Evidence-Based Health Care

Recent results of the NELSON Lung Cancer Screening Trial reports reductions in lung-cancer survival but not overall survival - The desire to detect disease even earlier means Overdiagnosis is on the rise. However, the interpretation of screening trial results is problematic and often gives rise to significant uncertainties that go unanswered. Carl Heneghan, Professor of Evidence-Based Medicine, employs evidence-based methods to research diagnostic reasoning, test accuracy and communicating diagnostic results to a wider audience. This talk was held as part of the Evidence-Based Diagnosis and Screening module which is part of the MSc in Evidence-Based Health Care and the MSc in EBHC Medical Statistics.

Dr Jamie Hartmann-Boyce discusses a case study of systematic reviews of electronic cigarettes for smoking cessation, looking across meta-analyses in this area. Dr Jamie Hartmann-Boyce is Senior Researcher, Health Behaviours team at the Nuffield Dept of Primary Care Health Sciences.

Should doctors with commercial interests lead research on their products? Should we forget ‘conflicts’ and discuss ‘declarations of interest’ instead? Who should hold and maintain conflicts of interest registers for doctors? Should practicing doctors work with the pharma industry as well as serve on guideline committees? Should researchers with extensive financial interests be disqualified from studies of their own products? The Physician Payments Sunshine Act requires US manufacturers to collect, track and report all financial relationships with clinicians and teaching hospitals. Professor Heneghan will discuss the failings with the current system of reporting of conflicts in medicine, what’s been tried so far, and why it is time for a UK Sunshine Act. Carl Heneghan, Professor of Evidence-Based Medicine, employs evidence-based methods to research diagnostic reasoning, test accuracy and communicating diagnostic results to a wider audience. This talk was held as part of the Practice of Evidence-Based Health Care module which is part of the MSc in Evidence-Based Health Care and the MSc in EBHC Systematic Reviews. Members of the public are welcome to attend.

Professor Karla Hemming discusses using evidence-based policy in the evaluation of policy interventions and answers the question 'how useful is the stepped-wedge study as an evaluation design? Professor Karla Hemming is the Professor of Biostatistics at the Institute of Applied Health Research, University of Birmingham.

Professor Bruno Marchal gives a talk illustrating the principles of realist evaluation using the case of the development of a new Tuberculosis control policy in Georgia. The talk focuses specifically on the central role of the programme theory, how this theory was developed and how it informed not only the policy, but also the study design. Professor Bruno Marchal is Associate Professor at the Health Systems and Equity unit, Department of Public Health, Institute of Tropical Medicine, Antwerp.

The logic and principles behind the drive for evidence-based health care are so compelling that often the limitations of evidence go unacknowledged. Despite a strong evidence base demonstrating the health risks associated with higher body weights, and health professionals routinely instructing patients to lose weight to improve their health, the incidence of obesity is predicted to continue to rise. Calling on his research into the relationships between obesity, inequality and health, Oli Williams - a fellow of The Healthcare Improvement Studies Institute - will argue that when it comes to reducing the burden on, and improving, health care a more critical approach to the way we generate, select, apply and communicate evidence is needed. Oli Williams completed his PhD in the Department of Sociology at the University of Leicester. He was subsequently awarded the NIHR CLAHRC West Dan Hill Fellowship in Health Equity which he held at the University of Bath. He later re-joined the University of Leicester in the Department of Health Sciences working in the SAPPHIRE Group and is now based at King's College London after being awarded a THIS Institute Postdoctoral Fellowship. His research focuses on health inequalities, the promotion of healthy lifestyles, obesity, weight stigma, equitable intervention and co-production. He co-founded the art collective Act With Love (AWL) to promote social change. The Weight of Expectation comic is one example of their work, view others at: www.actwithlove.co.uk In recognition of his work on weight stigma the British Science Association invited Oli to deliver the Margaret Mead Award Lecture for Social Sciences at the British Science Festival 2018. This talk was held as part of the Qualitative Research Methods course which is part of the Evidence-Based Health Care Programme.

The increased reliance of health systems on the digital record as the primary mechanism for storing data on consultations and other health interactions has opened new opportunities for research, healthcare innovation, and health policy. The electronic health record (eHR) is now ubiquitous in many countries, in hospital and primary care settings, and in some countries their health systems in terms of reporting patient care activity are essentially 'paperless'. Health systems globally are also facing accelerating challenges as they seek to deliver better value healthcare against the background of increasing levels of chronic disease, ageing populations, financial pressures and demands on public spending. Digital health tools and services are held up to be part of the solution to these challenges, potentially offering low-cost and patient-centred solutions. There has been huge investment in Big Data research in health, particularly in relation to digitised imaging and automated reporting and predictive modelling using phenotypic and increasingly genetic data. There have also been similar gains in more applied research that explores the potential of accessing the huge quantum of data held in the eHR, and linkage of these data to other national or regional databases, such as mortality records or cancer data. This session will explore some of the applications for routine data research, illustrated by projects that have resulted in research success and better healthcare. This will include the exemplars of using large eHR platforms and prescribing data platforms to create infrastructure for i) common disease surveillance, such as the UK RCGP RSC; ii) generation and validation of disease risk assessment tools, such as QRisk scores; iii) pragmatic electronic follow up trials; iv) within practice systems dashboard feedback reports, eg data normalised to regional and national rates on prescribing and investigation physician activity; v) traditional epidemiological linkage studies; and vi) linkage to long term phenotypic follow up of established disease cohorts. Richard Hobbs is Nuffield Professor of Primary Care at the University of Oxford, and Head of the Nuffield Department of Primary Care Health Sciences. He has served a decade as National Director of the National Institute for Health Research’s School for Primary Care Research and was Director of the NHS Quality and Outcomes Framework (QOF) Review panel from 2005-09. He has served many national and international scientific and research funding boards in UK, Ireland, Canada, and WHO, including the BHF Council, British Primary Care Cardiovascular Society, and the ESC Council for Cardiovascular Primary Care. He currently chairs the European Primary Care Cardiovascular Society, a WONCA Special Interest Group. He is one of the world's leading academics in primary care, and has developed at Oxford one of the largest and most highly ranked centres for academic primary care globally. He has also made major contributions to growing primary care academic capacity, in terms of people development and research networks. A highly cited primary care clinical scientist, he has authored over 450 peer reviewed publications, has an h-index of 90, with over 63000 citations (36000 since 2013) and 81 papers cited over 100 times, 14 papers cited over 1000 times and 7 papers with over 2000 citations. He has an outstanding track record in cardiovascular research, delivering trials that changed international guidelines and practice, especially in the areas of stroke prevention in atrial fibrillation (BAFTA, SAFE, and SMART trials), heart failure burden and diagnosis (ECHOES and REFER trials), and hypertension self-management (TASMINH series). He is only the fifth ever recipient of the RCGP Discovery Prize in 2018 (an occasional award made since 1953) and received an inaugural Distinguished Researcher Shine Prize plus Best Presentation Prize at the WONCA World Congress in 2018. He was awarded a CBE for services to medical research in the 2018 New Year's Honours. This talk was held as part of the Big Data Epidemiology course which is part of the Evidence-Based Health Care Programme.

Professor Jeffrey Aronson, Consultant Physician and Clinical Pharmacologist, Department of Primary Care Health Sciences, gives a talk on dose-response curves for the EBHC podcast series.

Carl Heneghan, Professor of Evidence-Based Medicine, employs evidence-based methods to research diagnostic reasoning, test accuracy and communicating diagnostic results to a wider audience. Professor Carl Heneghan will talk about his involvement in Tamiflu research that led to the discovery of 170,000 pages of clinical study reports, the subsequent development of Alltrials he was involved in and the current epidemic of publication and reporting bias that plagues much of the current research evidence. This talk was held as part of the Practice of Evidence-Based Health Care module which is part of the MSc in Evidence-Based Health Care and the MSc in EBHC Systematic Reviews.

This talk was delivered by Martin Bland. Martin Bland joined the University of York as Professor of Health Statistics in 2003, retiring and becoming Emeritus Professor in 2015. Earlier posts were at St. George's and St. Thomas's Hospital Medical Schools and in industry with ICI, working on agricultural experiments. He is the author of An Introduction to Medical Statistics, now in its fourth edition, and co-author of Statistical Questions in Evidence-based Medicine, both Oxford University Press, 303 refereed journal articles, and, with the late Prof. Doug Altman, the Statistics Notes series in the British Medical Journal. He and Doug Altman also invented the limits of agreement method for comparing methods of measurement, which led to the most highly cited papers in six different journals and one of the top 30 most highly cited papers over all fields. This is an account of a little research study which I carried out, using myself as the only research subject. I shall describe how I came to do it and some of the practical statistical problems which I encountered. These include serial P-values, the effect of other factors, and generalisability from a single subject.

This guest lecture draws on nearly thirty years' experience of doing qualitative research in a variety of health settings that contain people, blood, injury, disease, emotions, and technologies. Prof Catherine Pope will describe some of the practical difficulties and everyday challenges of doing ethnography in these environments, and reflect on what it feels like to be an embodied researcher. Catherine Pope is Professor of Medical Sociology, and, from July 2019, will be based at the Nuffield Department of Primary Care Health Sciences, University of Oxford. She has championed the use of qualitative methods in health research, and played a leading role in developing qualitative evidence synthesis. Her research includes studies of NHS urgent and emergency care, evaluations of health service organisation and reconfiguration, and projects about everyday health care work. This talk was held as part of the Qualitative Research Methods course which is part of the Evidence-Based Health Care Programme.

The global health burden of heart failure is high, both as the common end-point for many cardiovascular diseases (e.g. hypertension and heart attacks) and a common point on the trajectory of non-cardiovascular diseases (e.g. chronic respiratory disease). Despite advances in treatment, our ability to tailor strategies for prevention or management to individuals with heart failure is currently limited. Large-scale electronic health records and novel data analysis techniques have great potential to improve the status quo in both research and practice. In this talk, Amitava Banerjee examines the real progress and the limitations of recent big data research in heart failure, from epidemiology to machine learning. Amitava Banerjee is Associate Professor in Clinical Data Science at University College London, and Honorary Consultant Cardiologist at University College London Hospitals and Barts Health NHS Trusts. He is a pragmatic researcher, a passionate educator and a practising clinician, with interests spanning data science, cardiovascular disease, global health, training and evidence-based healthcare. After qualifying from Oxford Medical School, he trained as a junior doctor in Oxford, Newcastle, Hull and London. His interest in preventive cardiology and evidence-based medicine led to a Masters in Public Health at Harvard (2004/05), an internship at the World Health Organisation(2005) and DPhil in epidemiology from Oxford (2010). He was Clinical Lecturer in Cardiovascular Medicine at the University of Birmingham, before moving to UCL in 2015. He works across two busy tertiary care settings: University College London Hospitals and Barts Health NHS Trusts with both inpatient and outpatient commitments. Although he is subspecialised in heart failure, he has ongoing practice in acute general cardiology and a keen interest in the diagnosis and management of atrial fibrillation. His clinical work very much informs his research and vice versa, whether in the evaluation of medical technology or the ethics of large-scale use of patient data. This talk was held as part of the Big Data Epidemiology module which is part of the MSc in Evidence-Based Health Care and the MSc in EBHC Medical Statistics.

This evening lecture is given in conjunction with the Introduction to Study Design and Research Methods accredited short course, part of the Evidence-Based Healthcare programme at the University of Oxford's Department for Continuing Education. Carmen is a Public Health Nutrition scientist at the Department of Primary Care Health Sciences (University of Oxford). Her principal research interests lie in the prevention and management of non-communicable chronic disease through dietary improvements, in particular, obesity and cardiovascular disease. Diet is an important determinant of health, and food purchasing is a key antecedent to consumption hence improving the nutritional quality of food purchases presents a clear opportunity to intervene. She has been involved in a recent systematic review of interventions implemented in grocery stores which suggested that price manipulations, healthier swap suggestions, and perhaps manipulations to item availability change food purchasing and could play a role in public health strategies to improve health. However, the evidence base for interventions in grocery stores or at the individual level is still very limited. She is currently working on a range of studies aiming to examine the effectiveness of interventions based around healthier swaps on the quality of the food purchased and eaten as well as the short term effects on relevant health outcomes. She has recently conducted a complex behavioural intervention based in primary care to improve diet quality among patients with high cholesterol (PC-SHOP study). The intervention consisted of health professional (HP) advice alone, or in combination with personalised feedback based on the nutritional analysis of grocery store loyalty card data from one of the largest UK supermarkets. Overall her research aims to develop and test simpler and inexpensive ways to help people improve diet and prevent cardiovascular disease and obesity. This evening lecture is given in conjunction with the Introduction to Study Design and Research Methods accredited short course, part of the Evidence-Based Healthcare programme at the University of Oxford's Department for Continuing Education. Find out more.

Fiona Godlee, Editor in Chief of The BMJ, gives a talk for the EBHC podcast series Fiona Godlee is the Editor in Chief of The BMJ. She qualified as a doctor in 1985, trained as a general physician in Cambridge and London, and is a Fellow of the Royal College of Physicians. She has written and lectured on a broad range of issues, including health and the environment, the ethics of academic publishing, evidence based medicine, access to clinical trial data, research integrity, open access publishing, patient partnership, conflict of interest, and overdiagnosis and overtreatment. After joining The BMJ as an assistant editor in 1990, she moved in 2000 to help establish the open access publisher BioMedCentral as its founding Editorial Director for Medicine. In 2003 she returned to BMJ to lead its Knowledge division and was appointed Editor in Chief of The BMJ in March 2005. Fiona is honorary professor at the Netherlands School for Primary Care Research (CaRe), honorary fellow of the Royal College of General Practitioners, a senior visiting fellow at the Institute of Public Health at the University of Cambridge, honorary fellow of the Faculty of Public Health and a by-fellow of King’s College Cambridge. She is on the advisory or executive boards of the Health Improvement Studies (THIS) Institute (thisinstitute.cam.ac.uk), Alltrials (alltrials.net), the Peer Review Congress (peerreviewcongress.org), the International Forum for Quality and Safety and Healthcare (internationalforum.bmj.com), Evidence Live (evidencelive.org), Preventing Overdiagnosis (preventingoverdiagnosis.net), the UK Health Alliance on Climate Change (ukhealthalliance.org) and the Climate and Health Council. She was a Harkness Fellow (1994-5), President of the World Association of Medical Editors (WAME) (1998-2000), Chair of the Committee on Publication Ethics (COPE) (2003-5), and PPA Editor of the Year (2014). Fiona is co-editor of Peer Review in Health Sciences. She lives in Cambridge with her husband and two children.

Professor Carl Heneghan has extensive experience of working with the media. In this talk he will discuss some recent case examples, working with the BBC amongst others. This talk will discuss how using an evidence-based approach can help overcome the growing problem of fake news, and provide insights on how to work with the media to ensure your message is not distorted, and will discuss why academics should engage more with the media and the wider public. Professor Carl Heneghan is Director of CEBM, and an NHS Urgent Care GP, and has been interested for over twenty years in how we can use evidence in real world practice.

For many good reasons, semi-structured interviews, focus groups, thematic analysis, and realist tales have become key tools within the qualitative researcher's methodological toolkit. In this presentation, Dr Cassandra Phoenix invites the audience to consider the extent to which they may have (inadvertently) become the only tools within their toolkit. Drawing on examples from across the social sciences, she considers how else we might collect, analyse and represent qualitative data within health research, asking what it means and involves to truly advance qualitative research methods in this field. The short video played for the audience can be seen at: https://vimeo.com/43182928. Dr Cassandra Phoenix is a Reader in the Department for Health at the University of Bath. Her research examines ageing, health and wellbeing from a critical-socio-cultural perspective. She has authored numerous publications on topics including the social and cultural dimensions of: physical activity in mid and later life; the lived experiences of chronic conditions (e.g. late onset visual impairment, vestibular disorders); and engagement with nature. Cassandra's work is supported by a range of funders including ESRC, Wellcome Trust, Leverhulme Trust, WHO and the NIHR. This talk was held as part of the Advanced Qualitative Research Methods course which is part of the Evidence-Based Health Care Programme.

Dr. Martyn Sene is Deputy CEO of the National Physical Laboratory (NPL), here, he gives an introduction to the importance of measurement and metrology (the science of measurement). NPL is the UK's National Metrology Institute and is a world-leading centre of excellence in developing and applying the most accurate measurement standards, science and technology available. He is a member of the NPL Management Ltd. Board and also a member of the CIPM (Comite International des Poids et Mesures), established under the Metre Convention to promote world-wide uniformity in units of measurement and oversee the headquarters of the International Measurement System (BIPM) in Paris. This talk will provide an introduction to the importance of measurement and metrology (the science of measurement), how we ensure confidence in measurement and how measurement today requires and relies on leading edge (including Nobel prize winning) science and technology. It will also highlight why 2019 is such an important year for the International Measurement System - the year in which the SI units are redefined in a way that locks them to unchanging properties of the universe. The culmination of a project that traces its origins to the French Revolution - a measurement system 'a tous les temps, a tous les peuples'.

Andrea Cipriani is NIHR Research Professor at the Department of Psychiatry, University of Oxford and Honorary Consultant Psychiatrist at the NHS Foundation Trust in Oxford. His main interest in psychiatry is evidence-based mental health and his research focuses on the evaluation of treatments in psychiatry, mainly major depression, bipolar disorder and schizophrenia. Dr Cipriani is author of 267 peer reviewed scientific publications (Scopus), mainly systematic reviews, meta-analyses and randomised controlled trials in psychopharmacology, however in the past few years he has also been investigating relevant issues in epidemiological psychiatry and public health, like patterns of drug consumption, risk of serious adverse events (most of all suicide and deliberate self harm) and implementation of treatment guidelines. Being interested in the methodology of evidence synthesis, Dr Cipriani has now a specific focus on network meta-analysis and individual patient data meta-analysis, trying to assess the validity, breadth, structure and interpretation of these statistical approaches to better inform the mental healthcare decision-making process. He is currently Editor in Chief of Evidence-Based Mental Health (ebmh.bmj.com) and also on the Editorial Board of the Lancet Psychiatry, the Australian and New Zealand Journal of Psychiatry and the Cochrane Collaboration for Depression, Anxiety and Neurosis

Carl Heneghan asks the question, "What is driving the increase in diagnostic testing in healthcare?" and discusses why expectations, technology and the media are contributing to the problems of too much medicine and overdiagnosis. Carl Heneghan, Professor of Evidence-Based Medicine, employs evidence-based methods to research diagnostic reasoning, test accuracy and communicating diagnostic results to a wider audience. This talk was held as part of the Evidence-Based Diagnosis and Screening module which is part of the MSc in Evidence-Based Health Care and the MSc in EBHC Medical Statistics.

Professor David Torgerson, Director of the York Trials Unit, gives a talk for the Evidence Based Healthcare podcast series. He has published widely with over 250 peer reviewed papers many of them on the design of randomised trials including a student text book 'Designing Randomised Trials in Health Education and the Social Sciences' (2008, Palgrave MacMillan). He has a particular interest in the design and conduct of cluster randomised trials. Randomisation, if conducted properly, will abolish selection bias. Poor randomisation practice for individually randomised trials allows the allocation schedule to be predicted and can lead to subversion of the randomisation, which introduces selection bias. In cluster randomised controlled trials there is a particular problem with some trials in that cluster randomisation occurs before individual recruitment. When this occurs the allocation can become known to the potential participant and the recruiting clinician and research. This, then, allows selective recruitment to occur which means that selection bias is introduced at the level of the individual participant. In this talk the problem is illustrated in case studies and I discuss approaches to dealing with this potential source of selection bias.