nhs evidence

NHS Evidence – provided by NICE

Where can treatment uncertainties come from, and what do we do with

them?

Mark Fenton James Lind Initiative, Oxford

Editor, UK Database of Uncertainties about the

Effects of Treatments Thursday 19th April 2012


Types of uncertainty about the effects of treatments

‘We’re uncertain whether anyone knows the effects’ uncertain uncertainty

‘We’re uncertain what the effects will be on you’ stochastic uncertainty

‘We’re uncertain because we don’t know your values’ value uncertainty

‘We’re uncertain because no-one knows the effects’ certain

uncertainty


“As we know, there are known knowns. There are things we know we know. “We also know there are known unknowns. That is to say we know there are some things we do not know. “But there are also unknown unknowns, the ones we don't know we don't know.”

Donald Rumsfeld

One creditworthy contribution to posterity: identifying different types of uncertainty


Patient/Population

Intervention

Comparison

Outcome

What is an uncertainty?


Good Medical Practice is the core ethical guidance the GMC provides to doctors. It is also intended to let the public know what they can expect from doctors


Austin Bradford Hill, 1965

Four questions to which readers want answers when reading reports of research.

1. Why did you start? 2. What did you do? 3. What answer did you get? 4. And what does it mean anyway?


What are the effects of methylxanthines (caffeine, theophylline) for apnoea of

prematurity?


The results of five trials that enrolled a total of 192 preterm infants with apnea indicate that methylxanthine therapy leads to a reduction in apnea and use of IPPV in the first two to seven days.

The effects of methylxanthines on long-term outcomes will be addressed in data from the trial awaiting assessment.


Long-Term Effects of Caffeine Therapy for Apnea of PrematurityBarbara Schmidt, M.D., Robin S. Roberts, M.Sc., Peter Davis, M.D., Lex W. Doyle, M.D., Keith J. Barrington, M.D., Arne Ohlsson, M.D., Alfonso Solimano, M.D., Win Tin, M.D., for the Caffeine for Apnea of Prematurity Trial Group

Conclusions Caffeine therapy for apnea of prematurity improves the rate of survival without neurodevelopmental disability at 18 to 21 months in infants with very low birth weight

Volume 357:1893-1902 November 8, 2007 Number 19


What are the effects of prophylactic antibiotics for inhibiting preterm labour with

intact membranes?


This review fails to demonstrate a clear overall benefit from prophylactic antibiotic treatment for preterm labour with intact membranes on neonatal outcomes and raises concerns about increased neonatal mortality for those who received antibiotics…

The 17 citations awaiting classification may alter the conclusions of the review once assessed.


Because uncertainties about the long term effects of prescribing antibiotics in spontaneous preterm labour and caffeine for apnoea of prematurity were not investigated 25 years ago, tens of thousands of people are now living with cerebral palsy that might have been prevented.


We need to confront important uncertainties about the effects of treatment because otherwise:

● patients will be denied unrecognised beneficial care

● patients will be given unrecognised harmful care

● resources will be wasted on useless or unnecessarily expensive care


•Uncertainties from Patients, carers and clinicians

- from today onwards; challenging

•Uncertainties from research recommendations– easy access, Cochrane Systematic Reviews, NICE Guidelines, journals.

•Uncertainties from ongoing research

- no need to duplicate what is already

happening


UK DUETs

http://www.library.nhs.uk/duets

nhs evidence – provided by nice where can treatment uncertainties come from, and what do we do...

Documents

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effects uncertain uncertainty

nice types of uncertainty

effects of treatments

valuesvalue uncertainty

stochastic uncertainty

nice good medical practice