Session 4 - Evidence & Evidence-based practice / Resource Allocation Flashcards
(32 cards)
What constitutes ‘best evidence’?
Findings of rigorously conducted research that looks at the evidence in terms of effectiveness and cost-efficiency.
Why is evidenced-based healthcare important?
- Inappropriate interventions are a waste of resources.
- Variations in treatment create inequities.
- Care that has no evidence base is likely to cause harm.
- Represents a movement away from over-reliance on professional opinion (paternalistic care).
What are the origins of evidence-based healthcare?
Archie Cochrane - called for a register of all RCTs and wrote a book about effectiveness and efficiency.
The first registed focused on Obs & Gynae.
What is the standard definition of evidence-based practice?
The integration of individual clinical expertise with the best available external clinical evidence from systematic research
Why are systemic reviews needed?
- A traditional, narrative literature review may be subjective and biased.
- The quality of reviews varies, and some can be very poor.
- They provide an opportunity to highlight gaps in research.
Why are systemic reviews useful to clinicians?
- Offer quality control and increased certainty because they appraise and integrate findings.
- Offer up-to-date conclusions.
- Save clinicians from having to locate and appraise studies themselves.
- They can be easily converted into guidelines.
What are some critiques of evidence-based practice?
- May be impossible to create and maintain systematic reviews across all specialities.
- Can be challenging and expensive to disseminate and implement findings.
- RCTs are seen as the gold standard, but not always necessary or desirable.
What are some of the problems with trying to get evidence into practice?
- Doctors don’t know about the evidence.
- Doctors know about the evidence but don’t use it.
- Organisational systems cannot support innovation.
- Commissioning decisions reflect different priorities.
- Resources might not be available to implement change.
Why do priorities need to be set when thinking about resource allocation?
- Demand outstrips supply
- This scarcity of resources needs to be recognised.
What are the two forms of rationing when thinking about resource allocation?
- Explicit = based on defined rules of entitlement.
- Implicit = care is limited, but neither decisions nor the bases for these decisions are clearly expressed.
Provide a definition of EXPLICIT rationing and outlines some ADVANTAGES and DISADVANTAGES of this.
- The use of institutional procedures for the systematic allocation of resources within the health care system*
- ADVANTAGES*
- Transparent & accountable
- Opportunity for debate & equity in decision making.
- More clearly evidence-based
DISADVANTAGES
- Complex
- Some evidence of patient distress
- Can lead to patient and professional hostility
- Has an impact on clinical freedom
Provide a definition of IMPLICIT rationing and outlines some drawbacks of this approach
The allocation of resources through individual clinical decisions without the criteria for these decisions being explicit.
- Can lead to inequities and discrimination.
- Open to abuse.
- Decisions can be based on perceptions of ‘social deservingness’.
- Doctors appear unwilling to do this.
What is the National Institute for Health & Care Excellence (NICE)?
Set up to enable evidence of clinical and cost effectiveness to be integrated to inform a national judgement on the value of a treatment relative to alternative uses of resources.
Outline the 6 basic concepts in health economics.
- SCARCITY = need outstrips resources
- EFFICIENCY = getting the most out of limited resources.
- EQUITY = the extent to which the distribution of resources is fair.
- EFFECTIVENESS = the extent to which an intervention produces desired outcomes.
- UTILITY = the value an individual places on a health state.
- OPPORTUNITY COST = once you have used a resource in one way, it can’t be used elsewhere.
What is OPPORTUNITY COST?
When deciding to spend resources on a new treatment ‘A’, those resources cannot be used on treatments ‘B’, ‘C’, ‘D’ etc….
The OPPORTUNITY COST of the new treatment is the value of next best alternative use of those resources and it is measured in BENEFITS FOREGONE.
- What is techical efficiency?
- What is allocative efficiency?
- An interest in the most efficient way of meeting a need.*
- Choosing between the many needs to be met e.g. funding hip replacements vs neonatal care.*
What model is used for economic decision making?
INPUTS ===> OPTION ===> OUTPUTS
- Inputs are the resources
- Outputs are the benefits and value attached to them.
How can costs be measured?
- 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.
How can benefits be measured?
- Impact on health status (survival and/or quality of life)
- Savings in other healthcare resources (such as drugs, future hospitalisations & procedures) if the patient’s health status is improved
- Improved productivity if the patient, or family members return to work earlier.
What are the 4 types of economic evaluation used to compare costs and benefits?
- Cost minimisation analysis.
- Cost effectiveness analysis.
- Cost benefit analysis.
- Cost utility analysis.
What is COST MINIMISATION ANALYSIS?
- The outcomes are assumed to be equivalent and the focus is on the costs i.e. the INPUTS.
- Limited use as outcomes are rarely equivalent and so not easy to ignore.
What is COST EFFECTIVENESS ANALYSIS?
- Used to compare drugs or interventions which have a common health outcome e.g. reduction in BP.
- The comparison is in terms of cost per unit outcome e.g. cost per reduction of 5mm/Hg when thinking about BP.
- Key question is whether any additional benefit is worth the extra cost (if indeed there is one)…
What is a COST BENEFIT ANALYSIS?
- All inputs and outputs are valued in monetary terms.
- This allows comparison with interventions outside of healthcare.
- There are methodological difficulties with this approach i.e. trying to put a monetary value on non-monetary benefits.
What is a COST UTILITY ANALYSIS?
- Focuses on the quality of health outcomes produced or foregone.
- Most frequently measured in terms of Quality Adjusted Life Years (QALYs)
- Interventions can then be compared in cost per QALY terms.
