The Clinical Effectiveness / Evidence-Based Practice Movement

This transition to a more effective, collaborative team approach, incorporating strategic thinking and shared information and learning, is a generational change. The new way is strongly embedded in modern curricula where evidence, equity, teamwork, integrated care and patient participation are key words. The current generation of students in the health care sciences will see only the tail end of the old way whereas some current clinicians cannot or will not make the transition.

Information sharing is an essential ingredient of this culture change. There are many barriers to information sharing. Language and education barriers may inhibit effective communication with patients. Technical jargon can still permeate written and verbal information. Risk concepts can be confused and confusing. The language of individuals (relative risk) and that of populations (numbers needed to treat [NNT]) may not be easily understood and can be misinterpreted. Concepts of risk and probability are not simple –individual details that are potentially critical to a causal explanation or treatment decision mean that, in the individual patient, probability is ambiguous and elusive no matter how it is communicated.

Patients need information in an acceptable and usable form. A balanced view should be presented and uncertainties must be emphasised. Patients should be involved in developing and testing material. The aim is for participation rather than patronisation.

Sharpe warns against ‘over exultation’ of evidence and the need to use expertise and judgement alongside evidence. Patients have unique experiences of illness and patient narrative in a clinical encounter remains crucial. “The art of care provision is achieved through integration of the patient’s story with expertise and judgement in decision-making, backed by the evidence base.”

Evidence summation and review has an additional role in guiding new research in priority areas. The present Foresight process in New Zealand and the creation of research portfolios may mean that new research is more reliably planned and achieved through ‘smart purchasing’. Further, the true relevance of research that is carried out can be assessed by determining the extent to which new findings are actually incorporated into guidelines which will make a difference.

Evidence summation and review and the guideline process contributes to allocative efficiency, achieved when resources are applied to maximise the welfare of the community.

With limited resources, certain technical or productive efficiencies (efficiencies within a particular area or with different interventions) may be eliminated in favour of allocative efficiency, ie, redistribution of resources amongst different areas. While meritable, there is no simple or agreed method to enable this.

Sharpe highlighted the importance of finding ways to effectively moderate excessive or allocatively inefficient bids that can occur through the guideline process.

Special interest groups may promote guidelines to increase resources diverted to a subgroup of the population. Some areas of practice are much more amenable to guideline development than other more evidence-replete areas. Clinical and commercial interests may rapidly achieve market dissemination and raise public expectations through the media initially and then through publication of uncosted guidelines.

Prospective consideration of costs and conversation amongst all interested parties as an integral part of guideline process is preferable to overbidding, which can lead to antagonism and arbitrary salvage responses, illustrated through the statins example.

Health care professionals in the modern era have a responsibility to consider the opportunity costs of interventions and to balance patient interests against the for broader community responsibility. The need for balance creates tension in health care and presents a dilemma for many professionals. It is important to connect all stakeholders together in discussion of this key issue rather than having arbitrary solutions imposed.

The shared ethical principles published by the international multidisciplinary Tavistock Group provide a basis from which discussion can proceed. Five major principles should govern health care systems:

1. Health care is a human right.
2. The care of individuals is at the centre of health care delivery but must be viewed and practised within the overall context of continuing work to generate the greatest possible health gains for groups and populations.
3. The responsibilities of the health care delivery system include the prevention of illness and the alleviation of disability.
4. Co-operation with one another and those served is imperative for those working within the health care delivery system.
5. All individuals and groups involved in health care, whether providing access or services, have the continuing responsibility to help improve its quality.

[Click here for full text of Professor Norman Sharpe’s paper]

Evidence-Based Decision-Making

Dr Rod Jackson, Member of the NZGG Advisory Group, considered evidence-based decision-making in the clinical effectiveness movement.

Jackson summarised evidence-based decision-making as using epidemiological and economic evidence on risks benefits and costs more explicitly, more systematically and more quantitatively than it is currently used to inform decisions.

The ‘evidence’ in evidence-based practice is ‘probabilistic’ and it is because this evidence is not used very well or very often that there is an evidence-based practice movement.

Resistance to probabilistic evidence exists because it relegates clinical explanation to a secondary role, it undermines professional authority, as each patient requires uniquely tailored care, and it acknowledges uncertainty.

However, evidence-based decision-making enhances the chances of predictable improvement in health outcomes, relative to decision-making based on personal experience, pathophysiological reasoning or expert opinion.