Evidence-Based Practice Flashcards
Define evidence-based practice
Evidence-based practice involves the integration of individual clinical expertise with the best available external clinical evidence from systematic research
(“External clinical evidence can inform, but it can never replace, individual clinical expertise”)
What are the origins of evidence-based healthcare?
There was the argument that:
- Healthcare service delivery should be based on the
best available evidence
- Best evidence=findings of rigorously conducted
research
- Evidence of:
- Effectiveness (of drugs, practices, interventions)
- Cost-effectiveness (in a system with finite
resources where should the money be spent to
gain the maximum utility?)
Healthcare at the time:
- Ineffective and inappropriate interventions waste
resources that could be used more effectively
- Variations in treatment create inequalities
- Previously practice influenced (too much ) by:
professional opinion, clinical fashion, historical
practice and precedent, organisational and social
culture.
What did research reveal in problems with Healthcare before the use of evidence-based medicine?
Showed that clinicians:
- Persisted in using health care interventions that are
ineffective
- Failed to take up other interventions known to be
effective
- Tolerated huge variations in practice
Examples include the use of lidocaine as a prophylactic during MI, which was shown to be more harmful.
And clinicians in the UK not treating eclamptic seizures with MgSO4 even though it was proved to be effective in the US
And the Cochrane Collaboration was created, which compiled lots of RCTs, an example being the use of corticosteroids for pregnant women in risk of premature births, and the RCTs showed that this could have saved tens of thousands of babies lives.
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
How are systematic reviews useful to clinicians?
By appraising and integrating findings, they offer both quality control and increased certainty
They offer authoritative, generalisable and up to date conclusions
They save clinicians from having to locate and appraise the studies for themselves
They may reduce delay between research discoveries and implementation
What are the practical criticisms of evidence-based practice?
May be an impossible task to create and maintain systematic reviews
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 funded (e.g. NICE guidance)
Requires “good faith” on the part of the pharmaceutical companies
What are the philosophical criticisms 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) to create
“unreflective rule followers” out of professionals
Might be understood as a means of legitimising rationing, with the potential to undermine trust in the doctor-patient relationship, and ultimately the NHS
Professional responsibility/autonomy
What are the problems of getting evidence into practice?
Evidence exists but doctors don’t know about it
- Dissemination ineffective? Doctors not incentivised
to keep up-to-date?
Doctors know about the evidence but don’t use it
Organisational systems cannot support innovation
Commissioning decisions reflect different priorities
Resources not available
How is evidence getting into practice now?
Policies such as clinical governance and the establishment of the Care Quality Commission and NICE
- NHS organisations now legally obliged to follow NICE
guidance within three months of issue
Reluctance to fund things for which the evidence is poor
