CLINICAL GOVERNANCE

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CLINICAL GOVERNANCE

• Dr Stephen Newell
• February 2002

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CLINICAL GOVERNANCE

• ENSURING QUALITY IN ALL ASPECTS OF THE DELIVERY
  OF MEDICAL CARE

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COMPONENTS OF CLINICAL GOVERNANCE

• EVIDENCE-BASED MEDICINE
• DISSEMINATING BEST PRACTICE
• EFFICIENCY COST-EFFECTIVENESS
• AUDIT APPRAISAL
• EDUCATION TRAINING
• RISK MANAGEMENT
• PROBITY

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EVIDENCE-BASED MEDICINE

• DEFINITION AND SCOPE OF EBM
• WHY IS EBM IMPORTANT?
• EXAMPLES OF QUESTIONS FOR WHICH THERE COULD BE
  EVIDENCE
• SOURCES PROVIDING EBM

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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.

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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.

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WHY IS EBM IMPORTANT?

• SCIENTIFIC BASIS FOR MEDICAL PRACTICE
• ECONOMIC ARGUMENTS
• GOVERNANCE ISSUES

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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

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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

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GOVERNANCE ISSUES

• KNOWN OUTCOME FROM WHAT IS DONE
• KNOWN BENEFIT PROVIDES JUSTIFICATION FOR
  EXPENDITURE
• ETHICAL DIMENSION

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ETHICAL DIMENSION - 1

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

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ETHICAL DIMENSION - 2

• SCIENTIFIC BASIS FOR ADVISING PATIENTS
• GUIDANCE FOR PRACTITIONERS
• CONSISTENCY AMONGST PRACTITONERS

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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

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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

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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?

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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?

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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?

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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?

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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?

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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?

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THEMES FROM EXAMPLES

• ANSWERS TO QUESTIONS KNOWN ALREADY OR ANSWERABLE
• COULD PROVIDE A BASIS FOR RESEARCH
• CONSIDERING VALUE OF TREATMENTS AND NOT JUST COST

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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

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SOURCES FOR EBM - 2

• SPECIALIST JOURNALS
• Drug and Therapeutics Bulletin
• MeReC publications
• Bandolier
• CONSUMER VIEW?
• Which? surveys of OTC remedies

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SOURCES FOR EBM 3

• ELECTRONIC DATABASES e.g.
• Cochrane
• Medline
• INTERNET
• Pubmed
• Quackwatch

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LITERATURE SEARCHING

• How?
• What journals?
• What countries / languages?
• What dates?
• Use PUNs and DENs, not topics
• Finding time
• Need to avoid overload
• Rejecting chaff

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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?

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SOURCES FOR EBM 4

• BOOKS
• Clinical Evidence (BMJ)
• Evidence-based Medicine (Sackett et al, Churchill
  Livingstone, 1998)
• Evidence-based Healthcare (Gray, Churchill
  Livingstone, 1997)

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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

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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