W(h)ither evidence-based medicine

The BMJ on 30 October was a theme issue—on whether evidence based medicine makes a difference—and summed it all up with a resounding: probably. Among the systematic reviews, randomised controlled trials, anecdotes, and speculation a picture does emerge. There are positive answers to many questions that are asked about EBM: Does it benefit patients? How do you teach it? How do you change practice?

The clearest messages are probably about how to teach it and how to change practice. Arri Coomarasamy and Khalid Khan's systematic review in the same edition showed that when teaching EBM is integrated into clinical practice it improves skills, attitudes, and behaviour as well as knowledge. The importance of integration with clinical practice fitted well with the ethnographic analysis by Gabbay and le May of how general practices handle and integrate evidence. Their answer, through two years of study, is that clinicians rely on "mindlines"—collectively reinforced, internalised, tacit guidelines, formed through interactions with each other and wider networks of "communities of practice." Trevor Sheldon and colleagues looked at 12 pieces of "tracer" guidance issued by NICE and tracked changes in practice in UK trusts. Not surprisingly, they found that implementation was patchy. Guidelines were more likely to be followed when the evidence was strong and stable and clinicians already moving in that direction—and the change was not too expensive or difficult to implement.

Yet it's the sceptics in the issue who have the best quotes. Nick Freemantle wondered about the real return on the substantial resources used to produce NICE guidance and quoted what might serve as an epitaph to many guidelines: "Nothing is impossible for the man who doesn't have to do it himself."

And even when evidence is strong it doesn't move magically from Cochrane review to clinical practice. In his commentary on the patchy adoption of video assisted thoracic surgery (shown in a systematic review to be superior to thoractomy for pneumothorax and minor resections Peter McCulloch applied G K Chesterton's comment on Christianity to EBM: [it has] "not been tried and found wanting; it has been found difficult and left untried."

Overall doing EBM well—like most worthwhile endeavours—is hard and needs considerable concentration. The real question is; with what do we now, given how far we have travelled, replace it? Non-evidence-based medicine. Quackery-based medicine. There are plenty of practitioners of those arts.

Source; Web

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GPs Purchasing health care—Fundholding strikes back

Until relatively recently, general practitioners (GPs) have been allowed to work independently, with no requirement to consider the resource implications of their referral and prescribing decisions. In order to align the interests of GPs with the overall objectives of health systems a number of countries have introduced primary care based capitation, funds pooling and budget holding either as experiments or as an overall policy. Are these experiments and policies likely to work? This paper presents evidence from the UK total purchasing experiment, which was the first major quasi-market development in the NHS to be independently evaluated from the outset. Total purchasing gave volunteer groups of practices freedom to purchase all hospital and community health services for their patients. The evidence suggests that whilst GPs have great potential as purchasers, they also have considerable limitations.

The expectation that they will be able to improve the quality of patient experience of care, or to alter the use of resources, may not be generally realised. GP-based purchasing may be more appropriate where the task is to alter the balance or location of care between hospital and extramural settings. However, budgetary incentives are not 'magic potions' which have similar effects on behaviour wherever they are introduced. Holding budgets and having independent contracts, while important pre-requisites for being taken seriously in a quasi-market, were not sufficient for effective total purchasing. The paper concludes that health systems should not only value innovation and experimentation and encourage learning from evaluative research; they should also recognise the importance of supportive circumstances for any innovation to effect real and sustained change

Source: web

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Guidelines in mild hypertension in pregnancy

This was a study to determine the impact of a national strategy to promote implementation of a guideline on the management of mild, non-proteinuric hypertension in pregnancy. It was a simple, interrupted time series analysis in four maternity units in Scotland.

Women delivering a live or stillborn baby were studied. The Dissemination of the guideline was carried out under the auspices of a national clinical effectiveness programme, supported by a national launch meeting and feedback from a survey of obstetricians highlighting aspects of care that could be improved.

The main outcomes were the appropriateness of initial investigation and subsequent clinical management, and costs of guideline development and implementation activities. Data was collected twenty-four months pre-intervention and 12 months post-intervention. The data were abstracted from a random sample of case notes.

The initial investigation was consistent with recommendations for 59.9% out of 1263 women and subsequent clinical management for 67.6% out of 1081 in whom a diagnosis could be made from available data. There were no significant changes in the appropriateness of initial investigation (10.6%; 95% confidence interval [CI] -0.1% to 19.3%; decreasing by 1.2% per month post-implementation, 95% CI -2.5% to 0.1%) or clinical management (-0.3%; 95% CI -8.7% to 11.2%). Guideline development and implementation cost an estimated pound 2784 per maternity unit in Scotland.

It was concluded that clinical care of mild hypertension in pregnancy remains highly inconsistent. The lack of the intervention effect may be related to the complexity of the guideline recommendations and the nature of the implementation strategy.

Source: Web

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