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Applied Social Behavoural Sciences > Session 4 > Flashcards

Session 4 Flashcards

1
Q

What is evidence? How should health service be delivered? What is important with regards to evidence?

A

The available body of facts/information indicating whether a belief/proposition is true or valid.
-Health service: should be based on best available evidence - has to been effective (drugs/practice/interventions) and cost-effective (in a system with finite resources, where should money be spent to gain max utility?)

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2
Q

What is a systematic review?

A

Review of literature on a particular intervention –> reviews do higher level analysis, weighting different research/work for reliability, in order to get a big overarching conclusion on whether that intervention works or not (meta-analysis)

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3
Q

What are practices (negatively) influenced by?

A

Professional opinion
Clinical fashion
Historical practice/precedent
Organisational and social culture

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4
Q

What is a randomised control trial?

A

Answer later

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5
Q

What does evidence based practice involve?

A

•Evidence-based practice involves the integration of individual clinical expertise WITH the best available external clinical evidence from systematic research

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6
Q

Why are systematic reviews needed?

A

-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

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7
Q

What can systematic reviews help clinicians achieve?

A

• They can help to prevent biased decisions being
made
• They can be relatively easily converted into
guidelines and recommendations
• However, doctors need to be able to access
systematic reviews and to appraise them to be
satisfied about the quality of the evidence

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8
Q

What gaps/mistakes do systematic reviews help to avoid?

A

• They can help to prevent biased decisions being
made
• They can be relatively easily converted into guidelines and recommendations
• However, doctors need to be able to access systematic reviews and to appraise them to be satisfied about the quality of the evidence

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9
Q

What are critiques of the evidence-based practice movement?

A
  • ‘Practical criticisms’: around the possibility of evidence- based practice
  • ‘Philosophical criticisms’: around the desirability of evidence-based practice
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10
Q

What are practical limitations for evidence-based practice research?

A

• 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 (e.g. due to ethical considerations)
• Choice of outcomes often very biomedical, which may limit
which interventions are trialled, and therefore which are funded
(e.g. NICE guidance)
• Requires ‘good faith’ on the part of pharmaceutical companies

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11
Q

What are philosophical cliques of evidence based practice?

A

• ‘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, e.g. through NICE or clinical
governance) to create ‘unreflective rule followers’ out of
professionals
• Might be understood as a means of legitimising rationing, with
potential to undermine trust in the doctor-patient relationship, and
ultimately the NHS
• Professional responsibility/autonomy

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12
Q

What are some problems with getting evidence and then integrating it into practice?

A
  • Evidence exists but doctors don’t know about it
  • Doctors know about evidence but don’t use it
  • Organisational system cannot support innovation
  • Commissioning decisions reflects different priorities
  • Resources not available to implement change
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13
Q

What are the two forms of rationing? Describe them

A
  • Explicit rationing: based on defined rules of entitlement.
  • Implicit rationing: care is limited, but neither the decisions, nor the bases for those decisions are clearly expressed.
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14
Q

What are the drawbacks with implicit rationing?

A

Implicit rationing is the allocation of resources through individual clinical decisions without the criteria for those decisions being explicit
• Can lead to inequities and discrimination
• Open to abuse
• Decisions based on perceptions of “social
deservingness”
• Doctors appear increasingly unwilling to do it

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15
Q

What are advantages of explicit rationing?

A 
ADVANTAGES
• Transparent, accountable
• Opportunity for debate
• More clearly evidence-based
• More opportunities for equity in decision-making
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16
Q

What are disadvantages of explicit rationing

A
  • Very complex
  • Heterogeneity of patients and illnesses
  • Patient and professional hostility
  • Impact on clinical freedom
  • Some evidence of patient distress
17
Q

What is NICE?

-why where they set up? What does it do?

A

National institute for Health and Care Excellent
• Set up to ‘enable evidence of clinical and cost effectiveness to be
integrated to inform a national judgement on the value of a
treatment(s) relative to alternative uses of resources’ • Provides guidance on whether treatments (new or existing) can
be recommended for use in the NHS in England.
• Set up to ‘enable evidence of clinical and cost effectiveness to be
integrated to inform a national judgement on the value of a
treatment(s) relative to alternative uses of resources’
• Provides guidance on whether treatments (new or existing) can
be recommended for use in the NHS in England.

18
Q

What is scarcity? Efficiency? Equity? Effectiveness? Utility, Opportunity cost?

A

See PP

19
Q

What is opportunity cost? When is it relevant?

A

• When deciding to spend resources on a new treatment,
those resources cannot now be used on other treatments.
• The opportunity cost of the new treatment is the value of
the next best alternative use of those resources.
– Cost is viewed as sacrifice rather than financial
expenditure
• Opportunity cost is measured in BENEFITS FOREGONE

20
Q

What is technical efficiency? What allocative efficiency?

A

• Technical efficiency – you are interested in the most
efficient way of meeting a need (e.g. should antenatal
care be community or hospital-based?)
• Allocative efficiency – you are choosing between the
many needs to be met (e.g. fund hip replacements or
neonatal care?)

21
Q

What is economic evaluation? Why do we use it?

A

• Comparison of resource implications
and benefits of alternative ways of
delivering healthcare
• Can facilitate decisions so that they are more transparent and fair

22
Q

What does an economic analysis do?

A

An economic analysis compares the inputs (resources) and outputs (benefits and value attached to them) of alternative interventions. This allows better decisions to be made about which interventions represent best value for investment.

23
Q

How do you measure cost? What are categories of cost?

A 
• Identify, quantify and value resources needed 
• Categories of costs:
– 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, other
employees and the rest of society
24
Q

How do you measure benefits?

A

• Benefits are harder to measure
• Improved (or maintained) health hard to value
• Categories of benefits/consequences:
– Impact on health status (in terms of survival or quality of life or
both);
– Savings in other healthcare resources (such as drugs,
hospitalisations, procedures, etc.) if the patient’s health state is
improved
– Improved productivity if patient, or family members, returns to work
earlier

25
Q

What are four types of economic evaluation? (Allows you to compare costs and benefits)

A
  1. Cost minimisation analysis
  2. Cost effectiveness analysis
  3. Cost benefit analysis
  4. Cost utility analysis
    * All consider costs but differ in the extent they attempt to measure the value and consequences
26
Q

Explain cost minimisation analysis

A

• Outcomes assumed to be equivalent • Focus is on costs (i.e. only the inputs)
• Not often relevant as outcomes rarely equivalent
• Possible example:
– Say all prostheses for hip replacement improve
mobility equally. Choose the cheapest one.

27
Q

What is cost effectiveness analysis?

A

• Used to compare drugs or interventions which have a common health outcome e.g. reduction in blood pressure
• Compared in terms of cost per unit outcome e.g. cost per
reduction of 5mm/Hg
• If costs are higher for one treatment, but benefits are too,
need to calculate how much extra benefit is obtained for
the extra cost
• Key question: Is extra benefit worth extra cost?

28
Q

What is cost benefit analysis?

A

• All inputs and outputs valued in monetary terms
• Can allow comparison with interventions outside
healthcare
• Methodological difficulties e.g. putting monetary value on
non-monetary benefits such as lives saved
• “Willingness to pay” often used, but this is also
problematic

29
Q

What is cost utility analysis?

A

• Particular type of cost effectiveness analysis
• Cost utility analysis focuses on quality of health
outcomes produced or foregone
• Most frequently used measure is quality adjusted life year
(QALY)
• Interventions can be compared in cost per QALY terms

30
Q

What is a QALY? Why do we use them? NICE use QALYs

A

• To use cost-effectiveness as a guide to decision-making, we need to compare the cost-effectiveness of different uses of resources
• Therefore we need an effectiveness measure that can be
used in a wide range of settings:
• Life-years gained? only where survival is main outcome
• Quality adjusted life years (QALYs)
• Composite of survival and quality of life –> 1 year of perfect health = 1 QALY
• Assumes that 1 year in perfect health = 10 years with
a quality of life of 0.10 perfect health

31
Q

What are important QALY principles?

A

– You can trade off survival and quality of life
• 1 QALY = 2 years at 50% QOL for 1 person

– Each year of healthy life is of equal value
• 1 QALY = 6 months of healthy life for 2 people

32
Q

What are: HYEs, SAVEs, DALYs?

A 
– Health Year Equivalents (HYEs)
– Saved-young-life equivalents (SAVEs)
– Disability Adjusted Life Years (DALYs)
• Advantages and disadvantages to all but NICE uses
QALYs
33
Q

How does NICE use QALYS?

A

• To assess cost-effectiveness, the QALY score is
integrated with the price of treatment
• The result is a ‘cost per QALY’ figure, which allows
NICE to determine the cost-effectiveness of the treatment

34
Q

How does NICE make decisions based on QALYs?

A

-Below £20K per QALY technology will normally be approved

• £20 - £30K judgements will take account of:
– Degree of uncertainty
– If change in HRQoL is adequately captured in the QALY
– Innovation that adds demonstrable and distinctive benefits not

• Above £30K need an ‘increasingly stronger case’
captured in the QALY

35
Q

What are criticisms of QALYs?

A

• Controversy about the values they embody
• Do not distribute resources according to need, but
according to the benefits gained per unit of cost
• May disadvantage common conditions
• Technical problems with their calculations
• QALYs may not embrace all dimensions of benefit;
values expressed by experimental subjects may not be
representative
• QALYs do not assess impact on carers or family

36
Q

If needed: Why are CRTs not perfect?

A 
– Comparison therapies may differ
– Length of follow-up
– Atypical care
– Atypical patients
– Limited generalisability
– Sample sizes

Applied Social Behavoural Sciences (3 decks)

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