- Evidence, guidelines and - Evidence, guidelines and practice:practice:

the way forward in a digital the way forward in a digital age -age -

SYDNEYSYDNEY11 April, 201311 April, 2013

Bill RuncimanBill RuncimanProfessor – Patient Safety & Healthcare Human Factors –Professor – Patient Safety & Healthcare Human Factors –University of South Australia - Centre for Sleep Research University of South Australia - Centre for Sleep Research

Research Fellow, Australian Institute of Health Innovation, University of NSWResearch Fellow, Australian Institute of Health Innovation, University of NSWClinical Professor – Joanna Briggs Institute, Faculty Health Sciences – Clinical Professor – Joanna Briggs Institute, Faculty Health Sciences –

The University of Adelaide The University of Adelaide President, Australian Patient Safety Foundation President, Australian Patient Safety Foundation

- The ideal healthcare - The ideal healthcare system -system -

The right thing In the right way At the right time For the right person

- - The relationship between The relationship between QALYS purchased and QALYS purchased and

expenditure - expenditure -

QALYs purchased

Expenditure

Mindlines – Daniel KahnemanMindlines – Daniel Kahneman

Acumen – pattern recognitionAcumen – pattern recognition

Reference booksReference books

GuidelinesGuidelines

Google Google

“ “Up-to-date”Up-to-date”

- The right thing? -

““Appropriate” care – 57% of Appropriate” care – 57% of

encountersencounters Guidelines Guidelines - voluminous- voluminous

- hard to assimilate- hard to assimilate

- most are out-of-date- most are out-of-date

- some overlap- some overlap

- not actionable- not actionable

- don’t usually guide- don’t usually guide

- Guidelines – CareTrack -

Indicators:Over 70% – consensus basedOnly 15% – Level I or II evidenceOnly 18% – Grade A or B

recommendations

BUTCompliance with Level I & II, A or B:

54%Compliance with consensus

recommendations: 62%

- Appropriate care - CareTrack -

- agnostic selection -

- % of - % of evidence/recommendation per evidence/recommendation per indicator modality – CareTrack indicator modality – CareTrack

--

- % of - % of evidence/recommendation evidence/recommendation per indicator modality – per indicator modality –

CareTrack -CareTrack -

Guidelines are necessary and Guidelines are necessary and

desirable – but not sufficientdesirable – but not sufficient

Internet – creates more Internet – creates more

confusion than enlightenmentconfusion than enlightenment

PCEHR – limited benefit in PCEHR – limited benefit in

assiduously documenting what assiduously documenting what

is done if we don’t know what is done if we don’t know what

to do in the first place to do in the first place

- What should we do? -

Clinical standards, indicators and Clinical standards, indicators and

toolstools

For basic care – the “at leasts”For basic care – the “at leasts”

National (& international) National (& international)

agreementagreement

Inclusive, transparent, succinct, Inclusive, transparent, succinct,

useableuseable

Conflicts of interest taken care ofConflicts of interest taken care of

Up-to-date and dynamic Up-to-date and dynamic

A wiki process – “Apps”A wiki process – “Apps”

- Proposal -

- Evidence -- Evidence - 77 RCTs/day, 11 meta-analyses77 RCTs/day, 11 meta-analyses

Some untrustworthy players - Some untrustworthy players -

reputationreputation

Systematic manipulation (bias, 24 Systematic manipulation (bias, 24

ways)ways)

Often fails to get traction in practiceOften fails to get traction in practice

Cognitive dissonance – evidence on Cognitive dissonance – evidence on

evidenceevidence

Whole area needs reconsiderationWhole area needs reconsideration

A list of do’s (“at leasts”)A list of do’s (“at leasts”) A list of dont’sA list of dont’s Standard operating Standard operating

proceduresprocedures

- screening- screening

- monitoring- monitoring

- checklists- checklists

- procedures- procedures Rehabilitation of consensusRehabilitation of consensus Restoration of HOPERestoration of HOPE

- Challenges -

- Common sense - - Common sense -

The only problem with common The only problem with common

sense is that it is not all that sense is that it is not all that

commoncommon

VoltaireVoltaire

Will RogersWill Rogers