Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (7 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Healthcare professionals have always sought evidence on which to base their clinical practice. Unfortunately, the evidence has not always been available, reliable or explicit, and when it was available it has not been implemented immediately. James Lancaster in 1601 showed that lemon juice was effective in the treatment of scurvy, and in 1747 James Lind repeated the experiment. The British Navy did not utilise this information until 1795 and the Merchant Navy not until 1865. When implementation of research findings is delayed, ultimately the people who suffer are the patients.
A number of different groups of people may need to be committed to the changes before they can take place with any degree of success. These include:
healthcare professionals (doctors, nurses, etc.);
healthcare providers and purchasers;
researchers;
patients and the public;
government (local, regional and national).
Each of these groups has a different set of priorities. To ensure that their own requirements are met by the proposal, negotiation is required, which takes time. There are many potential barriers to the implementation of recommendations, and clinicians may become so embroiled in tradition and dogma, that they are resistant to change. They may lack knowledge of new developments or the time and resources to keep up to date with the published literature. Lack of training in a new technology, such as laparoscopic surgery or interventional radiology, may thwart their use, even when shown to be effective. Researchers may become detached from the practicalities of clinical practice and the needs of the health service and concentrate on inappropriate questions or produce impractical guidelines. Managers are subject to changes in the political climate and can easily be driven by policies and budgets. The resources available to them may be limited and not allow for the purchase of new technology, and even potentially cost-saving developments may not be introduced because of the difficulties in releasing the savings from elsewhere in the service.
Patients and the general public can also influence the development of the healthcare offered. They are susceptible to the persuasion of the mass media and may demand the implementation of ‘miracle cures’ or fashionable investigations or treatments. Such interventions may not be practical or of any proven benefit. They can also determine the success or failure of a particular treatment. For instance, a treatment may be physically or morally unacceptable, or there may be poor compliance, especially with preventative measures such as diets, smoking cessation or exercise. All these aspects can lead to a delay in the implementation of research findings.
Potential ways of improving this situation include the following:
Provision of easy and convenient access to summaries of the best evidence, electronic databases, systematic reviews and journals in a clinical setting.
Development of better disease management systems through mechanisms such as clinical guidelines, ICPs and electronic reminders.
Implementation of computerised decision-support systems.
Improvement of educational programmes – practitioners must be regularly and actively apprised of new evidence rather than relying on the practitioner seeking it out; passive dissemination of evidence is ineffective.
More effective systems to encourage patients to adhere to treatment and general healthcare advice; the information must be clear, concise, correct and actively distributed.
There is a gap between research and practice, and there is a need for evidence about the effectiveness of different methods of implementing changes in clinical practice. The NHS Central R&D Committee set up an advisory group to look into this problem and identified 20 priorities for evaluation, as shown in
Box 1.2
.
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Box 1.2
Priority areas for evaluation in the methods of implementation of the findings of research: recommendations of the advisory group to the NHS Central Research and Development Committee
Influence of source and presentation of evidence on its uptake by healthcare professionals and others
Principal sources of information on healthcare effectiveness used by clinicians
Management of uncertainty and communications of risk by clinicians
Roles for health service users in implementing research findings
Why some clinicians but not others change their practice in response to research findings
Role of commissioning in securing change in clinical practice
Professional, managerial, organisational and commercial factors associated with securing change in clinical practice, with particular focus on trusts and primary care providers
Interventions directed at clinical and medical directors and directors of nursing trusts to promote evidence-based care
Local research implementation and development projects
Effectiveness and cost-effectiveness of audit and feedback to promote implementation of research findings
Educational strategies for continuing professional development to promote the implementation of research findings
Effectiveness and cost-effectiveness of teaching critical appraisal skills to clinicians, patients/users, purchasers and providers to promote uptake of research findings
Role of undergraduate training in promoting the uptake of research findings
Impact of clinical practice guidelines in disciplines other than medicine
Effectiveness and cost-effectiveness of reminder and decision support systems to implement research findings
Role of the media in promoting uptake of research findings
Impact of professional and managerial change agents (including educational outreach visits and local opinion leaders) in implementing research findings
Effect of evidence-based practice on general health policy measures
Impact of national guidelines to promote clinical effectiveness
Use of research-based evidence by policymakers
From NHS Central Research and Development Committee. Methods to promote the implementation of research findings in the NHS: priorities for evaluation: report to the NHS Central Research and Development Committee. London: Department of Health, 1995. © Crown copyright 2008. Reproduced under the terms of the Click-Use Licence.
An EPOC review has examined the different methods of implementing evidence-based healthcare and classified them into three broad groups:
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consistently effective – educational visits and interactive meetings;
sometimes effective – audit and feedback;
little or no effect – printed guideline distribution.
Several groups have looked at implementing evidence-based practice, such as grommet use in glue ear and steroids in preterm delivery:
Successful implementation of research findings into practice appears to be due to a multipronged approach and the UK National Association of Health Authorities and Trusts (NAHAT) has produced an action checklist in order to facilitate this process.
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It must be remembered, however, that EBM is not the sole preserve of experts or clinicians. The research, dissemination and implementation of clinical and economic evaluations have wide-reaching repercussions for the health service. Managers are under increasing pressure to be effective both clinically and for costs, and are accountable at local, regional and national levels. They need to be actively involved and understand the process. As with all interactions between elements in the health service, there must be collaboration, the ultimate goal being an improvement in patient care.
Audit is the systematic critical analysis of the quality of medical care, including the procedures used for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient.
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The Department of Health has set out policy documents that outline the development and role of audit in today's healthcare system.
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,
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Everyone involved in the healthcare process has a responsibility to conduct audit and to assess the quality of care that they provide. In 1996, Donabedian categorised three important elements in the delivery of healthcare:
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Structure – this relates to physical resources available, e.g. the number of theatres, hospital beds and nurses, etc.
Process – this refers to the management of the patient, e.g. procedures carried out, drugs used, care delivered, etc.
Outcome – this refers to the result of the intervention, e.g. the amount of time off work, incidence of complications, morbidity and length of stay.
Audit is a dynamic cyclical process (an audit loop) in which standards are defined and data are collected against these standards (
Fig. 1.3
). The results are then analysed and if there are any variances, proposals for change are developed to address the needs. These changes are then implemented and the quality of care reassessed. This closes the audit loop and the procedure begins again. The key to effective audit is that the loop must begin with the development of evidence-based standards. Any success in changing care to meet proposed standards is unlikely to produce more effective clinical care if such standards are set in an arbitrary way. The Royal College of Surgeons of England has published its own guidelines on clinical audit in surgical practice.
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Figure 1.3
The audit loop.
One result of the drive to implement audit in the UK was the development in 1993 of a National Confidential Enquiry into Perioperative Deaths (NCEPOD). This is an ongoing national audit and has produced a series of reports and recommendations based upon a peer review process. The process has a high rate of participation and reports with recommendations have resulted in a number of changes in clinical practice. For example, there has been a dramatic reduction in out-of-hours operating following recommendations suggesting that much of this was unsafe and unnecessary.
Key points
The formulation of clear and answerable questions is a key element of EBM in surgery.
Identification of all the relevant evidence is required.
Critical appraisal of the evidence is necessary.
Synthesis of information from multiple sources needs to provide a clear message through systematic review and/or meta-analysis.
Findings should be implemented through mechanisms such as the use of clinical guidelines and ICPs.
Monitoring through audit is necessary to ensure continuing adherence to best practice.
Regular review to incorporate new evidence or take account of clinical developments should be carried out.
Throughout this book and the other volumes in this series, an attempt will be made to take an evidence-based approach. This will include the identification of high-quality evidence from RCTs and systematic reviews, underlining key statements and recommendations relating to clinical practice. All clinicians have a duty to ensure that they act in accordance with current ‘best evidence’ in order to give patients the highest chance of favourable outcomes and make the best use of limited healthcare resources.