM (or its implementation, e.g. through NICE or clinical
governance) to create ‘unreflective rule followers’ out of
professionals
• Might be understood as a means of legitimising rationing, with
potential to undermine trust in the doctor-patient relationship, and
ultimately the NHS
• Professional responsibility/autonomy
What are some problems with getting evidence and then integrating it into practice?
- Evidence exists but doctors don’t know about it
- Doctors know about evidence but don’t use it
- Organisational system cannot support innovation
- Commissioning decisions reflects different priorities
- Resources not available to implement change
What are the two forms of rationing? Describe them
- Explicit rationing: based on defined rules of entitlement.
- Implicit rationing: care is limited, but neither the decisions, nor the bases for those decisions are clearly expressed.
What are the drawbacks with implicit rationing?
Implicit rationing is the allocation of resources through individual clinical decisions without the criteria for those decisions being explicit
• Can lead to inequities and discrimination
• Open to abuse
• Decisions based on perceptions of “social
deservingness”
• Doctors appear increasingly unwilling to do it
What are advantages of explicit rationing?
ADVANTAGES • Transparent, accountable • Opportunity for debate • More clearly evidence-based • More opportunities for equity in decision-making
What are disadvantages of explicit rationing
- Very complex
- Heterogeneity of patients and illnesses
- Patient and professional hostility
- Impact on clinical freedom
- Some evidence of patient distress
What is NICE?
-why where they set up? What does it do?
National institute for Health and Care Excellent
• Set up to ‘enable evidence of clinical and cost effectiveness to be
integrated to inform a national judgement on the value of a
treatment(s) relative to alternative uses of resources’ • Provides guidance on whether treatments (new or existing) can
be recommended for use in the NHS in England.
• Set up to ‘enable evidence of clinical and cost effectiveness to be
integrated to inform a national judgement on the value of a
treatment(s) relative to alternative uses of resources’
• Provides guidance on whether treatments (new or existing) can
be recommended for use in the NHS in England.
What is scarcity? Efficiency? Equity? Effectiveness? Utility, Opportunity cost?
See PP
What is opportunity cost? When is it relevant?
• When deciding to spend resources on a new treatment,
those resources cannot now be used on other treatments.
• The opportunity cost of the new treatment is the value of
the next best alternative use of those resources.
– Cost is viewed as sacrifice rather than financial
expenditure
• Opportunity cost is measured in BENEFITS FOREGONE
What is technical efficiency? What allocative efficiency?
• Technical efficiency – you are interested in the most
efficient way of meeting a need (e.g. should antenatal
care be community or hospital-based?)
• Allocative efficiency – you are choosing between the
many needs to be met (e.g. fund hip replacements or
neonatal care?)
What is economic evaluation? Why do we use it?
• Comparison of resource implications
and benefits of alternative ways of
delivering healthcare
• Can facilitate decisions so that they are more transparent and fair
What does an economic analysis do?
An economic analysis compares the inputs (resources) and outputs (benefits and value attached to them) of alternative interventions. This allows better decisions to be made about which interventions represent best value for investment.
How do you measure cost? What are categories of cost?
• Identify, quantify and value resources needed • Categories of costs: – Costs of the healthcare services – Costs of the patient’s time – Costs associated with care-giving – Other costs associated with illness – Economic costs borne by the employers, other employees and the rest of society
How do you measure benefits?
• Benefits are harder to measure
• Improved (or maintained) health hard to value
• Categories of benefits/consequences:
– Impact on health status (in terms of survival or quality of life or
both);
– Savings in other healthcare resources (such as drugs,
hospitalisations, procedures, etc.) if the patient’s health state is
improved
– Improved productivity if patient, or family members, returns to work
earlier
