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Nearly 10 years since its inception, evidence-based
healthcare (EBH) remains focused on encouraging informed
decision-making by integrating clinical expertise with the
explicit and judicious consideration of the best available
"scientific" evidence. The language and concepts of EBH are being
institutionalised in almost every facet of the healthcare system,
from medical education, policy development and resource allocation
to research funding and consumer advocacy. But has EBH delivered on
its promises?
Despite the explosion in the number of controlled trials, systematic
reviews and clinical practice guidelines, there remain large gaps
between what should be done and what is actually done. Clearly, we
can't hold EBH responsible for the outcomes of the entire healthcare
system, but we should be asking why the gap between the best available
evidence and current practice persists.
We now have in place many of the "upstream" strategies to support EBH.
For example, clinical research is being strengthened and more
strategically aligned to target the areas where evidence is
required.1 Systems are in place through
organisations like the Cochrane Collaboration to provide
up-to-date summaries of rigorous research in an accessible
format.2 Organisations such as the
clinical colleges and societies have embraced the concepts of EBH
through initiatives such as evidence appraisal of new technologies
and procedures and development of clinical guidelines, as well as
refocusing much of the content and methods used in their continuing
education and quality assurance programs.
But what about the "downstream" strategies? What happens to the
endless sets of evidence reports, guidelines and audits? What
strategies are in place to ensure effective uptake and
implementation of the evidence? How can clinicians' behaviour be
changed where necessary? What systems are in place to collect the
necessary data to monitor the effect of applying evidence in daily
practice?
The further downstream we look, the greater the challenges.
Generating and synthesising the evidence is the easy part;
effectively implementing it is not. Our understanding of the
effective methods of implementing evidence is limited. Research
into behavioural and organisational change in healthcare has been
poorly funded, so, while we may have access to some of the best
treatments and technologies in the world, our understanding of the
strategies needed to promote their effective use is rudimentary.
Enter the new National Institute of Clinical Studies Ltd (NICS).
Established in December 2000 as a Commonwealth-owned company (with
the Federal Minister for Health and Aged Care as the sole
shareholder), NICS aims to provide a national, integrated focus for
work being undertaken to continuously improve the quality of
clinical practice and its delivery to patients. Its terms of
reference are broad ranging Box.
Unlike international bodies with similar names (such as the National
Institute of Clinical Excellence in the United Kingdom), NICS is not a
disguise for a new form of rationing or a new national guideline
development agency. Rather, NICS, by fostering a scientific
approach to the implementation of evidence, will help to turn
evidence into action by working in partnership with consumers,
healthcare professionals, researchers and organisations to close
the gap between evidence and practice.
NICS enters an arena in which there is already much activity to do with
quality improvement and best practice. Clearly, NICS will need to
develop a close relationship with groups such as the National Health
and Medical Research Council, the Australian Council for Safety and
Quality in Health Care, the Medicare Services Advisory Committee,
the Pharmaceutical Benefits Advisory Committee and the National
Health Priorities Action Council. Each of these has a different focus
from NICS, whose purpose will be complementary to such groups.
NICS will engage clinicians from all disciplines and practice
settings to identify and prioritise the gaps between evidence and
practice, and then develop strategies to close or minimise the gaps,
using a scientific approach to quality improvement. These
strategies, together with the findings of related initiatives in
Australia and internationally, will help to develop practical
resources to support clinicians in providing best clinical
practice. Finally, NICS will work with other public and private
organisations to create an environment in which these resources can
be used to maximum effect.
NICS is in its early days and is still very much engaged in dialogue and
planning. Its challenge will be to use its modest funding to stimulate
innovative approaches to promoting the use of best clinical
practice. If NICS can't deliver, it runs the risk of becoming just
another forgettable acronym!
Chris A Silagy
Professor, and Director, Monash Institute of Health Services
Research, and
Chair, Board of National Institute of Clinical Studies
Ltd
Monash Medical Centre, Melbourne, VIC
chris.silagyATmed.monash.edu.au
- Wills P, Chairman. The virtuous cycle. Working together for health
and medical research. Health and Medical Research Strategic Review.
Canberra, 1999.
-
Bero L, Rennie D. The Cochrane Collaboration. Preparing,
maintaining, and disseminating systematic reviews of the effects of
health care. JAMA 1995; 274(24): 1935-1938.
©MJA 2001
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