CLINICAL GOVERNANCE Dr Stephen Newell

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 AVOIDING HARM FROM UNPROVEN TREATMENTS FAIRNESS TO ALL PATIENTS “EFFECTIVE TREATMENT SHOULD BE FREE” (Cochrane)

ETHICAL DIMENSION - 2 SCIENTIFIC BASIS FOR ADVISING PATIENTS GUIDANCE FOR PRACTITIONERS CONSISTENCY AMONGST PRACTITONERS

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 prescribing, “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 routine vaginal examination done at booking or postnatal examinations? Does padding accelerate the healing of corneal abrasions? 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? Do steroids have 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 MeReC publications Bandolier – web-based CONSUMER VIEW? e.g. “Which?” surveys of OTC remedies

SOURCES FOR EBM – 3 ELECTRONIC DATABASES e.g. Cochrane Medline INTERNET Pubmed Quackwatch

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? Are / 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 SHOULD BE DONE WHEN THERE IS NO EVIDENCE? HOW TO DISSEMINATE BEST PRACTICE