Evidence, guidelines and possible solutions

I was looking at the guidelines on the management of community acquired pneumonia (CAP) in adults: This got me interested into looking at the BTS guidelines update 2009 ( https://www.brit-thoracic.org.uk/document-library/clinical-information/pneumonia/adult-pneumonia/bts-guidelines-for-the-management-of-community-acquired-pneumonia-in-adults-2009-update/ ).

Here are some observations and thoughts on it.

The 2009 British guidelines for pneumonia in adults:

Has 12 Authors W S Lim, S V Baudouin, R C George, A T Hill, C Jamieson, I Le Jeune, J T Macfarlane, R C Read, H J Roberts, M L Levy, M Wani, M A Woodhead

Endorsed by 10 major clinical professional societies British Thoracic Society Standards of Care Committee in collaboration with and endorsed by the Royal College of Physicians of London, Royal College of General Practitioners, College of Emergency Medicine, British Geriatrics Society, British Infection Society, British Society for Antimicrobial Chemotherapy, General Practice Airways Group, Health Protection Agency, Intensive Care Society and Society for Acute Medicine

502 references

45 pages of guidelines, 6 pages for the synopsis of the guidelines

Giving us 137 specific guidelines for management of CAP in adults.

Very extensive and formidable work. Would not have been easy to do and
must have consumed a lot of time and other resources.

The evidence was classified as ABCD. You know all about it but I detail
here for the purpose of my own clarity.

A+ A good recent systematic review of studies designed to answer the
question of interest

A - One or more rigorous studies designed to answer the question, but
not formally combined

B+ One or more prospective clinical studies which illuminate, but do not
rigorously answer, the question

B - One or more retrospective clinical studies which illuminate, but do
not rigorously answer, the question

C Formal combination of expert views

D Other information

BTS guidelines' recommendations are based on the following evidence levels:


4 A+ evidence recommendations (3%)
8 A- recommendations (5%)
19 B+ recommendations (17 + 2 : some recommendations have some
sub-sections with different levels of evidence) (13%)
6 B - recommendations (4 + 2 : some recommendations have some
sub-sections with different levels of evidence) (4%)
19 C recommendations (13%)
91 level D recommendations (62%)

147 evidence points resulting in 137 recommendations

My commentary

It looks like an overwhelming majority of recommendations are based on level C and D evidence which in my mind translates basically as 'individuals' opinions'. To put it radically, level C and D 'evidence' is mere opinion masquerading as evidence just because it comes in a list where the level A is properly scientific.

Whom would I trust for my own care, if I had pneumonia? I would trust our own local clinicians' opinions more as it will have local and personal context than someone who has published (guidelines comprising of 75% opinion) but has no bearing on who we are and what we do. Even the 25% level B recommendations are according to the definition 'do not rigorously answer the question'. If I had CAP why would I want my clinical treatment based on recommendations that do not rigorously
answer the question combined with the opinion of non-local physicians?







Solutions

The way forward would be groups of local clinicians agreeing on local delivery protocols based on their personal local knowledge, context and resources. Once agreed, the outcomes of the delivery can be tracked and the protocols continuously improved. We know this approach reaches us a better place than externally mandated approaches.

This blog site has outlined some ideas on this approaches which can be found at:
http://successinhealthcare.blogspot.co.uk/2012/01/hemadris-four-fundamental-questions-for.html
http://successinhealthcare.blogspot.co.uk/2012/09/letter-to-my-nieces.html
http://successinhealthcare.blogspot.co.uk/2012/08/clinical-wrongology.html

There are significant unresolved issues on the question of evidence based practice. They need to be dealt with by the Quality Improvement approaches. Let us do it.

©M HEMADRI

Follow me on Twitter @HemadriTweets

My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html

 

PS:  If you want to learn more about QI and creating local shared baselines formally, you may want to sign up for the University of Hull course where I teach this http://successinhealthcare.blogspot.co.uk/2015/06/msc-in-healthcare-improvement-leadership.html 

If you wanted to consult me feel free to get in touch by leaving a comment or by contacting me on FB or Twitter

Getting paid for performance - Buffet does, why not healthcare?

Top performers high achievers are amazing.

Marshall Goldsmith when he coaches senior executives does not get paid for his time; Marshall only gets paid if his clients are successful in a pre-defined and measurable way as defined by pre-selected stakeholders.

Warren Buffet when he was accepting money from his associates to invest did not get paid till he realised a minimum 6% profit on the clients money; only after Warren made more than 6% for his clients he asked clients to pay his charges/fees/profit-share.

Monish Pabrai who some say could be the Buffet of the future does the same; he does not charge his clients any fees unless he first makes 6% return for them. Above 6% he takes 1/4 of the profits – like Buffet does.

IHI – clearly states that if for any reason a participant is not fully satisfied with their course/meeting/conference/etc IHI will give a full refund of the fees paid. Check their website.

It looks like they don’t get paid (or prefer not to get paid) for their time or activity – they want to get paid for their successful performance.

There is surely something to learn from these people and institutions. On wondering how they do it it seems that they first develop their credentials, they are confident of the success of their methodology and they have the conviction to back it by putting the client’s returns ahead of their own.

It is interesting to note how they got there. They had discipline. They had the discipline to agree and write out what they wanted to do in the form of a checklist (not the tick box check list that many of us often use but the explicit work order/process type of checklist) and stick to it. They had the discipline to track their successes and failures of their checklist and change the things that did not work. They then again stuck to those checklists and tracked them again. Over a period of time their checklists have become amazingly superior. They give up opportunities which are not cleared by their checklists. They work by protocol, they have a protocol when the original protocol does not work, they have a protocol on when and how to change protocols.

Agreement on the methodology – explicitly writing it down step by step (checklist) – following the checklist – tracking the results of the checklist – changing/amending the checklist on the basis or measured performance. That seems to be their methodology. Atul Gawande has written about Monish Pabrai's method in his book, the 'Checklist Manifesto'. Enough has been written about Buffet's stock screening techniques (though no one exactly knows what they are).

An extended version of this is what they do at Intermountain Healthcare, Salt Lake City, Utah. Intermountain calls it clinical protocols (and not checklist). They are obviously a very successful healthcare organisation.

Pabrai says in an interview that if only investors quite simply followed Buffet's investment decisions even after it became completely public, the investment would clearly outperform the market, but people don't. In a similar manner, if only healthcare simply followed Intermountain (or Jonkoping) principles we could all be in a better place. Never mind reinventing the wheel, we in healthcare are possibly quite passionate about reinventing the flat tyre (to misquote Berwick).

Most of us in healthcare and I am specifically talking about clinicians and clinical health delivery, neither have the discipline nor the needed nerves of steely persistence to be able to replicate what is a very well described process/methodology that has seen sustained success for more than a decade. Actually, we may have both, it is likely we have not bothered to try it out.

Clinicians do not often have local agreement, they do not like to write out explicit protocols and then agree as a group to work to those protocols. We think it interferes with our 'clinical freedom'. That is why most of us get paid for our time and would hesitate to get paid for our performance.

 

©M HEMADRI

Follow me on Twitter @HemadriTweets


My mini e-book 'Standardised Management Conversation' is available - click http://www.amazon.co.uk/Standardised-Management-Conversation-Hemadri-ebook/dp/B018AWBJTU 
till 31 December 2016 all my earnings from the sale of this book will be donated to charity  http://successinhealthcare.blogspot.co.uk/2015/11/standardised-management-conversation.html