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Transcript of Professionals and patients need clean clear knowledge for decision making just as they need clean...
Professionals and patients need clean clear knowledge for decision making just as they need clean clear water for hand washing
Water may look clear but be polluted and poisonous
At present people simply hold out a basin to collect knowledge, or
dip a bucket in the sea of PubMed, one of the wonders of
modern healthcare but peer review is no guarantee of
freedom from pollutants - bias and errors due to chance- or
poison due to the deficiencies of the peer review and editorial
process
3 types of generalisable knowledge
Knowledge from research - Evidence
Knowledge from measurement of healthcare performance-Statistics
Knowledge from experience-Of patients and clinicians
2 types of particular knowledgeKnowledge about this patient
Knowledge about this service
Better decisions
Finding out what knowledge people need
Obtaining the knowledge
Organising the knowledge
Mobilising the knowledge
Utilising the knowledge
Protocols for systematic reviews or additional research
Reports of research
Systematic reviews of research
Guidelines informed by systematic reviews
Summaries of knowledge eg BNF
Information about uncertainties eg DUETs
Patient Experience Reports
Tools for diagnosis, treatment & monitoring
Prompts & reminders
BETTER DECISIONS&
ACTIONS
‘Conclusions in trials funded by for profit organisations may be more
positive due to biased interpretation of trial results’
The experimental drug was recommended as treatment of choice in16% of trials funded by nonpofit organisations51% of trials funded by for-profit organisations (p<0.001)Trials funded by for-profit organisations were significantly more likely to recommend the experimental drug as the treatment of choice – odds ratio 5.3 (CI 2.0-14.4)
Association of funding and conclusions in randomised drug trialsAls-Nielsen B et al (2003) JAMA 290; 921-928
“evidence from recent trials, no matter how impressive, should be interpreted
with caution”claims for efficacy made in 45 highly
cited citations were subsequently contradicted or weakened for 14 of
the interventionsIonnidis JPA (2005)
Contradicted and initially stronger effects in highly cited clinical research
JAMA 294; 218-228
All serious health problems are managed by more than
one bureaucracy and always will be.
They are managed by clinical networks which cross many
bureaucracies.
Shared Vision
Hypertext organisation Bureaucratic Organisation(Nonaka & Takeuchi OUP 1995 ; The Knowledge Creating Company
A National IBD Service would have A National set of objectives, criteria and
standards A nationally agreed templates of a care pathways
expressed using the Map of MedicineA National DatasetA single specification for all information system providersA National knowledge base updated annually
A National community of practice, including patientsA single web site www.nhs.uk/ibd
X local services, where X is >1 and <150
Patient centred care
• The Clinician was the driving force in the 20th Century , the patient will be the driving force in the 21st century
Most patients in 2011 •Feel responsible for their own record •Know their NHS number•Read and think about the quality assured knowledge sent to them before the consultation•Enter their own data before the consultation•Use a decision aid before taking the decision to have an operation •Know where they are on a care pathway•Accept that medical knowledge is of variable quality
Muir Gray has familial hypercholesterolaemia
Every six months he receives an email reminder from the lab to have a blood test
He receives 2 SMS reminders if no blood sample is received within 2 weeks
If no specimen is received his GP receives a copy email
If there is a result is sent to the GP and to his Healthspace where it is stored in sequence
Appropriate advice and support is automatically generated
Mrs A is worried about familial breast cancer and phones for a GP appointment
The healthcare assistant asks if Mrs A would like to tell her the nature of her problem
On learning it, she
1. Ascertains her access to NHS Direct
2. identifies the relevant page on NHS Direct
3. Sends it to Mrs A
Mrs A consults the site which1. Ascertains her preferred reading level 2. Ascertains her knowledge of genetics eg the meaning of the term mutation3. Offers information about genetics and familial breast cancer including the experience of other women in DIPEX4.Allows her to complete a family risk assessment5. Stores all this information on her Healthspace
“The false positive rate [for Hepatitis C] is especially
important in low prevalence settings where the number of false positives may exceed
the number of true positives”Booth JCL et al (2001)
Gut 49 (Suppl 1) i4 column 1 Section 3.1 lines 23-27
Royal Cornwall Lab Service
Muir Gray 21/06/1944 NHS number 400 186 6897
ELISA25.5
Hepatitis C is of low prevalence in Cornwall. National guidance is that diagnosis should be confirmed by PCR test in low prevalence populationsFor PCR test click here
For access to full text of guidance click here To test your knowledge in one minute click here
1,275 librarians
Image from Sinasis Technologies via free clip art service http://www.artvex.com
“It is not the strongest of the species that survives, nor
the most intelligent that survives. It is the one that
is the most adaptable to change.”