Evidence Base Practice

Ann Winter

3 main components

Use of evidence

Clinical/professional judgement

Patient preference

Chronological context

Healthcare not systematically investigated/attained visibility until 1980’s

Briggs Report 1972 – nursing should be a research-based profession

First strategy for research in the NHS – Research for Health (DoH, 1991) aimed to ensure ‘..the content and delivery of care in the NHS is based on high-quality research relevant to improving the health of the nation…’

Emphasised dissemination, development and implementation

Research based knowledge- central mantra audit, effectiveness

NICE – to give new coherence and prominence to information about clinical and cost effectiveness

Sceptics view of EBP

Clinical experience –

‘…making the same mistakes with increasing confidence over an impressive number of years…’

Evidence Based Practice

‘…perpetuating other people’s mistakes instead of your own…’

Why?

Treating conditions previously untreatable More expensive treatment, drugs, imaging, tests,

staff Treating patients who would previously have been

untreated due to changing needs/public perceptions Curbing medical power Controlling strong clinical trades/professions Rationalise care Value for money

EBP - Definition

‘…an opportunistic marriage of convenience between the rationalist iconoclasts of medicine and the policy elite of the NHS R&D initiatives…’

Rafferty A and Traynor M 1997 Quality and quantity in research policy for nursing

Nursing Times Research 2.1.16-27

Evidence-based medicine (EBM) is “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic researchSackett DL, Rosenberg WMC , Muir Gray JA, Haynes RB and Richardson WS. Evidence based medicine : what it is and what it isn’t. British Medical Journal 1996; 312 : 71-72.

“Evidence-based medicine (EBM) is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable patient-reported, clinician-observed, and research-derived evidence. The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments”

McKibbon KA, Wilczynski N, Hayward RS, Walker-Dilks CJ, Haynes RB. The medical literature as a resource for Evidence Based Care, at http://hiru.mcmaster.ca/hiru/medline/mdl-ebc.html

Other views

EBP will improve reputation and status Professionalisation - the goal for a scientific

knowledge base

What?

To start stopping ineffective practice -Quality To stop starting unproven practice -

Effectiveness To minimise variations in care To maximise cost-benefit - Efficiency To enable informed choices

How

1. Health care decisions should where possible be based on the best patient, laboratory & population based evidence

2. The problem determines the nature and source of evidence NOT habits and traditions

3. Different ways of thinking i.e. epidemiological, economic

4. Search and critical appraisal worthwhile only if translated into actions

5. Continuous performance evaluation

September - 1990

1st biopsy - diagnosed as non-Hodgkin’s lymphoma and had treatment

December 1993

Developed acute myeloid leukaemia-chemo-remission

March 1994

Bone marrow transplant

January 1995

Went for routine blood tests relapse: leukaemia returns

Recommendation was for palliative care

‘..go home and enjoy the rest of her life..’

Approx 6-8 weeks

2nd opinion

Dr arranged for referral to a professor for a 2nd opinion and the diagnosis was confirmed

What happened next

Opinion sought further afield- USA, New Zealand & Europe

USA-2nd BMT success @60%- 30% chance of remission after 2 years

UK doctors disagreed with these optimistic views

British advice sought from a distinguished Prof. of leukaemia-20% chance of chemo induced remission when could consider a 2nd BMT

February 1995

Doctors reluctantly referred to Prof at request of father

Influencing policyFebruary 1995

Local HA requesting funding for treatment by Prof. (outside geographical area)

Treatment declined

Values : equity, appropriateness, effectiveness, efficiency and responsiveness

Decision was based on 2 grounds

1The proposed treatment would not be in the best interests of….

2The substantial expenditure on treatment with such a small prospect of success would not be an effective use of the limited resources bearing in mind the present and future needs of the patient

Prof. Suggested private treatment by another doctor

HA declined

Legal proceedings against HA- to be reconsidered-overruled by 3 High Court judges

March 1995

Media attention-anonymous donor donor funded private treatment

Outcome

Following chemo donor lymphocyte infusion given rather than BMT

HA took over continuing care costs Developed complications Died May 1996 Considered to have had a few extra months

of life of a reasonable quality

‘The juggler trying to keep too many balls in the air;like the juggler we must do our best to improve our juggling skills to keep more balls in the air for more of the time and to avoid letting any ball stay on the ground for too long. We must accept,however that in the context of competing and mutually incompatible claims there will always be some balls on the ground’

Citing Calabresi in Ham & Pickard 1998

Chief exec

‘…no longer could we be secure in the knowledge that in all circumstances their doctors would do all they could regardless of cost… Child B helped people grasp the reality that expectation and demand has outstripped public funded system’s ability to pay without regard for opportunity cost…’

Issues

1. Role of the patient and family2. Role of the HA – decision making process

and ECR’s – financial considerations – objectivity

3. Role of clinician’s – clinical dissent – in UK and between specialists in USA and UK

4. Role of DoH and priority setting – ethics5. Influence of evidence/knowledge

Effectiveness – does treatment work? Rescue principle – at all costs Entitlement – fair does for those who’ve paid

taxes- social judgements – citizenship Cost-utility – priority for treatments with

lowest cost – maximise benefits – QUALY Equity – treatment for those with equal need

EBHC de-emphasises intuition, unsystematic clinical experience and pathophysiological rationale as sufficient grounds for clinical decision making

EBHC is about applying the best available evidence to a specific clinical question

Minimises clinicians choice Regulates practice

resources

http://www.shef.ac.uk/scharr/ir/netting/ http://www.cks.library.nhs.uk/

information_for_patients/clients www.patient.co.uk http://www.badscience.net/

Evidence Based Practice

To start stopping ineffective practice To stop starting unproven practice To minimise variations in clinical care To maximise cost-benefit decisions To enable informed choices between

effective practices with different/similar outcomes

5 Steps for Evidence based decision-making

1. Ask the right questions2. Find relevant evidence3. Appraise the evidence4. Decision making based on evidence5. Storing the evidence for future use