Peter Littlejohns: Generating the right kind of clinical evidence and guidance


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Peter Littlejohns, Clinical and Public Health Director, NICE, discusses how they are working to help patients and clinicians make choices about health care.

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  • Peter Littlejohns: Generating the right kind of clinical evidence and guidance

    1. 1. Generating the right kind of clinical evidence and guidance Professor Peter Littlejohns Clinical and Public Health Director
    2. 2. Evaluating the evidence Judgements to be made Evidence Research Evidence Patient Experience Clinical Practice
    3. 3. The Nature of Evidence (i) <ul><li>‘ What is now proved </li></ul><ul><li>was once only imagined’ </li></ul>Picture of Sir Isaac Newton by William Blake – English Poet and Artist (1757-1827) To support innovation NICE needs to be able to handle ‘immature’ evidence
    4. 4. The Nature of Evidence (ii) <ul><li>‘ God forbid that truth should be confined to mathematical demonstration’ </li></ul>Picture of the grand architect William Blake – English Poet and Artist (1757-1827) NICE makes scientific and social values judgements
    5. 5. The Nature of Evidence (iii) <ul><li>‘ One law for the lion and the ox is oppression.’ </li></ul>Picture of Job after his tribulations by William Blake – English Poet and Artist (1757-1827) Assess evidence in relationship to its ‘fitness for purpose’ rather than according to pre-ordained hierarchies
    6. 6. NICE approach has 4 steps to assessing evidence Step 1: Define the clinical or public health question Step 2: Identify the evidence Step 3: Synthesise and assess the body of evidence Step 4: Issue the recommendations
    7. 7. A short history of NICE’s products QOF Public health Interventional Procedures Clinical guidelines Quality standards
    8. 8. NICE range of products aimed at reducing variation and saving money All NICE guidance Commissioning guides Costing tools ‘ Do not do’ database Referral database NHS Evidence QIPP page
    9. 9. Disinvestment <ul><li>Reducing variation can mean encouraging clinicians to do something but more often means encouraging clinicians to stop doing something. </li></ul><ul><li>Health technology appraisal has been used as a tool to manage the entry of new interventions into system. </li></ul><ul><li>Interest turning to methods involving identification of existing interventions thought to be clinically or cost ineffective. </li></ul><ul><li>Concept described by the term disinvestment : </li></ul><ul><li>‘ The practice of stopping or restricting the use of low-value health care practices to enable resources to be shifted to higher-value care. ’ </li></ul>
    10. 10. BMJ 2011; 343:d4519 doi: 10.1136/bmj.d4519 (Published 27 July 2011) Cite this as: BMJ 2011; 343:d4519
    11. 11. NICE and Cochrane work together <ul><li>NICE and Cochrane produce gold standard products of evidence-based medicine. </li></ul><ul><li>For a pilot project the UK Cochrane Centre sent NICE published Cochrane systematic reviews concluding an intervention could not be recommended. </li></ul><ul><li>NICE summarised reviews and published as ‘Cochrane Quality and Productivity’ topics on NHS evidence . </li></ul>
    12. 12. Summary of the process from Cochrane review to QIPP topic
    13. 13. Results <ul><li>65 reviews were appraised over five months </li></ul><ul><li>43% highlighted candidate interventions for local disinvestment </li></ul><ul><li>57% of reviews were rejected </li></ul><ul><li>36 Cochrane Quality Improvement topics have now been published on the NHS website suggesting potential candidates for local disinvestment. </li></ul><ul><li> </li></ul>
    14. 14. Results: Reasons for rejecting reviews
    15. 15. Lessons learnt <ul><li>This pilot project was designed as a rapid response process to identify potential low-value health care practices that would not be considered priorities for national guidance, based on the conclusions of high-quality systematic reviews. </li></ul><ul><li>The process proved very resource-intensive, with a rejection rate of 57%. </li></ul><ul><li>The process highlighted the need for more detailed data on health care expenditure than is routinely collected in the NHS. </li></ul>
    16. 16. <ul><li>Few interventions identified as ineffective were in regular use in the NHS. </li></ul><ul><li>Additional work is generally needed to evaluate interventions for which there is inadequate evidence: Stopping an intervention based on insufficient evidence can be potentially harmful and requires more rigorous investigation. </li></ul>
    17. 17. Implications for the health service (i) <ul><li>An evidence-based approach to identifying clinical activity for disinvestment proved challenging </li></ul><ul><li>Often there is an absence of evidence rather than conclusive evidence of a lack of benefit </li></ul><ul><li>More resource-intensive analysis is needed to facilitate local NHS implementation of disinvestment </li></ul><ul><li>To achieve real productivity savings, people, structures and values need to be assessed as well as marginal clinical activity </li></ul>
    18. 18. Implications for the health service (ii) <ul><li>This suggests alternative disinvestment strategies may be needed to achieve productivity savings requiring infrastructure, resources and robust national processes. </li></ul><ul><li>Encouraging guideline developers to identify inappropriate practices as opportunities for disinvestment is likely to be more productive than relying on systematic reviews alone. </li></ul>