Evidence-Based Healthcare

Question 0

What are some of the arguments for evidence-based healthcare?

Answer 0

• health service delivery should be based on best available evidence (findings of rigorously conducted research)
• effectiveness of drugs, practices, and interventions
• cost-effectiveness: where money should be spent to gain then maximum utility
• ineffective/inappropriate interventions waste resources
• variations in treatment create inequities
• previous practices overly influenced: professional opinion, clinical fashion, historical practice & precedent

Question 1

What are the origins of evidence-based healthcare?

Answer 1

Cochrane criticised the medical profession for failing to take medical research into account:

• doctors persisted in using health care interventions that are ineffective/harmful e.g. prophylactic use of lidocaine during MI shown to be more harmful than placebo
• failure to take up other interventions known to be effective e.g. despite long term use of magnesium sulfate to treat eclampsia seizures in the USA, by 1992 only 2% of clinicians in the UK used this treatment
• tolerated huge variations in practice —> inequities

Cochrane called for register of all RCTs. Group in Oxford responded by:

• producing registers of all RCTs in OBGYN
• performing systematic reviews & meta-analyses of data and evidence produced by RCTs

This became the first Cochrane Centre —> later formed Cochrane Collaboration

Question 2

What is the main criticism of evidence-based practice?

Answer 2

How evidence-based practice is implemented

e.g. incentives, targets

Takes away from patients’ wishes & clinicians’ judgements

Question 3

Why are systematic reviews needed? How are they useful to clinicians?

Answer 3

• traditional literature reviews may be biased/subjective
• difficult to see how studies were identified for review
• quality of studies reviewed are variable
• help address clinical uncertainty
• highlight gaps in research
• provides quality control/increased certainty for intervention
• offers authoritative, generalisable, and up-to-date conclusions
• saves clinicians from having to locate and appraise studies themselves
• reduces delay between research discoveries and implementation
• prevents biased decisions being made
• relatively easily converted into guidelines/recommendations

Question 4

What is a critical appraisal tool?

Answer 4

Tool which suggests things to look for & questions to ask of research articles

Question 5

Give some examples of sources of systematic reviews.

Answer 5

• medical journals (peer-reviewed)
• evidence-based practice specific journals (focus on critical appraisals/systematic reviews)
• Cochrane Collaboration = Cochrane Controlled Trials Register, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Cochrane Review Methodology Database
• NHS Centre for Reviews and Dissemination (review, management, and dissemination of research findings)
• NIHR Health Technology Assessment Programme (produce high quality research information on the costs, effectiveness, and broader impact of health technology)

Question 6

What are some practical criticisms of evidence-based practice?

Answer 6

• may be impossible to create and maintain systematic reviews across all specialities
• may be challenging/expensive to disseminate/implement findings
• RCTs not always feasible or even necessary/desirable e.g. due to ethical considerations
• choice of outcomes often very biomedical, which limits which interventions are trialled/funded
• requires ‘good faith’ on part of pharmaceutical companies

Question 7

What are some philosophical criticisms of evidence-based practice?

Answer 7

• does not align with most doctors’ modes of reasoning: probabilistic causality (whether on average, it is likely to work) v.s. deterministic causality (why it works/method of action)
• aggregate, population-level outcomes do not mean that an intervention will work for an individual
• potential of evidence-based medicine (or its implementation) to create ‘unreflective rule followers’
• understood as means of legitimising rationing (potential to undermine trust in the doctor-patient relationship & NHS)
• professional responsibility/autonomy

Question 8

What are some of the problems involved in the implementation of evidence-based practice?

Answer 8

• evidence exists, but doctors do not know about it (ineffective dissemination? doctors not incentivised to keep up-to-date)
• doctors do not know how to use evidence (habit? organisational culture? professional judgement?)
• organisational systems cannot support innovation e.g. managers lack clout to invoke changes
• commissioning decisions reflect direct priorities e.g. what if patients say they want something else?
• resources not available to implement change (financial or human)

Question 9

What are some challenges in conducting randomised controlled trials? ….

Answer 9

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