CLINICAL GOVERNANCE Ensuring quality in all aspects of
the delivery of medical care
COMPONENTS OF CLINICAL GOVERNANCE EVIDENCE-BASED MEDICINE DISSEMINATING BEST PRACTICE EFFICIENCY & COST-EFFECTIVENESS AUDIT & APPRAISAL EDUCATION & TRAINING RISK MANAGEMENT PROBITY
EVIDENCE-BASED MEDICINE DEFINITION AND SCOPE OF EBM
WHY IS EBM IMPORTANT?
EXAMPLES OF QUESTIONS FOR WHICH THERE COULD BE EVIDENCE
SOURCES PROVIDING EBM
EVIDENCE-BASED MEDICINE: WHAT IS IT? DEFINED AS “CONSCIENTIOUS, EXPLICIT
AND JUDICIOUS USE OF CURRENT BEST EVIDENCE IN MAKING DECISIONS ABOUT THE CARE OF INDIVIDUAL PATIENTS” (Sackett et al, BMJ, 1996; 312: 71)
INVOLVES INTEGRATING CLINICAL EXPERTISE AND RESEARCH FINDINGS – ”Doing the right things right”.
SCOPE OF EVIDENCE-BASED MEDICINE INVOLVES PRIMARY AND SECONDARY
CARE, DOCTORS AND NURSES
COVERS ALL MANAGEMENT, NOT JUST PRESCRIBING guidelines and protocols care pathways, referral operations etc.
WHY IS EBM IMPORTANT? SCIENTIFIC BASIS FOR MEDICAL
PRACTICE
ECONOMIC ARGUMENTS
GOVERNANCE ISSUES
SCIENTIFIC BASIS KNOWLEDGE BASIS FOR PRACTICE
from RCT results predictive value of certain results
POTENTIAL ANSWERS TO PROBLEMS e.g. when prescription is not appropriate
BASIS FOR FURTHER RESEARCH
ECONOMIC ARGUMENTS LESS WASTE e.g.
generic prescribing - usually cheaper drugs of limited value
MORE COST EFFECTIVE usefulness of treatments known for money
spent can provide basis for comparing treatments
NOT NECESSARILY CHEAPER e.g. warfarin in AF ACE inhibitors in heart failure
GOVERNANCE ISSUES KNOWN OUTCOME FROM WHAT IS
DONE
KNOWN BENEFIT PROVIDES JUSTIFICATION FOR EXPENDITURE
ETHICAL DIMENSION
ETHICAL DIMENSION - 1 SCIENTIFIC BASIS FOR ADVISING
PATIENTS
GUIDANCE FOR PRACTITIONERS
CONSISTENCY AMONGST PRACTITONERS
ETHICAL DIMENSION - 2 AVOIDING HARM FROM UNPROVEN
TREATMENTS
FAIRNESS TO ALL PATIENTS
“EFFECTIVE TREATMENT SHOULD BE FREE” (Cochrane)
POTENTIAL DIFFICULTIES - 1 MUCH OF MEDICAL PRACTICE NOT BEEN
SCIENTIFICALLY EVALUATED lots of questions, not so many answers audit is not research is there a gold standard?
MAY INVOLVE CHANGES IN PRACTICE AND CHANGE CAN BE DIFFICULT changes to prescribing difficult – generic,
“therapeutic trial”, Friday evening changes to referral patterns difficult
POTENTIAL DIFFICULTIES - 2 RESEARCH VS. THIS PATIENT, NOW
WHO ARE THE STAKEHOLDERS IN EBM – government, doctors, regulatory bodies, patients?
PATIENT SATISFACTION ISSUES generic vs. branded prescribing do patients believe evidence applies to them? may involve saying “no” to patients
POTENTIAL DIFFICULTIES - 3 PERCEPTION BY SOME AS IMPOSING
RESTRICTIONS ON PRACTICE
DOES EDUCATION CHANGE THE WAY DOCTORS BEHAVE?
DO STICKS AND CARROTS CHANGE THE WAY DOCTORS BEHAVE?
EXAMPLES - 1 What is the value of the vaginal
examinations done at BUPA medicals?
Does padding for corneal abrasions help healing?
What is the treatment for positive H. pylori serology?
EXAMPLES - 2 Does spironolactone help hirsutism?
Is minocycline a better treatment than oxytetracycline for acne vulgaris?
Is E45 better than aqueous cream for dry skin conditions?
EXAMPLES - 3 Is is safe to prescribe aspirin when there
is a history of dyspepsia?
Is it safe to prescribe aspirin when there is a history of peptic ulcer if a PPI is prescribed as well?
What is the evidence for steroids having benefit when injected for soft tissue rheumatism?
EXAMPLES - 4 What is the value of physiotherapy
in back pain?
Does periodontal treatment help prevent tooth loss in adults?
What is the value of homeopathy?
EXAMPLES - 5 Is bed rest of any value in
threatened miscarriage?
Which catheter is best for intermittent self-catheterisation?
What is the value of “Ensure” and other food supplements?
THEMES FROM EXAMPLES ANSWERS TO QUESTIONS KNOWN
ALREADY OR ANSWERABLE
COULD PROVIDE A BASIS FOR RESEARCH
CONSIDERING VALUE OF TREATMENTS AND NOT JUST COST
SOURCES FOR EBM - 1 PEER REVIEWED JOURNALS e.g.
BMJ BJGP
NATIONAL / LOCAL SERVICE FRAMEWORKS e.g. CANCER IHD HEALTH IMPROVEMENT PROGRAM
N.I.C.E. ADVICE
SOURCES FOR EBM - 2 SPECIALIST JOURNALS
Drug and Therapeutics Bulletin Prescriber’s Journal (now defunct) Bandolier
CONSUMER VIEW? “Which?” surveys of OTC remedies
SOURCES FOR EBM – 3 ELECTRONIC DATABASES e.g.
Cochrane Medline
INTERNET Search engines - e.g. searching
“homeopathy” found “Quackwatch”, a website which considers the scientific evidence for alternative therapies.
LITERATURE SEARCHING How? What journals? What countries / languages? What dates? Use PUNs and DENs, not topics Finding time Need to avoid overload Rejecting chaff
READING A PAPER Relevant? Applicable? Primary-care based? Does it answer the questions it set out
to? Appropriate design? Which patients excluded? Appropriate and correct statistics? Concepts understood – risk, NNT, etc?
SOURCES FOR EBM – 4 BOOKS
Clinical Evidence (BMJ) Evidence-based Medicine (Sackett et
al, Churchill Livingstone, 1998) Evidence-based Healthcare (Gray,
Churchill Livingstone, 1997)
CONCLUSIONS EVIDENCE BASED MEDICINE HERE TO STAY
FOR SCIENTIFIC AND ECONOMIC REASONS
IT PROVIDES A MORE RATIONAL BASIS FOR PRACTICE
IT HELPS PREVENT WASTE
IT PROVIDES REASSURANCE FOR PATIENTS ABOUT MEDICAL ADVICE AND TREATMENT
CHALLENGES FOR THE FUTURE DO YOU PRACTISE EVIDENCE-
BASED MEDICINE? WHAT BARRIERS TO EBM EXIST IN
YOUR PRACTICE AND WHAT CAN YOU DO TO OVERCOME THESE?
WHAT DO YOU DO WHEN THERE IS NO EVIDENCE?
DISSEMINATING BEST PRACTICE