ASBHDS Session 4 - Evidence and Evidence-based Practice Flashcards Preview

Applied Social, Behavioural and Healthcare Delivery Science I > ASBHDS Session 4 - Evidence and Evidence-based Practice > Flashcards

Flashcards in ASBHDS Session 4 - Evidence and Evidence-based Practice Deck (28)
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1
Q

What are the origins of evidence-based healthcare?

A
  • Health service delivery should be based on best available evidence
  • Best evidence = findings of rigorously conducted research
  • Evidence of:

I. Effectiveness (of drugs, practices, interventions)

II. Cost-effectiveness (in a system with finite resources where should money be spent to gain the maximum utility?)

  • Ineffective and inappropriate interventions waste resources that could be used more effectively
  • Variations in treatment create inequities
  • Care that is non-evidence based likely to cause harm
  • Practices influenced (too much) by:

I. Professional opinion

II. Clinical fashion

III. Historical practice and precedent

IV. Organisational and social culture

2
Q

What is evidence based practice?

A

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

“Evidence based medicine is not ‘cookbook’ medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients’ choice, it cannot result in slavish, cookbook approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise.”

3
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
4
Q

Why are systematic reviews useful to clinicians?

A
  • 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 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
5
Q

How does one assess the quality of evidence?

A
  • Easiest and best done using a “critical appraisal tool” or instrument
  • Critical appraisal tools suggest the things to look for, and the questions to ask of, research articles
6
Q

What are some of the critiques of evidence-based practice movement?

A
  • Practical criticisms’: around the possibility of evidence-based practice

I. May be an impossible task to create and maintain systematic reviews across all specialities.

II. May be challenging and expensive to disseminate and implement findings.

III. RCTs are seen as the gold standard but not always feasible or even necessary/desirable (e.g. due to ethical considerations).

IV. Choice of outcomes often very biomedical, which may limit which interventions are trialled, and therefore which are funded (e.g. NICE guidance).

V. Requires ‘good faith’ on the part of pharmaceutical companies

  • ‘Philosophical criticisms’: around the desirability of evidence-based practice

I. ‘Does not align with (most) doctors’ modes of reasoning (probabilistic versus deterministic causality).

II. Aggregate, population-level outcomes don’t mean that an intervention will work for an individual.

III. Potential of EBM (or its implementation, e.g. through NICE or clinical governance) to create ‘unreflective rule followers’ out of professionals.

IV. Might be understood as a means of legitimising rationing, with potential to undermine trust in the doctor-patient relationship, and ultimately the NHS.

V. Professional responsibility/autonomy

7
Q

What are the problems with getting evidence into practice?

A
  • Evidence exists, but doctors don’t know about it – Dissemination ineffective? Doctors not incentivised to keep up-to-date?
  • Doctors know about the evidence but don’t use it – Why not? Habit? Organisational culture? Professional judgement?
  • Organisational systems cannot support innovation – E.g. because managers lack ‘clout’ to invoke changes
  • Commissioning decisions reflect different priorities – E.g. what if patients say they want something else?
  • Resources not available to implement change – Financial or human resources: change management is a complicated and demanding process
8
Q

What are key considerations withr regards to resource allocation?

A
  • Setting priorities: scarcity of resources
  • NHS spending
  • Demand driven by demographics: age&LTCS
  • Costs of new technology
  • Setting priorities: scarcity and ethics
9
Q

What are the two forms of rationing?

A
  • Explicit rationing – based on defined rules of entitlement

I. Explicit health care rationing or priority-setting is the use of institutional procedures for the systematic allocation of resources within health care system.

II. Care is limited and the decisions are explicit, as is the reasoning behind those decisions.

  • Implicit rationing – care is limited, but neither the decisions, nor the bases for those decisions, are clearly expressed.

I. Implicit rationing is the allocation of resources through individual clinical decisions without the criteria for those decisions being explicit

II. Can lead to inequities and discrimination

III. Open to abuse

IV. Decisions based on perceptions of “social deservingness”

V. Doctors appear increasingly unwilling to do it

10
Q

What are some pros and cons with rationing?

A

- ADVANTAGES

I. Transparent, accountable

II. Opportunity for debate

III. More clearly evidence-based

IV. More opportunities for equity in decision-making

- DISADVANTAGES

I. Very complex

II. Heterogeneity of patients and illnesses

III. Patient and professional hostility

VI. Impact on clinical freedom

V. Some evidence of patient distress

11
Q

Outline some basic concepts in health economics.

A
  • Scarcity: need outstrips resources. Prioritisation is inevitable
  • Efficiency: getting the most out of limited resources
  • Equity: the extent to which distribution of resources is fair
  • Effectiveness: the extent to which an intervention produces desired outcomes
  • Utility: the value an individual places on a health state
  • Opportunity costs: once ou have used a resource in one way, you no longer have to use it in another way.
12
Q

Outline choices and 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?)
13
Q

Explanation economic evaluations and decision-making.

A
  • Comparison of resource implications and benefits of alternative ways of delivering healthcare.
  • Can facilitate decisions so that they are more transparent and fair.
14
Q

How do you measure costs?

A
  • Identify, quantify and value resources needed
  • Categories of costs:

I. Costs of the healthcare services

II. Costs of the patient’s time

III. Costs associated with care-giving

IV. Other costs associated with illness

V. Economic costs borne by the employers, other employees and the rest of society

15
Q

How do you measure benefits?

A
  • Benefits are harder to measure
  • Improved (or maintained) health hard to value
  • Categories of benefits/consequences:

I. Impact on health status (in terms of survival or quality of life or both);

II. Savings in other healthcare resources (such as drugs, hospitalisations, procedures, etc.) if the patient’s health state is improved

III. Improved productivity if patient, or family members, returns to work earlier

16
Q

How do you compare costs and benefits?

A
  • Four types of economic evaluation

I. Cost minimisation analysis

II. Cost effectiveness analysis

III. Cost benefit analysis

IV. Cost utility analysis

  • All consider costs, but differ in the extent they attempt to measure and value consequences/ benefits
17
Q

Outline the 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.
18
Q

Outline 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?
19
Q

Outline 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
20
Q

Outline 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
21
Q

Discuss the types of economic evaluation.

A
22
Q

Why 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? But only where survival is main outcome
  • Quality adjusted life years (QALYs): Composite of survival and quality of life
23
Q

What is QALY?

A
  • QALYs adjust life expectancy for quality of life

I. 1 year of perfect health = 1 QALY

II. Assumes that 1 year in perfect health = 10 years with a quality of life of 0.10 perfect health

  • One year of healthy life for one person

I. You can trade off survival and quality of life

1 QALY = 2 years at 50% QOL for 1 person

II. Each year of healthy life is of equal value

1 QALY = 6 months of healthy life for 2 people

24
Q

Provide an example of QALY.

A
  • Told he has 1 year to live if he does not have treatment
  • His quality of life, without treatment, will be 0.8 of perfect health and he will then die quickly
  • Without treatment = 0.8 QALYs
  • If he receives treatment he will live for 4 years, but his QoL will be 0.2 of perfect health
  • With treatment = 0.8 QALYs
  • No gain in QALYS associated with treatment
25
Q

What are some alternatives to QALYs?

A
  • The QALY has attracted considerable controversy
  • You may see alternatives

I. Health Year Equivalents (HYEs)

II. Saved-young-life equivalents (SAVEs)

III. Disability Adjusted Life Years (DALYs) - advantages and disadvantages to all but NICE uses QALYs

26
Q

Explain QALY and NICE.

A
  • Costs per QALY used by NICE

I. To assess cost-effectiveness, the QALY score is integrated with the price of treatment

II. The result is a ‘cost per QALY’ figure, which allows NICE to determine the cost-effectiveness of the treatment

  • How does NICE make its decisions?

I. Below £20K per QALY technology will normally be approved

II. £20 - £30K judgements will take account of:

A. Degree of uncertainty

B. If change in HRQoL is adequately captured in the QALY

C. Innovation that adds demonstrable and distinctive benefits not captured in the QAL

III. Above £30K need an ‘increasingly stronger case’

  • NICE and legitimacy

I. May be resented by patient groups

II. May be resented by pharmaceutical companies

III. CCGs prioritise NICE-approved interventions, sometimes with unintended consequences.

IV. Concerns about political interference

27
Q

What are some criticims 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
28
Q

What are more problems with QALYs?

A
  • RCT evidence is not perfect…

I.Comparison therapies may differ

II. Length of follow-up

III. Atypical care

IV. Atypical patients

V. Limited generalisability

VI. Sample sizes.

  • Statistical modelling can address some problems and areas of uncertainty