Evidence-Based Practice Flashcards
What should heatlh service delivery be based on?
The best available evidence
What is the best evidence based on?
The findings of rigorously conduced research
What does the evidence that health service delivery should be based on concern?
- Effectiveness
- Cost-effectiveness
What needs evidence regarding effectiveness?
- Drugs
- Practices
- Interventions
Why does the health service need best evidence regarding cost-effectiveness?
In a system with finite resources, should be considered where money can be spent ot gain maximum utility
What is the problem with ineffective and inappropriate interventions?
They waste resources that could be used more effectively
What do variations in treatment cause?
Inequities
What are practices influenced too much by?
- Professional opinion
- Clinical fashion
- Historical practice and precedent
- Organisational and social culture
What has research shown that clinicians often do regarding evidence-based practice?
- Persisted in using interventions that are ineffective
- Failed to take up other interventions known to be effective
- Tolerated huge variations in practice
What sets out the principles of evidence-based practice?
Archie Cochrane’s book, Effectiveness and efficiency; random reflections of health services
What did Archie Cochrane’s book say?
- Criticised medical profession for failing to take account of research
- Caller for register of all RCTs
What resulted from Archie Cochranes call for a register of all RCTs?
Group in Oxford lead by Iain Chalmers responeded to this, and produced a register of all RCTs in obstetrics and gynacology, becoming the first ‘Cochrane Centre’
What did Iain Chalmers Cochrange centre contain?
Systematic reviews and meta-analyses of data and evidence produced by RCTs
What followed from Iain Chalmers Cochrane Centre?
Other Cochrane Centres were set up elsewhere
What does evidence based practice involve?
The integration of individual clinical expertise with the best available external clinical evidence from systematic research
What is evidence based practice also known as?
Evidence-based healthcare and evidence-based medicine
Where have systematic reviews and meta-analyses become very important?
In informing evidence base
What do doctors need, regarding systemic reviews and meta-analyses?
Need to have an understanding of these methods and be able to critically appraise them
Why are systematic reviews and meta-analyses needed?
- Some traditional, ‘narrative’ literature reviews may be biased and subjective
- Not easy to see how studies were identified for review
- Quality of studies variable and sometimes poor
- Systematic reviews are useful to help address clinical uncertainty
- Systematic reviews can highlight gaps in research/poor quality research
Why 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
- They can help prevent biased decisions being made
- They can be relatively easily converted to guidelines and recommendations
Why do doctors need to be able to access systematic reviews?
To appraise them and be satisfied about the quality of the evidence
How is assessment of the quality of evidence easiest and best done?
Using a ‘critical appraisal tool’ or instrument
What do critical appraisal tools do?
Suggest the things to took for, and the questions to ask of, research articles
Where can evidence be found?
- Medical journals
- Cochrane Collaboration
- Centre for Reviews and Dissemination
- NIHR Dissemination Centre
- NIHR Health Technology Assessment Programme
What is the advantage of medical journals?
They are ruptable and peer reviewed
What do medical journals often publish?
Systematic reviews
What are EBP-specific journals?
A more recent phenomenon that focus on critical appraisal and dissemination of research findings relevant to population health
What does the Cochrane library include?
Links to databases and other resources
Who is in charge of the Centre for Reviews and Dissemination?
The University of York
What is the Centre for Reviews and Dissemination?
A national centre to lead the review, management, and dissemination of research findings relevant to population health
What does the NIHR Dissemination Centre do?
Critically appraises the latest health research from both within NIHR and other research organisations to identify the most reliable, relevant, and significant findings
What does the NIHR Health Technology Assessment Programme do?
Aims to produce high quality research information on the costs, effectiveness, and broader impact of health technologies
What does the NIHR Health Technology Assessment Programme include?
Primary research and systematic reviews
On what basis has the evidence-based practice movement been criticised?
- Practical criticisms around possibility of evidence based practice
- Philosophical criticisms around desirability of evidence-based practice
What are the practical cricisms around the possibility of evidence based practice?
- 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
- Choice of outcomes are often very biomedical
- Requires good faith on the part of the pharmacuteical companies
What is the result of the choice of outcomes of evidence-based practice being very biomedical?
May limit the interventions which are trialled, and therefore which are funded
What are the philosophical critcisms around desirability of evidence-based practice?
- Does not align with most doctors modes of reasoning
- Aggregate, population-level outcomes don’t mean that the intervention will work for an individual
- Potential of EBM (or it’s implementation, e.g. through NICE or clinical governance) to create ‘unreflective rule followers’ out of professionals
- Might be understoof as a means of legitimising rationing
- Professional responsibility/autonomy
What is the problem with EBM being seen as a means to legitimise rationing?
Potential to undermine trust in doctor-patient relationship, and ultimately the NHS
What are the limitations of evidence-based practice?
- Many ineffective practices continue
- Some effective practices are not implemeted
- Existence of evidence does not ensure implementation of evidence based practice
Why doesn’t existence of evidence ensure that implementation of EBP?
- Evidence exists, but doctors don’t know about it
- Doctors know about the evidence, but don’t use it
- Organisational systems cannot support innervation
- Commissioning decisions reflect different priorities
- Resources not available to implement changes
Why may doctors not know about existing evidence?
- Dissemination may be ineffective
- Doctors aren’t incentivised to keep up to date
Why may doctors not use evidence that they know about?
- Habit
- Organisational culture
- Professional judgement
Why can’t organisational systems support innervation?
Because managers lack ‘clout’ to invoke changes
What is meant by commissioning decisions reflecting different priorities?
What if patients want something else?
What kind of resources are not available to implement change?
- Financial
- Human
What is the problem with changing management?
A complicated and demanding process
What are the widespread changes in healthcare due to?
Partly due to policies such as clinical governance and establishment of Care Quality Commission and NICE
What are NHS organisations legally obliged to do, regarding NICE?
Follow NICE guidelines within 3 months
Why may the problem of being reluctant to fund things for which the evidence is poor become more prominent?
Because of the increasing austerity in the NHS
