ASBHDS - Session 1

Question 1

Give some arguments in favour of using evidence-based healthcare.

Answer 1

• 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.

Question 2

What is the Cochrane Collaboration?

Answer 2

A global group of all the Cochrane Centres, which register and analyse all RCTs

Question 3

What is the standard definition of evidence-based practice?

Answer 3

Evidence based practice involves the integration of individual clinical expertise with the best available external clinical evidence from systematic research

Question 4

Why are systematic reviews required?

Answer 4

• Traditional reviews may be biased/subjective
• Not easy to see how studies were identified for review
• quality of reviewed studies is variable

Question 5

Give some reasons why systematic reviews are useful to clinicians.

Answer 5

• offer quality control and increased certainty
• save clinicians from having to locate/appraise studies for themselves
• may reduce delay between research discoveries and implementation

Question 6

Give some PRACTICAL criticisms of the evidence-based practice movement

Answer 6

• 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

Question 7

Give some PHILOSOPHICAL criticisms of evidence-based practice.

Answer 7

• 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

Question 8

Give some problems with getting evidence into practice

Answer 8

• 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

Question 9

Define scarcity

Answer 9

Need outstrips resources, prioritisation is inevitable

Question 10

Define efficiency

Answer 10

Getting the most out of limited resources

Question 11

Define equity

Answer 11

The extent to which distribution of resources is fair

Question 12

Define effectiveness

Answer 12

The extent to which an intervention produces desired outcomes

Question 13

Define utility

Answer 13

The value an individual places on a heath state

Question 14

Define opportunity cost

Answer 14

Once a resource has been used in one way, it can no longer be used in another way

Question 15

What is the difference between technical and allocative efficiency?

Answer 15

Technical efficiency - the most efficient way of meeting a need
Allocative efficiency - choosing between the many needs to be met

Question 16

What does an economic analysis do?

Answer 16

Compares the inputs (resources) and outputs (benefits and value attached to them) of alternative interventions, allowing better decisions to be made about investment values.

Question 17

How are costs measured?

Answer 17

Identify, quantify and value resources needed

Question 18

How are benefits measured?

Answer 18

• impacts on health status
• savings in other healthcare resources
• improved productivity if patient/family returns to work earlier

Question 19

What are the four types of economic evaluation?

Answer 19

• cost minimisation analysis
• cost effectiveness analysis
• cost benefit analysis
• cost utility analysis

Question 20

What is cost minimisation analysis?

Answer 20

• 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

Question 21

What is cost effectiveness analysis?

Answer 21

• 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)

Question 22

What is cost benefit analysis?

Answer 22

• all inputs and outputs valued in monetary terms

- allows comparisons with interventions outside healthcare

Question 23

What is cost utility analysis?

Answer 23

• sub-type of cost effectiveness analysis

- measured in ‘cost per QALY’ terms

Question 24

If there is good evidence about the effectiveness of the interventions and they are equally effective, which study should be used?

Answer 24

Cost minimisation study

Question 25

If outcomes cannot be measured in monetary terms or QALYs, what study should be used?

Answer 25

Cost-effectiveness analysis

Question 26

What is a QALY?

Answer 26

A Quality Adjusted Life Year adjusts life expectancy for quality of life, so one year of perfect health = 1 QALY

Question 27

Give an example of a way of measuring quality of life.

Answer 27

The EQ-5D

Question 28

Up to what monetary value will NICE approve technology?

Answer 28

- below £20k per QALY, technology approved - at £20k-30k it will be evaluated - above £30k needs a 'strong case' to be accepted

Question 29

Give some criticisms of QALYs

Answer 29

- 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

Question 30

Why must priorities must be set in healthcare?

Answer 30

Due to scarcity of resources - demand outstrips supply

Question 31

What is the difference between explicit and implicit rationing?

Answer 31

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

Question 32

Give some disadvantages of implicit rationing

Answer 32

- can lead to inequities and discrimination - open to abuse - decisions based on perceptions of 'social deserving-ness' - doctors increasingly unwilling to do it

Question 33

Give some advantages of explicit rationing

Answer 33

- transparent and accountable - opportunity for debate - more clearly evidence-based - more opportunities for equity in decision-making

Question 34

Give some disadvantages of explicit rationing

Answer 34

- very complex - heterogeneity of patients and illnesses makes it difficult - patient/professional hostility - impact on clinical freedom - evidence of patient distress

Question 35

What does NICE stand for?

Answer 35

National Institute for Health and Care Excellence

Question 36

What is the purpose of NICE?

Answer 36

Enables evidence of clinical and cost effectiveness to be integrated to form a judgement on the value of a treatment

Question 37

Why is the role of NICE in approving/rejecting expensive treatments sometimes seen as controversial?

Answer 37

- if not approved, patients effectively denied access to treatment - if approved, NHS organisations must fund them, even if with adverse consequences for other priorities