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