Person-centred healthcare requires a re-conception, not renaissance �of evidence-based practice

Jack Dowie, LSHTM

Mette Kjer Kaltoft and Jesper Bo Nielsen, University of Southern Denmark�Øystein Eiring, Norwegian Knowledge Centre for the Health Services�Glenn Salkeld, University of Sydney School of Public Health

Second Annual Conference of European Society for Person Centered Healthcare�Madrid 18-19 June 2015

In best practice and ethical Person-Centred Healthcare it is accepted:�

• that the individual person has multiple criteria (outcomes and process considerations) that are important to them, and that these criteria have different weights

​

• that the clinical decision making process must explicitly elicit these criteria and importance weights at the Point of Decision (POD); this is a necessary condition and cannot be compensated for, however well an institution or individual professional performs on other aspects of PCH (such as attitudes to, and relationships with, the person)�
• that the person’s importance weights must be integrated, at the POD, with Best Estimates Available Now (the BEANs) for the performance rates of the available options on each of the person-important criteria�[Note that the E stands for Estimates not Evidence]

‘patient/s’ appears 63 times ‘person/s’ only twice.

Two problems with reborn EBM�(from PCH perspective)

​

• Conception of ‘evidence base’ for a decision�
• Assumptions about the decision making ability of clinicians

​

• The problems are linked

​

• Both are inimical/incompatible to PC decision making as defined

Adam Neate

What should we do?

What do we prefer?

What do we know?

Decision

Sandwich

Preferences

Filling

Beliefs

Bread

Beliefs / �Knowledge

Translation

Preferences/ Values

Translation

Informatics

‘Valuematics’

Forward

‘Decisionics’

MCDAnalysis�MCDDeliberation

Clinical Judgment

Backward

MCDA via Annalisa: one screen fits all - and fits all

Evidence Base

Preference Base

Option Scores

Options

Options

Attributes

High quality BEANs from robust Evidence via Network Meta-Analysis

Patient-produced BEANs

BEANs from clinical Expertise

Best

Estimates

Available Now

‘Evidence Base’: the two meanings

• Conventional Evidence Base consists of
• Conclusions about options which are
• necessarily based on value judgments about the relevant criteria and their weighting
• can only reflect some average person.�
• Person-Centred Healthcare Evidence Base consists of
• data on performance rates for a single criterion individualised as much as possible but not further processed i.e. the cell-by cell BEANs for the person’s ratings matrix, to be integrated with their importance weights (their value judgments) at the Point of Decision to produce personalised option evaluations

​

​

PCH requires decision support

• Task of storing personalised BEANs matrices and integrating with with person’s importance weights at POD (in 10 minutes) is simply beyond ability of most competent clinician
• Decision support a no brainer (literally)
• MCDA seems only likely contender.�
• Future is not a better trained clinician, but one who can concentrate on the human aspects of PCH and leave the unsustainable burden of information processing to the machine�
• Sorry Trisha, but your renaissance of EBM is not going to happen... and shouldn’t happen if PCH is the future

​

​

Unless u want to use .. I will use sharks in moat

Thanks for attending

Level of complexity

MDS via Annalisa/Elicia

Beyond ‘Tipping Point’