Evidence-based healthcare and public health : how to make decisions about health services and public health

A guide to evidence-based decision making for healthcare, medical and nurse managers. New edition of a highly praised and successful book in one of the hottest areas of medicine. Covers the vital areas for healthcare managers - finding and appraising evidence and developing the capacity of individuals and organisations to use evidence. Pressure on healthcare services is growing - this book will be indispensable for managers making difficult decisions about the allocation of scarce resources. Exceptionally well written - highly praised by the Journal of the American Medical Association and the British Medical Journal. More on managerial decision making and managerial options in the face of financial pressure on resources. More focus on how to get better outcomes - how to improve quality rather than just how to measure quality. Updating throughout.

• Preface to Third Edition p. xiii
• References
• Confessions of an Amanuensis p. xv
• Reference
• How to Use This Book p. xvii
• Finding and appraising evidence p. xvii
• Developing the capacity for evidence-based decision-making p. xvii
• Getting research into practice p. xviii
• References
• Defining Our Terms p. xxi
• Defining words with words p. xxi
• Defining words by their usage p. xxi
• Word euthanasia p. xxii
• Defining words by numbers p. xxiv
• Meaning, reality and language p. xxiv
• Indefinite definitions p. xxv
• References
• Prologue: The Globalisation of Healthcare Problems and Their Solutions p. 1
• Common problems: common solutions p. 2
• Problems and solutions in poorer countries p. 3
• Pre-conditions for evidence-based healthcare p. 5
• The USA and the rest of the developed world p. 5
• Reference
• Chapter 1 Evidence-Based Health Services p. 11
• 1.1 Evidence-based healthcare: a scientific approach to health services management p. 11
• 1.2 Why focus on decision-making? p. 12
• References
• 1.3 The drivers of decision-making: evidence, values, and resources and needs p. 13
• 1.4 Evidence-based decision-making p. 13
• 1.4.1 Skills for healthcare decision-makers
• 1.4.2 Pre-requisites for good decision-making
• 1.4.3 Reviewing decisions in the light of new evidence
• Reference
• 1.5 Defining the scope of evidence-based healthcare p. 17
• 1.5.1 Stage 1: Producing evidence
• 1.5.1.1 Ignorance is a type of evidence
• 1.5.2 Stage 2: Making evidence available
• 1.5.3 Stage 3: Using evidence
• 1.5.3.1 Evidence-based patient choice
• 1.5.3.2 Evidence-based clinical practice
• 1.5.3.3 Evidence-based policy-making, and paying for and managing health services on the basis of evidence
• References
• 1.6 Realising the potential of evidence-based healthcare p. 23
• 1.7 Strategic approaches to implementing evidence-based decision-making in healthcare systems p. 23
• 1.7.1 Managed care
• 1.7.2 Care pathways
• 1.7.3 Clinical guidelines
• 1.7.3.1 Who is accountable for guidelines?
• 1.7.3.2 Clinical guidelines and the law
• References
• 1.8 The limitations of healthcare in improving health p. 33
• 1.8.1 Improving the health of populations
• 1.8.2 Improving the health of individual patients
• 1.8.2.1 Disease without illness
• 1.8.2.2 Illness without disease
• References
• 1.9 Evidence and other types of knowledge p. 36
• References
• 1.10 Thinking and feeling p. 38
• 1.10.1 The need for bounded rationality
• References
• Chapter 2 'Doing the Right Things Right' p. 41
• 2.1 The growing need for evidence-based healthcare p. 41
• 2.1.1 Population ageing
• 2.1.2 New technology and new knowledge
• 2.1.3 Expectations about healthcare
• 2.1.3.1 Rising patient expectations
• 2.1.3.2 Rising professional expectations
• References
• 2.2 The evolution of evidence-based healthcare p. 44
• 2.2.1 Doing things cheaper
• 2.2.2 Doing things better
• 2.2.3 Doing things right
• 2.2.4 Doing the right things
• 2.2.5 Doing the right things right
• 2.3 Decision rules for resource allocation in healthcare p. 48
• Reference
• 2.4 Value for money in healthcare p. 50
• 2.4.1 Better value healthcare
• Reference
• 2.5 The new management agenda for health services p. 52
• 2.5.1 Strategies to increase the good-to-harm ratio
• 2.5.1.1 Starting starting right
• 2.5.1.2 Stopping starting and starting stopping
• 2.5.1.3 Slowing starting
• 2.5.2 Promoting relevant research
• 2.5.2.1 Preventing unnecessary research
• 2.5.3 Managing change in clinical practice
• 2.5.4 Minimising health inequalities
• References
• 2.6 The impact of science on clinical practice and healthcare costs p. 62
• Reference
• 2.7 Who 'carries the can'? p. 64
• 2.8 Industry and evidence-based decision-making p. 65
• Chapter 3 Making Decisions About Health Services p. 67
• 3.1 Making decisions under pressure p. 67
• 3.1.1 Dealing with difficult decisions
• 3.1.2 Battalions of difficult decisions
• Reference
• 3.2 Therapeutic and preventive interventions p. 69
• 3.2.1 Dimensions and definitions
• 3.2.2 Searching
• 3.2.3 Appraisal
• 3.2.3.1 The balance of good and harm
• 3.2.3.2 Assessing innovations in health service delivery
• 3.2.4 Getting research into practice
• 3.2.4.1 Therapy
• 3.2.4.2 Innovations in health service delivery
• References
• 3.3 Tests p. 74
• 3.3.1 Dimensions and definitions
• 3.3.1.1 Sensitivity and specificity
• 3.3.1.2 Predictive values
• 3.3.1.3 Types of test result
• 3.3.1.4 Between a rock and a hard place
• 3.3.1.5 Tests: the producer's perspective
• 3.3.1.6 Tests: the clinician's perspective
• 3.3.1.7 Tests: the perspective of those who pay for healthcare
• 3.3.2 Searching
• 3.3.3 Appraisal
• 3.3.4 Getting research into practice
• References
• 3.4 Screening p. 90
• 3.4.1 Dimensions and definitions
• 3.4.1.1 The changing balance of good and harm
• 3.4.2 Searching
• 3.4.3 Appraisal
• 3.4.4 Getting research into practice
• References
• 3.5 Health policy p. 101
• 3.5.1 Dimensions and definitions
• 3.5.1.1 Healthcare policy
• 3.5.1.2 Public health policy
• 3.5.2 Searching
• 3.5.3 Appraisal
• 3.5.3.1 Appropriate study designs for evidence about healthcare policies
• 3.5.3.2 Natural experiments as sources of evidence about healthcare policy
• 3.5.3.3 Appraising research on public health policies
• 3.5.4 Getting research into practice
• References
• Chapter 4 Finding Good-Quality Evidence p. 109
• 4.1 The searcher's problems p. 109
• 4.1.1 The relevance gap: absence of high-quality evidence
• 4.1.2 The publication gap: failure to publish research results
• 4.1.3 The hunting gap: difficulties in finding published research
• 4.1.4 The quality gap: the need for critical appraisal
• 4.1.4.1 Flaws in the methodology and reporting of research
• 4.1.4.2 Misleading abstracts
• 4.1.4.3 Peer review: the death of another sacred cow
• References
• 4.2 Coping alone p. 119
• 4.2.1 Becoming a better scanner
• 4.2.2 Becoming a better searcher
• 4.2.3 Becoming better at critical appraisal
• 4.2.4 Use it or lose it
• 4.3 A knowledge service for the 21st century p. 121
• Reference
• Further reading
• Chapter 5 Appraising the Quality of Research p. 125
• 5.1 What is research? p. 125
• 5.1.1 Hypothesis-testing research
• 5.1.2 Fraud in medical research
• References
• 5.2 Choosing the right research method p. 129
• 5.3 Systematic reviews p. 129
• 5.3.1 Dimensions and definitions
• 5.3.1.1 Meta-analysis
• 5.3.2 Searching
• 5.3.3 Appraisal
• 5.3.3.1 Systematic reviews
• 5.3.3.2 Systematic reviews including meta-analysis
• 5.3.4 Uses and abuses
• References
• 5.4 Randomised controlled trials p. 140
• 5.4.1 Dimensions and definitions
• 5.4.1.1 Mega trials
• 5.4.1.2 Patient preference in trials
• 5.4.1.3 'N of 1'trials
• 5.4.2 Searching
• 5.4.3 Appraisal
• 5.4.3.1 Subgroup analysis
• 5.4.4 Uses and abuses
• 5.4.4.1 Interpretation and presentation
• 5.4.4.2 Reporting trial end points
• Further reading
• References
• 5.5 Case-control studies p. 154
• 5.5.1 Dimensions and definitions
• 5.5.1.1 Study of the causation of disease
• 5.5.1.2 Study of the adverse effects of treatment
• 5.5.2 Searching
• 5.5.3 Appraisal
• 5.5.4 Uses and abuses
• References
• 5.6 Cohort studies p. 157
• 5.6.1 Dimensions and definitions
• 5.6.1.1 The role of clinical databases
• 5.6.2 Searching
• 5.6.3 Appraisal
• 5.6.4 Uses and abuses
• References
• 5.7 Controlled before and after studies p. 162
• 5.7.1 Dimensions and definitions
• 5.7.2 Searching
• 5.7.3 Appraisal
• 5.7.4 Uses and abuses
• Reference
• 5.8 Interrupted time series p. 165
• 5.8.1 Dimensions and definitions
• 5.8.2 Searching
• 5.8.3 Appraisal
• 5.8.4 Uses and abuses
• Reference
• 5.9 Surveys p. 168
• 5.9.1 Dimensions and definitions
• 5.9.2 Searching
• 5.9.3 Appraisal
• 5.9.4 Uses and abuses
• References
• 5.10 Qualitative research p. 170
• 5.10.1 Dimensions and definitions
• 5.10.2 Searching
• 5.10.3 Appraisal
• 5.10.4 Uses and abuses
• References
• 5.11 Decision analysis p. 173
• 5.11.1 Dimensions and definitions
• 5.11.2 Searching
• 5.11.3 Appraisal
• 5.11.4 Uses and abuses
• References
• Chapter 6 Assessing the Outcomes Found p. 181
• 6.1 Five key questions about outcomes p. 181
• 6.1.1 How many outcomes were studied?
• 6.1.2 How large were the effects found?
• 6.1.2.1 Which yardstick?
• 6.1.3 With what degree of confidence can the results of the research be applied to the whole population?
• 6.1.4 Does the intervention do more good than harm?
• 6.1.5 How relevant are the results to the local population or service?
• 6.2 Measuring outcomes p. 187
• 6.2.1 Problems and pitfalls of performance measurement
• 6.2.1.1 Natural problems
• 6.2.1.2 Man-made problems
• 6.2.1.3 Resurgence of outcome measures in the measurement of quality
• 6.2.2 In praise of process
• References
• 6.3 Equity p. 189
• 6.3.1 Dimensions and definitions
• 6.3.1.1 Measuring equity
• 6.3.1.2 Assessing equity: evidence-based cuts at the margin
• 6.3.2 Searching
• 6.3.3 Appraisal
• 6.3.4 Applicability and relevance
• References
• 6.4 Effectiveness p. 192
• 6.4.1 Dimensions and definitions
• 6.4.1.1 Assessing effectiveness from the patient's perspective
• 6.4.1.2 Improving outcomes by providing emotional support
• 6.4.1.3 Improving outcomes through patient participation
• 6.4.1.4 Improving outcomes through process: in the absence of an effective technical intervention
• 6.4.2 Searching
• 6.4.3 Appraisal
• 6.4.3.1 Experimental studies of effectiveness
• 6.4.3.2 Observational studies of effectiveness
• 6.4.4 Applicability and relevance
• References
• 6.5 Safety p. 201
• 6.5.1 Dimensions and definitions
• 6.5.2 Searching
• 6.5.3 Appraisal
• 6.5.3.1 Which method?
• 6.5.3.2 Appraising the quality of studies on safety
• 6.5.4 Applicability and relevance
• References
• 6.6 Patient satisfaction and patients' experience of care p. 207
• 6.6.1 Dimensions and definitions
• 6.6.1.1 Acceptability of care
• 6.6.1.2 Patient satisfaction
• 6.6.1.3 Patients' experience of care
• 6.6.1.4 The benefits of measuring patient experience
• 6.6.2 Searching
• 6.6.3 Appraisal
• 6.6.4 Applicability and relevance
• References
• 6.7 Cost-effectiveness p. 213
• 6.7.1 Dimensions and definitions
• 6.7.1.1 Productivity
• 6.7.1.2 Efficiency and cost-effectiveness
• 6.7.1.3 The use of quality-adjusted outcome measures: QALYs and DALYs
• 6.7.1.4 Marginal and opportunity costs
• 6.7.1.5 Evaluations of cost-effectiveness
• 6.7.2 Searching
• 6.7.3 Appraisal
• 6.7.4 Applicability and relevance
• References
• 6.8 Quality p. 221
• 6.8.1 Dimensions and definitions
• 6.8.1.1 Quality assessment by measuring the process of care
• 6.8.1.2 Quality assessment by measuring the outcome of care
• 6.8.1.3 Reporting outcomes in the public domain
• 6.8.2 Searching for and appraising evidence on standards of care
• 6.8.2.1 Searching for papers on quality standards
• 6.8.2.2 Appraising evidence on quality standards
• 6.8.3 Searching for and aappraising evidence on variations in healthcare outcome
• 6.8.3.1 Searching for papers on variations in healthcare outcome
• 6.8.3.2 Appraising evidence on variations in healthcare outcome
• 6.8.4 Applicability and relevance
• References
• 6.9 Appropriateness p. 231
• 6.9.1 Dimensions and definitions
• 6.9.1.1 Appropriateness for individual patients
• 6.9.1.2 Appropriateness for groups of patients or populations
• 6.9.1.3 Identifying concerns about appropriateness
• 6.9.1.4 It may be appropriate but is it necessary?
• 6.9.1.5 Who defines necessity?
• 6.9.1.6 Medical futility
• 6.9.2 Searching
• 6.9.3 Appraisal
• 6.9.4 Applicability and relevance
• References
• Chapter 7 Evidence-Based Health Service Management p. 247
• 7.1 Creating the context for an evidence-based organisation p. 247
• 7.1.1 Tacit and explicit knowledge management
• 7.1.1.1 Knowledge from experience
• 7.1.2 The learning organisation
• 7.1.3 Hypertext organisations
• 7.1.4 The evidence-based knowledge-rich learning organisation
• References
• 7.2 Culture p. 252
• 7.2.1 The evidence-based chief executive
• 7.2.2 The evidence-based board
• 7.3 Systems p. 254
• 7.3.1 Systems that provide evidence
• 7.3.1.1 The 'evidence centre'
• 7.3.1.2 The National Library for Health
• 7.3.2 Systems that promote the use of evidence
• 7.3.2.1 Evidence-based clinical audit
• 7.3.2.2 Training for evidence-based decision-making
• 7.3.3 Systems that consume and use evidence
• 7.3.3.1 Systems that should be more evidence-based
• 7.3.3.2 Systems for managing innovation
• References
• 7.4 Change management p. 265
• 7.4.1 Evidence-based re-organisation?
• References
• 7.5 Evidence-based primary care p. 267
• 7.5.1 Improving access: promoting finding
• 7.5.1.1 Ease of access to information
• 7.5.1.2 Provision of relevant information
• 7.5.2 Improving appraisal skills
• References
• 7.6 Paying for or commissioning healthcare using the evidence base p. 271
• 7.6.1 Resource re-allocation among disease management systems
• 7.6.2 Resource re-allocation within a single disease management system
• 7.6.3 Managing innovation
• 7.6.3.1 Promoting innovation: starting starting right
• 7.6.3.2 Stopping starting
• 7.6.3.3 Starting stopping
• 7.6.3.4 Promoting trials
• 7.6.4 Improving the quality of care
• 7.6.4.1 Competition as a way of improving healthcare
• 7.6.5 Evidence-based insurance
• 7.6.6 'Black belt' decision-making
• 7.6.7 The limits of structural reform
• References
• 7.7 The ethics of prioritisation p. 288
• 7.7.1 Prioritising the good of the individual or that of society?
• 7.7.2 Decision-making in the context of prioritisation
• References
• 7.8 Evidence-based policy making p. 290
• 7.8.1 The dominance of values in policy-making
• 7.8.2 The influence of budgetary pressures
• 7.8.3 The growing influence of evidence in policy-making
• 7.8.4 Evidence-based healthcare policy-making
• 7.8.5 Evidence-based policy-making in the developing world
• References
• 7.9 Evidence-based litigation p. 295
• 7.9.1 'Evidence' in court
• 7.9.2 Death of an expert witness
• 7.9.3 The influence of clinical guidelines in malpractice litigation
• 7.9.4 Failure to act on the evidence
• References
• Chapter 8 Evidence-Based Public Health p. 303
• 8.1 The development of public health and the evolution of an evidence base p. 304
• 8.1.1 Public health practice and service development 1850-1950
• 8.1.2 Public health practice and health service development since 1950
• 8.1.2.1 The evidence base for preventive services
• 8.1.3 Public health practice and health education
• 8.1.4 Public health practice and health promotion
• 8.1.4.1 The evidence base for health promotion
• 8.1.5 Public health practice and legislation
• 8.1.6 Public health practice and policy-making
• 8.1.6.1 The evidence base in policy-making
• 8.1.6.2 Using the public health evidence base to achieve health gain from non-health and health-related proposals
• 8.1.7 Public health practice and humanitarianism
• References
• 8.2 Developing systematic reviews for the evidence base in public health p. 319
• 8.2.1 The Campbell Collaboration
• 8.2.2 The use of systematic reviews in public health decision-making
• References
• 8.3 The need for an eclectic approach towards the evidence base for public health p. 322
• References
• 8.4 The basis for public health decision-making p. 325
• 8.4.1 The need for judgement
• Reference
• 8.5 Public health practice in the 21st century: knowledge-based public health p. 327
• 8.5.1 Knowledge-based health improvement
• 8.5.2 Supporting an evidence-based approach in healthcare systems
• References
• Chapter 9 Developing the Skills of Individuals p. 333
• 9.1 Developing skills for evidence-based practice p. 333
• References
• 9.2 Approaches to learning p. 334
• 9.2.1 Problem-based learning
• 9.2.1.1 Problem-based learning and continuing professional development
• 9.2.2 Self-directed and reflective learning
• 9.2.2.1 Meeting appraised learning needs
• 9.2.3 e-Learning
• 9.2.4 Learning by doing
• 9.2.4.1 Informatics support for staff who are learning by doing
• 9.2.4.2 Support for staff learning by doing: the educational prescription
• References
• 9.3 Teaching and learning evidence-based practice p. 341
• 9.4 The five steps to evidence-based practice p. 342
• 9.4.1 Asking the right question
• 9.4.1.1 Competencies
• 9.4.2 Searching for evidence
• 9.4.2.1 Retrieval
• 9.4.2.2 Competencies
• 9.4.3 Appraising evidence
• 9.4.3.1 The GATE frame
• 9.4.3.2 Competencies
• 9.4.4 Integrating and applying the evidence
• 9.4.4.1 Competencies
• References
• 9.5 Developing capacity as well as skills p. 351
• 9.6 Case-studies of applying evidence-based practice skills p. 352
• 9.6.1 Diagnosis
• 9.6.2 Decision analysis
• 9.6.2.1 Introduction
• 9.6.2.2 Case-study
• 9.6.3 Treatment
• References
• 9.7 Resources p. 356
• 9.7.1 Resources for critical appraisal
• 9.7.2 Guidelines to improve the standrd of reporting published research
• 9.7.3 Educational resources
• Chapter 10 Evidence-Based Clinical Practice p. 361
• 10.1 Clinical decision-making p. 361
• 10.1.1 'Faceless' decision-making
• 10.1.2 Face-to-face decision-making
• 10.2 Communicating with patients p. 363
• 10.2.1 The provision of evidence-based information
• 10.2.1.1 Other sources of information for patients
• 10.2.2 Interpretation
• 10.2.3 Discussion
• References
• 10.3 Facilitating evidence-based patient choice p. 367
• 10.3.1 Factors inhibiting evidence-based patient choice
• 10.3.1.1 Clinical ignorance
• 10.3.1.2 Emphasising the benefits of intervention
• 10.3.1.3 Disclosure
• 10.3.1.4 Withholding information about organisational policies
• References
• 10.4 Understanding evidence-based clinical practice p. 370
• 10.4.1 Definitions and dimensions
• 10.4.1.1 Failures in clinical decision-making
• 10.4.2 The clinician's dilemma
• 10.4.2.1 Treating individual patients
• 10.4.2.2 Clinical freedom
• 10.4.2.3 Clinical governance
• 10.4.2.4 To whom should the clinician be loyal: patient or State?
• 10.4.2.5 Remember the multiple goals of therapy: applying wisdom and discretion
• 10.4.3 Shared decision-making
• 10.4.3.1 Decision aids
• References
• 10.5 Dealing with the patient's anxiety p. 388
• Reference
• 10.6 Dealing with conflict around limiting treatment p. 389
• Reference
• Epilogue: Evidence-Based Healthcare in the 21st Century p. 391
• Evidence, economics and ethics p. 391
• Values trump evidence p. 392
• References
• Doing better, feeling worse p. 393
• Reference
• The modernisation of medicine p. 394
• Post-modern medicine p. 395
• Die Risikogesellschaft
• Evidence-based risk management
• References
• Post-modern clinical practice p. 397
• Anxiety and disease
• Dealing with uncertainty
• Reference
• Back to the future: 21st century healthcare p. 399
• The 21st century clinician
• The 21st century patient
• Does the 21st century patient want choice?
• Sharing knowledge from experience
• References
• Conclusion p. 403
• Index p. 405