Evidence-Based Health Care

Professor Mike Kelly, Primary Care Unit, Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, gives a talk for the Evidence Based Healthcare seminar series. Professor Mike Kelly is Senior Visiting Fellow in the Department of Public Health and Primary Care at the Institute of Public Health and a member of St John's College at the University of Cambridge. Between 2005 and 2014, when he retired, he was the Director of the Centre for Public Health at the National Institute of Health and Care Excellence (NICE). From 2005 to 2007, he directed the methodology work stream for the World Health Organisation's (WHO) Commission on the Social Determinants of Health. His research interests include the prevention of non-communicable disease, living with chronic illness, health inequalities, health related behaviour change, end of life care, dental public health, the relationship between evidence and policy and the methods and philosophy of evidence based medicine. This talk will describe the approach to development of public health guidelines adopted by NICE (the National institute for Health and Care Excellence) between 2005 and 2014 when Mike Kelly was leading the public health team there. It will consider the influences that realist theories and methods had on the process which NICE engineered as it applied the conventional model of evidence based medicine to public health matters. Some of the academic opposition to this endeavour will be noted and the broader political environment described. Using the development of the guideline on the prevention of alcohol misuse as a case study, the paper will examine the political consequences of taking a realist approach to the evidence. The controversy, which ensued after NICE, published the guideline, which among other things recommended minimum unit pricing, will be analysed. Some of the lessons of working at the policy/practice/politics/academy interface will be discussed.

Professor Alan Silman is an epidemiologist and a rheumatologist and is the co-author of 'Epidemiological Studies: A Practical Guide', which is the recommended textbook for the module 'Introduction to Study Design and Research Methods'. Alan Silman is currently Professor of Musculoskeletal Health at the University of Oxford. He was Director of the UK's Arthritis Research Epidemiology Unit in Manchester from 1988-2006, and then Medical Director of Arthritis Research UK, before moving to Oxford to take up his current position. He has published over 500 articles in the broad field of arthritis and musculoskeletal disease epidemiology. This talk was held as part of the Introduction to Study Design and Research Methods module, which is part of the MSc in Evidence-Based Health Care.

Jamie Hartmann-Boyce is a Senior Researcher in Health Behaviours, based at the Nuffield Department of Primary Care Health Sciences, University of Oxford. Her work focusses on obesity and tobacco control and her particular interests lie in evidence synthes Though the vast majority of people trying to lose weight do so on their own, without support from healthcare professionals or formal weight loss programmes, most research into weight loss focuses on more intensive programmes. We therefore set out to find out more about what people do when trying to lose weight on their own. As part of this work, we conducted three qualitative systematic reviews to explore people's experiences with self-directed weight loss. The first review provides an overview of the cognitive and behavioural strategies used during self-directed weight loss attempts, and the second two reviews delve further into particular weight loss strategies that emerged as part of the overview, namely self-monitoring and reframing. In this talk, I'll cover key findings from each of the three reviews, and also use these reviews to illustrate how qualitative syntheses can be conducted and used to shed light on people's experiences. This talk was held as part of the Qualitative Research Methods module which is part of the MSc in Evidence-Based Health Care.

Dr Jeffrey Aronson gives a talk for the Evidence Based Healthcare series.

Professor Mike Clarke gives a talk for the Evidence Based Healthcare series.

Professor Carl Heneghan gives a talk for the Evidence Based Healthcare series. Patients are being let down by serious flaws in the creation, dissemination, and implementation of medical research. Too much of the resulting research evidence is withheld or disseminated only piecemeal. As the volume of clinical research activity has grown, the quality of evidence has often worsened, which has compromised medicine's ability to provide affordable, effective, high-value care for patients. Professor Carl Heneghan will discuss the CEBM initiatives that have grown out of EBM Live, a yearly conference designed to "develop, disseminate, and implement better evidence for better healthcare. He 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. In preparation for this talk you are invited to read the following: https://doi.org/10.1136/bmj.j2973

There has never been such a high demand for our personal data, such that it is often said that individuals are the product, not just the client. Using the donation of general personal data and health data in example scenarios, areas such as: the unknown element in data content; trust and trustworthiness in data custodians; and meaningful public engagement, will be explored. The alternative is that data are not used, with the corresponding harms this may bring. Ironically, this is not an unusual situation in settings where having adequate data on which to base decisions is paramount for individual well-being. By drawing upon an international case study of health data non-use, it will be shown that this is a complex, global problem with multiple explanations resulting in untold harms to individuals and society. But there are many scenarios where our personal data are in demand, not just for public good. As individuals we need to consider the bioethical balance between individual autonomy, personal exploitation and social responsibility in making our donation decisions. Ultimately, the question is whether we, as individuals and society, want to 'gift' our data in some circumstances and grant its use under licence in others; and whether we can really make informed choices with the panoply of issues that may influence our decisions. Kerina Jones is an Associate Professor of Health Informatics at Swansea University, where she is the academic lead for Information Governance and Public Engagement to ensure data protection and maximise socially-acceptable data utility across the various Swansea University-based data intensive/linkage initiatives, including: the SAIL Databank, Administrative Data Research Centre Wales, Farr@CIPHER and the recently awarded HDRUK collaboration between Swansea University and Queen's University Belfast. Kerina leads the active Innovative Governance working group of the Farr Institute, which works collaboratively to advise and influence the developing data governance landscape to promote the safe reuse of data. She leads an IG research programme including work to inform cross-centre research and how emerging data types, such as genetic data, can be used in conjunction with health record data. This includes a programme of public engagement and Kerina enjoys working with the public on the use of anonymised data for research. This talk was held as part of the Big Data Epidemiology module which is part of the MSc in Evidence-based Health Care.

In this talk Karolina presented various types of study design she has used in trials of treatments for chronic pain. Karolina also discussed why blinding is important and why a placebo control may be necessary, even in surgical trials. This talk was held as part of the Introduction to Study Design and Research Methods module, which is part of the MSc in Evidence-Based Health Care.

Carol Lefebvre gives a talk for the Evidence based healthcare seminar series. Carol Lefebvre will address the shift in focus over the last 20 years away from purely ‘literature searching’, i.e. only searching databases such as MEDLINE/PubMed for published literature, such as journal articles and books for identifying studies for evidence synthesis. She will consider the ever-increasing role of unpublished data sources such as trials registers and regulatory agency sources. Carol Lefebvre is an Independent Information Consultant and was previously the Senior Information Specialist at the UK Cochrane Centre in Oxford from 1992 to 2012. She is a founder member of the Cochrane Collaboration. She is Co-Convenor of the Cochrane Information Retrieval Methods Group, serves on the Cochrane Methods Executive and is lead author on the searching chapter of The Cochrane Handbook. She also co-led the development of the Cochrane standards for searching (MECIR). She was awarded an M.Sc. in Library and Information Science from the University of Loughborough (UK) in 1985 and an Honorary Fellowship of the Chartered Institute of Library and Information Professionals in 2007. She now focusses on teaching and consultancy in information retrieval for evidence synthesis, such as systematic reviews, health technology assessment and guideline development.

Communication taboos surround many aspects of women’s health and wellbeing, from menstruation to menopause to sexual pleasure. This presentation will briefly discuss the historical and socio-cultural roots of such stigmas before outlining the latest research on how these taboos come to negatively impact girls’ and women’s health. Dr Weckesser will focus on her qualitative research on endometriosis as a case study for how cultural codes of silence around menstruation play a part in the delayed diagnosis of the condition. She will also discuss her STEAM-funded project, ‘The VQ: A Women’s Health, Sex and Pleasure Pop Up,’ which is an impact initiative that creates spaces and events for women to learn about, and purchase products related to, their (sexual) health. Dr Annalise Weckesser is a Senior Research Fellow at the Centre for Social Care and Health Related Research at Birmingham City University. She trained as a medical anthropologist at the University of Warwick and specialises in qualitative research on women’s sexual and reproductive health. This talk was held as part of the Qualitative Research Methods module which is part of the MSc in Evidence-based Health Care.

Professor Alexander Bird, Professor of Philosophy and Medicine, King's College London, gives a talk for the Centre for Evidenced Based Medicine. The replication (replicability, reproducibility) crisis in clinical medicine and in other fields arises from the fact that many apparently well-confirmed experimental results are subsequently overturned by studies that aim to replicate the original study. The culprit is widely held to be poor science: questionable research practices, failure to publish negative results, bad incentives, and even fraud. In this paper I argue that the high rate of failed replications is consistent with high quality science. We would expect this outcome if the field of science in question produces a high proportion of false hypotheses prior to testing. If most of the hypotheses under test are false, then there will be many false hypotheses that are apparently supported by the outcomes of well conducted experiments and null-hypothesis significance tests with a type-I error rate (alpha) of 5\%. Failure to recognize this is to commit the fallacy of ignoring the base rate. I argue that this is a plausible diagnosis of the replication crisis and examine what lessons we thereby learn for the future conduct of medical science.

A light hearted account of being treated by the 'wrong' guideline - with a serious conclusion about making sure this doesn’t happen. Professor Trish Greenhalgh is a Professor of Primary Care Health Sciences and the Nuffield Department of Primary Care Health Sciences. Trish Greenhalgh is an internationally recognised academic in primary health care and trained as a GP. She joined the Nuffield Department of Primary Care Health Sciences in January 2015 after previously holding professorships at University College London and Queen Mary University of London.

Professor Carl Heneghan and Dr David Nunan from the Oxford Centre for Evidence-Based Medicine presented the launch of a new website that catalogues the important biases affecting health and medical research. The website is in response to a call-to-arms raised nearly 40 years ago by the late David Sackett, where he called for 'The continued development of an annotated catalog of bias. Each citation should include a useful definition, a referenced example illustrating the magnitude and direction of its effects, and a description of the appropriate preventive measures, if any. I volunteer for this task, would welcome collaboration, and would appreciate receiving nominations and examples of additional biases.' In honour of David's memory and legacy, the CEBM have taken up where he left off. We are now ready to share the catalogue with the rest of the world for welcome feedback, discussion and further evolution. Additional input from Professor Sir Iain Chalmers. This talk was held as part of the Practice of Evidence-Based Health Care course which is part of the Evidence-Based Health Care Programme.

Point-of-care or near-patient-tests, are as these descriptors suggest, medical diagnostic tests which can be performed by a clinician, patient, or carer of a patient, without the need for samples to be transported to laboratories. These tests usually yield results rapidly, with clear convenience benefits for patients but with the potential to variably impact on clinicians. Our research suggests that evaluations of point-of-care tests usually focus on the accuracy of these tests when compared to the ‘reference standard’ laboratory tests, with manufacturers aiming to achieve equivalence or non-inferiority. This is admirable and essential, however the broader impact of tests on the relevant clinical pathways and patient health are often neglected. This talk will outline the areas of evidence which are frequently underrepresented in point-of-care test evaluations and will explore some of the more nuanced and unusual barriers and impacts of test introduction using some true and hypothetical examples to illustrate the inherent complexity of the test-pathway nexus. Phil Turner is a diagnostics researcher and Manager of the Community Healthcare MIC. His role incorporates responsibility for liaising with members of the in vitro diagnostics industry and for facilitating interactions with the MIC research team. His research has focussed on the diagnostic needs of clinicians, barriers to implementation, and the identification of evidence gaps which commonly exist in the evidence base for point-of-care diagnostic tests. He has a personal interest in IVDs which could be deployed in resource-limited settings. His background is in cell physiology, membrane transport processes and signalling and he has a particular interest in the control of ventilation and in particular how humans respond to changes in the partial pressure of inspired oxygen. He has an associated interest in the physiology and medicine of life in remote regions and at high altitude. This talk was held as part of the Evidence-Based Diagnosis and Screening course which is part of the Evidence-Based Health Care Programme.

Dr Katherine Pollard gives a talk for the Evidence Based Healthcare seminar series. This talk focuses on mixed methods research in health care education and practice, drawing on Kathy's experience of two large mixed methods projects to demonstrate salient issues: a longitudinal evaluation of an interprofessional undergraduate curriculum and a case study of quality measurement in community nursing. Kathy discusses research design and implementation, highlighting the challenges that arose, and the strategies employed to ensure successful project delivery. Dr Pollard has been an active researcher since 1998 and is currently employed as a Senior Research Fellow at the University of the Wet of England, Bristol. She has a clinical background in midwifery.

Muir Gray is now working with both NHS England and Public Health England to bring about a transformation of care with the aim of increasing value for both populations and individuals. Here he gives a talk on improving healthcare systems. Here are some questions we cannot answer after nearly 70 years of a purportedly National Health Service. The lecture will address these questions and how they can be answered. 1. Is the service for people with seizures and epilepsy in Manchester of higher value than the service in Liverpool? 2. How many liver disease services are there in England and how many should there be? 3. Which service for people at the end of life in London provides the best value? 4. Is the service for people with asthma of higher than the service in Somerset? 5. How many services are there for people with MusculoSkeletal Disease in the North East, and which gives best value? We cannot answer them because we deliver care that is institutionally based not population based but to do so will need new knowledge and skills to answer questions such as: 1. What do you understand by the term complexity? 2. What is meant by the term system and how does it differ from a network? 3. What is meant by population based healthcare rather than bureaucracy based care? 4. What are the three meanings of the term value in 21st Century healthcare? Not ‘values’ as in 'we value diversity' but the economic meanings 5. What is the relationship between value and efficiency? 6. What is meant by the optimal use of resources? 7. What is meant by the term quality and how does it relate to value? 8. What is a system and a standard? 9. How would you assess the culture of an organisation? 10. How would you decide if an organisation had a strong culture of stewardship? Muir Gray is now working with both NHS England and Public Health England to bring about a transformation of care with the aim of increasing value for both populations and individuals and published a series of How To Handbooks for example, How to Get Better Value Healthcare, How To Build Healthcare Systems and How To Create the Right Healthcare Culture. His hobby is ageing and how to cope with it and he has published a book for people aged seventy called Sod 70! and one for the younger decade called Sod 60! This with Dr Claire Parker, and his book for people aged 40-60, titled Midlife, appeared in January 2017. Other books in the series on Sod Ageing are Sod it, Eat Well, with Anita Bean and Sod Sitting, Get Moving with Diana Moran, the Green Goddess. For people of all ages Dr Gray’s Walking Cure summarises the evidence on this wonderful means of feeling well, reducing the risk of disease and minimising disability should disease strike. This talk was held as part of the Practice of Evidence-Based Health Care course which is part of the Evidence-Based Health Care Programme.

Professor Jonathan Cook is a Senior Medical Statistician at the Oxford Clinical Trials Research Unit. His main research interest is in the design, conduct, analysis and reporting of randomised controlled trials (particularly surgical trials). Key areas of interest include specification of the target difference in the sample size calculation, addressing interventional expertise, and methods for improving recruitment. In this light-hearted talk he discusses his experiences during his career as a trial statistician, picking out the good the bad and the ugly.

Professor Paul Aveyard, Nuffield Department of Primary Care Health Sciences gives a talk on behavioural change in evidence based medicine. In our society, we tend to view motivation, the state of 'wanting it' as a prime mover of behaviour. However, research calls this into question both directly and by showing that, even among people with lukewarm motivation, we can enable behaviour change. Using randomised data mainly from randomised trials and other research, we will examine what these forces are and show how they can be harnessed to change behaviour, even when people have seemingly strong preferences.

Dr Andrew Booth gives a talk for the Realist Reviews and Realist Evaluations short course. Realist synthesis has positioned itself as a potentially valuable tool within health services research and evaluation. Opportunistically, it now inhabits the shadowy borderland between the messy domain of real world evaluation and the perceived rigorous scientific method of systematic review and evidence synthesis. Occupying this methodological demilitarised zone is not without its challenges; offering ongoing friction, perceptible tensions but not, at least to date, incandescent light! In this presentation Dr Booth will explore the extent to which realist synthesis can be seen as a bona fide member of the review family or, alternatively, as a rogue claimant syphoning off time, expertise and resources from the systematic reviews movement. He will explore his own experience on over half-a-dozen funded and unfunded realist syntheses against a backdrop of developments and current controversies within synthesis methods. Underpinning mechanisms will include conflict, rapprochement and, ultimately, reconciliation.

Dr John MacArtney gives a talk for the Evidence Based Healthcare seminar series. Qualitative researchers employ a range of different approaches to conducting qualitative analyses. In the process, they describe and interpret data, explaining the relationships between the patterns they find and interrogating their findings in various ways to provide thick descriptions of phenomena or explanatory theories. Drawing on his own qualitative analyses on experiences of cancer, Dr John MacArtney will explore some of the ways in which qualitative analysts approach these processes. This lecture will provide the opportunity to demystify an often intangible process and tackle some of the challenges facing qualitative health researchers today. Dr MacArtney is a Senior Researcher with the Nuffield Department of Primary Care Health Sciences at the University of Oxford and is a sociologist of health and illness with specific interests in the diagnosis of cancer, end of life and palliative care, and bereavement. He specialises in qualitative research. This talk was held as part of the Qualitative Research Methods module which is part of the MSc in Evidence-based Health Care.