Jonathan Richards presentation WSPCR 2011

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  • 1. We had the experience but missed the meaning:can we balance patient choice, evidence based practice and quality improvement? Professor Jonathan Richards General Practitioner, Morlais Medical Practice Locality Clinical Director, Cwm Taf HB Visiting Professor of Primary Care, University of Glamorgan
  • 2. Our values: ‘the universality of the best’A critique of Utilitarian rational choice waysof thinking:• Commensurability:how do we measure things?• Aggregation: pooling choices• Maximising:will every person want more?• Exogenous:preferences taken for granted
  • 3. Life on the boundariesThe boundary is the best place for acquiringknowledge. At almost every point I have hadto stand between alternative possibilities ofexistence, to be completely at home inneither. This position is fruitful for thought; butit is difficult and dangerous in life, whichagain and again demands decisions and thusthe exclusion of alternatives. Paul Tillich, On the Boundary 1967
  • 4. VREONABA Evidence- based practiceCitizen Performancechoice Management
  • 5. NussbaumContext Evidence-based practiceValuesCandidacyGenomicsSurrogate markers Citizen choice ent Managem ce Performan
  • 6. Gaps between the evidence and the real world Evidence- Lag times between the evidence based practice and the performance review Whose priorities? Surrogate markersCitizen Performance Managementchoice
  • 7. Do we tell the citizen why we are doingsomething?Who does the data belong to?What really matters andEvi whom? to denGaming and informed choice. ce -Surrogate markers praInsights from Ariely, Kahneman and Haidt ctic e Citizen Performance choice Management
  • 8. Data from the real world35%30%25%20%15%10%5%0% <100 >100 >110 >120 >130 >140 >150 >160 >170 >180 >190 well bp only 2007 BP only 2008 BP 2010
  • 9. Blood Pressure distribution35%30%25%20%15%10%5%0% BP <100 last BP 100- last BP 110- last BP 120- last BP 130- last BP 140- last BP 150 last BP>160 109 119 129 139 149 -159 low risk intermediate risk high risk very high risk
  • 10. Work to be done if the citizens agree 70% 4500 4000 60% 3500 50% 3000 40% 2500 30% 2000 1500 20% 1000 10% 500 0% 0 no BP reading no smoking history no measure of BMI no record of FHnumbers 20% 16% 44% 65%proportions 1300 1017 2847 4224
  • 11. Missing data80%70%60%50%40%30%20%10%0% blood pressure smoking history BMI Family History recorded low risk intermediate risk high risk very high risk
  • 12. A worked example
  • 13. ResourcesTS Eliot Dry Salvages part II from The Four Quartets Faber 1944MC Nussbaum Poetic Justice Beacon Press 1995P Tillich Life on the Boundaries 1967 Micheel (Ed), JR. Ball (Ed) Evaluation of Biomarkers and SurrogateEndpoints in Chronic Disease 2010