Health informatics and evidence based practice (don't need to regurgitate but understand) Flashcards
Evidence based medicine definition
-The conscientious explicit and judicious use of evidence in making decisions about the care of individual patients
What 3 concepts did evidence based medicine challenge?
-Clinical freedom
-Doctor knows best
-Established practice
How do we synthesise information into evidence?
-Hypothesis generating and experiments
-Replicating experiments
-RCTs
Hierarchy of experimental evidence pyramid (EXAM)
Features of electronic patient record
-Clinical decision support systems - CDSS
-Learning health system - AI/machine learning
-Etiquette of consulting with computer screen
4 Vs of big data
-Variety
-Volume
-Velocity
-Veracity
What is implementation science?
-The scientific study of methods to promote the systematic uptake of research findings and other evidence based practices into routine practice
-To improve the quality and effectiveness of health services
What is the WHO surgical safety checklist?
-Ensures patients are protected from risks during surgery
What is the Cochrane library?
-Database of systematic reviews of RCTs
Features of evidence based medicine
-Translation of uncertainty to an answerable question and includes critical questioning, study design and levels of evidence
-Systematic retrieval of best evidence available
-Critical appraisal of evidence for internal validity that can be broken down into a range of aspects
Characteristics of RCT
-Population selection - as few competing health and social issues as possible
-Randomisation - participants randomised to intervention or control groups
-Conduct - participants in both groups dealt with in comparable ways
-Number of participants allow analysis to show a difference between the 2 groups
Pros and Cons of RCT
Pros
-Accurate, unbiased measurement of treatment effect
-High degree of internal validity
-Strict eligibility criteria - homogenous study population
-Accurate measurement of treatment effect
-Reduced inter-patient variability
Cons
-Suboptimal representation of patients treated in real world setting
-Most marked in patients with advanced age or greater comorbidities
What is a systematic review
-Methodical and comprehensive way of synthesising existing research on a particular topic/question
-Aims to identify, evaluate and summarise the findings of all relevant studies in a transparent and unbiased manner
Steps in a systematic review
-Begins with a research question
-To answer question, a comprehensive search for all publications relevant to question
-May be 5000 references identified
-Usually less than 20 references are relevant
-Evidence is synthesised and summarised
What is a meta analysis?
-Usually conducted within a systematic review
-Quantitative, formal, epidemiological study design used to systematically assess the results of previous research to derive conclusions about that body of research
-Statistical integration of evidence from multiple studies that address a common research question
Features of clinical guidelines
-Made the volume of research manageable for the individual clinician
-Resolved clinician’s disagreement on appropriate management
-Funding from special interest groups and government
Why the need for NICE?
-Address inappropriate variations in clinical practice and “post code” access to expensive treatments
-Support clinicians to keep up to date with relevant new evidence
-Assess the value (cost effectiveness) of new and existing treatments
-Encourage innovation
What are QALYs?
QALY = added life x quality during that added time
Added duration of life quality of that life quality from 0-1
0 = no quality 1 = full quality
What does NICE value cost of QALY?
-Treatments that cost between £20000 and £30000 per Quality adjusted life year (QALY) represent good value for money
How are NICE guidelines formed?
Distillation of:
-Expert opinion
-Observational studies
-Cohort and case control studies
-Systematic reviews
-RCTs
What is a learning health system?
-Advanced approach to healthcare where data and experiences from clinical practice are continuously collected, analysed and used to improve patient care
What is in electronic patient record (EPR)?
-Patient’s demographic data
-Biometric data
-Disease and treatment data
-Presenting history
-Examination data
Clinician’s action:
-proposed diagnosis, investigation, treatment
What happens when evidence is implemented?
-replace a behaviour
-reject a behaviour
-adopt a new behaviour
-individual, group or system level
How could you change the behaviour of prescribing?
-Install a pop up in the computer
-Block the prescribing of the expensive versions of the drug within the NHS
-Provide an educational programme for all prescribers
-Run a national media programme to inform patients what to expect
-Prevent the dispensing by chemists of the more expensive statins without justification
What are obstacles to implementation?
-Lack of leadership
-Lack of necessary resources
-Lack of experience in the executors of the implementation plan
-Inadequate planning
-Disorganised work structure
-Poor readiness to change
-Poor team structure
-Lack of commitment
-Lack of prioritisation
Efficacy vs Effectiveness
Efficacy (in theory)
-the power or ability to produce an effect
-best tested in medicine with a RCT
Effectiveness (in real world)
-the degree to which something is successful in producing a desired result
-best tested in medicine with a ‘real’ world trial
What is the efficacy - effectiveness gap?
-Describes the differences in outcomes between patients treated in RCTs and those treated in the ‘real world’
-In an RCT, everything is arranged to represent an ideal
-In real world trials the experiment is messy because the restrictions on participants, staff and patients, is much less
RCT summary
-Experiment to reduce bias when testing treatment efficacy
-Random allocation of subjects to 2 or more groups
-Treat them differently, compare the response
-The experimental group - receives the intervention (e.g. a drug)
-The control group - receives an alternative (placebo)
-The groups are monitored to determine the efficacy of the experiment
Areas of implementation
-Individual clinician
-Local groups
-Professional groups
-Organisation
-Region
-Society
Factors which facilitate implementation
-Experienced leadership
-Detailed planning
-Team engagement
-Prioritisation
-Provision of required resources
Factors which are obstacles to implentation
-Lack of commitment by management
-Disorganised work culture
-Poor readiness to change
-Poor team structure
Clinical decision support systems (CDSS) definition?
“Clinical decision support systems link health observations with health knowledge to influence health choices by clinicians for improved health care”
What actually are CDSS?
-Computer algorithms
-‘Execute’ rules
-Clinician prompted by system about a way to improve care
What is the pyramid of evidence
-CDSS keep on top of this pyramid of literature
Evolution of recording information
Paper records -> Electronic records plain text -> Electronic records coded (SNOMED)
What is SNOMED?
-Standardised vocabulary with definitions and references
-Allows you to write rules for results
What can CDSS allow you to do?
-Identify patients in risk groups
-Offer them a referral
-Create alert for this referral
How can CDSS be used in prescribing?
-Warn clinicians of drug interactions/contraindications
-Recommend preferred brand to save money
-Alert about dosing regime
-Test renal profile before certain drugs
What is alert fatigue?
Too many alerts can:
-Waste time
-Confuse clinicians
-Worsen patient care
Types of bias in big health data
-Collection data used for multiple purposes
-Patient information may not be complete, accurate or current
-Reimbursement bias
-Data extraction/processing
-Research dataset/methodologies
-Practice workload
Obstacles in big data collection
-Restrictive policies on data access
-Licences for data access can be expensive
-Lack of standard policy on patient data privacy/confidentiality
-No international standardisation on data collection routes
Challenges of research data management
-Insufficient incentive for researchers to publish datasets
-Governance models outdated and too restrictive, with little or no audit of adherence
-Lack of awareness of data available to researchers within institutions
-Little or no provenance captured during data analysis
-Poor data management and lack of coherent analytical software strategy
AI in medicine
-Computers can identify patterns faster and in greater numbers
-Function of speed, opposed to intelligence
Challenges of AI
-Limited by nature of available training data for AI
-Autophagia of AI (training on its own outputs)
-Data provenance (what was my AI algorithm trained on?)
-Digital inequalities
-Potential bias
Features of learning health systems
-Learn from every patient encounter
-Improve the care that patient receives, their family receives, their community receives
-Creates a feedback cycle that enables “Evidence Generating Medicine” across and between scales of measurement and decision-making
