Flashcards in ASBHDS - Session 1 Deck (37):
Give some arguments in favour of using evidence-based healthcare.
- evidence of effectiveness and cost-effectiveness required in a system with finite resources
- variations in treatment cause inequities
- practices influenced too much by professional opinion, clinical fashion, culture etc.
What is the Cochrane Collaboration?
A global group of all the Cochrane Centres, which register and analyse all RCTs
What is the standard definition of evidence-based practice?
Evidence based practice involves the integration of individual clinical expertise with the best available external clinical evidence from systematic research
Why are systematic reviews required?
- Traditional reviews may be biased/subjective
- Not easy to see how studies were identified for review
- quality of reviewed studies is variable
Give some reasons why systematic reviews are useful to clinicians.
- offer quality control and increased certainty
- save clinicians from having to locate/appraise studies for themselves
- may reduce delay between research discoveries and implementation
Give some PRACTICAL criticisms of the evidence-based practice movement
- may be an impossible task to maintain systematic reviews across all specialities
- challenging and expensive to disseminate/implement findings
- not always feasible/necessary
- requires 'good faith' from pharmaceutical companies
Give some PHILOSOPHICAL criticisms of evidence-based practice.
- does not align with most doctors' modes of reasoning
- population-level outcomes don't mean an intervention will work for an individual
- could relate 'unreflective rule followers' from professionals
- might be seen as way of legitimising rationing
- professional responsibility/autonomy
Give some problems with getting evidence into practice
- evidence exists but doctors don't know about it
- doctors know about evidence but don't use it
- organisational systems cannot support innovation
- commissioning decisions reflect different priorities
- resources not available to implement change
Need outstrips resources, prioritisation is inevitable
Getting the most out of limited resources
The extent to which distribution of resources is fair
The extent to which an intervention produces desired outcomes
The value an individual places on a heath state
Define opportunity cost
Once a resource has been used in one way, it can no longer be used in another way
What is the difference between technical and allocative efficiency?
Technical efficiency - the most efficient way of meeting a need
Allocative efficiency - choosing between the many needs to be met
What does an economic analysis do?
Compares the inputs (resources) and outputs (benefits and value attached to them) of alternative interventions, allowing better decisions to be made about investment values.
How are costs measured?
Identify, quantify and value resources needed
How are benefits measured?
- impacts on health status
- savings in other healthcare resources
- improved productivity if patient/family returns to work earlier
What are the four types of economic evaluation?
- cost minimisation analysis
- cost effectiveness analysis
- cost benefit analysis
- cost utility analysis
What is cost minimisation analysis?
- outcomes assumed to be equivalent
- focus is on costs only
- not relevant very often
- eg. All prostheses for hip replacement improve mobility equally; choose cheapest one
What is cost effectiveness analysis?
- used to compare drugs/interventions with a common health outcome
- compared in terms of cost per unit outcome (eg per reduction in blood pressure of 5 mm Hg)
What is cost benefit analysis?
- all inputs and outputs valued in monetary terms
- allows comparisons with interventions outside healthcare
What is cost utility analysis?
- sub-type of cost effectiveness analysis
- measured in 'cost per QALY' terms
If there is good evidence about the effectiveness of the interventions and they are equally effective, which study should be used?
Cost minimisation study
If outcomes cannot be measured in monetary terms or QALYs, what study should be used?
What is a QALY?
A Quality Adjusted Life Year adjusts life expectancy for quality of life, so one year of perfect health = 1 QALY
Give an example of a way of measuring quality of life.
Up to what monetary value will NICE approve technology?
- below £20k per QALY, technology approved
- at £20k-30k it will be evaluated
- above £30k needs a 'strong case' to be accepted
Give some criticisms of QALYs
- controversy about values they embody
- may disadvantage common conditions
- do not distribute resources according to need, but according to benefit gained
- technical problems with calculation
- do not assess impact on careers/family
- RCT evidence can not always be relied upon
Why must priorities must be set in healthcare?
Due to scarcity of resources - demand outstrips supply
What is the difference between explicit and implicit rationing?
Implicit - allocation of resources through individual clinical decisions without the criteria for decisions being explicit
Explicit - the use of institutional procedures for the systematic allocation of resources within a health care system
Give some disadvantages of implicit rationing
- can lead to inequities and discrimination
- open to abuse
- decisions based on perceptions of 'social deserving-ness'
- doctors increasingly unwilling to do it
Give some advantages of explicit rationing
- transparent and accountable
- opportunity for debate
- more clearly evidence-based
- more opportunities for equity in decision-making
Give some disadvantages of explicit rationing
- very complex
- heterogeneity of patients and illnesses makes it difficult
- patient/professional hostility
- impact on clinical freedom
- evidence of patient distress
What does NICE stand for?
National Institute for Health and Care Excellence
What is the purpose of NICE?
Enables evidence of clinical and cost effectiveness to be integrated to form a judgement on the value of a treatment