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Triple targets

6 Nov, 15 | by Bob Phillips

EBP triadThere’s a triple target that I often splurge about evidence based medicine being the ‘combination of patient preference, clinical expertise and best-available research’ which in context addresses an EBM-is-copying-the-trial critique. The #RealEBM hashtag (go on … give it a go ..) is addressing this quite eloquently and has been graven in stone by the superb @RichardLehman1 in Ten Commandments*

There’s another triple target too, that I bumped into quite recently while doing more work on transition from child into adult health services. This is the aim for transition services to

  • improve patient experience
  • increase community health
  • have an appropriate and affordable cost

Why on earth have I not considered before that these three aims are core to EVERY health care system that we undertake?


Nice and easy doesn’t do it.

3 Nov, 15 | by Bob Phillips


With very little need to comment – this model of getting research into practice by dr prof Trish Greenhalsh – can be used to slap down anyone who turns to you and claims all you need to get X, Y or Z working is just

You’re welcome.


Collecting patients’ views

20 Oct, 15 | by Bob Phillips

There’s a hugely understandable drive to make health care centre around the person with the health condition and include them in their care, rather than place the focus on the operator of the health machinery or the accountant that balances the cash flows. There’s the recent launch of the Me First! initiative from the UK, for example, and a drive to patient-led safety campaigns (Have you washed your hands?) But is there any evidence that such approaches make a difference, and how can a systems effectively and efficiently measure such approaches, in order to check that Good Things are happening?

Well, there have been a nice pair of contrasting systematic reviews recently that deal with the topics of patient participation, and patient experience of quality, in healthcare systems. more…

The Emperor’s New Biomarker

13 Oct, 15 | by Bob Phillips

Please tell me that I’m not the only one, who hearing about the magical properties of S100, CD64, microbiomology or ILx (where x >8, probably prime, and is instantly forgettable) recalls the scam of the century as told by Hans Christian Andersen in 1837.

Well. There may be more to biomarkers of disease than just a tailor wanting to get away with an awful lot of cash for a very little work.

In a really nice review article by Pak Cheung Ng and colleagues in the F&N edition, they describe the ideal properties of a biomarker for detecting neonatal sepsis or necrotising enterocolitis. Even if you don’t ‘do’ neonates, if you’re involved with acute paediatrics of any or no subspeciality the themes they bring out are worth thinking on:

  1. Your biomarker should be able to be done on a TINY bit of blood/fluid
  2. That blood shouldn’t mind if it’s venous or capillary
  3. It should probably be interpreted in the light of the clinical setting (with prognostic scoring)
  4. It might be a diagnostic / early warning marker, or an organ specific damage marker, or a response to treatment marker – or ideally all of those – but your interpretation should involve understanding what the biomarker is doing
  5. It should ideally be able to be done without the lab (point of care)

It’s worth thinking about the biomarkers you probably do request … I’d class a full blood count, serum albumin, lactate level or CRP in this gang … and work out what they actually do, rather than what you want them to do, and how well they do it … and then when you see the next paper declaiming F64z-soluble-activation-factor-subunit-B as the perfect marker for lupus renalitis (or whatever), you’ll have an idea of what questions need to be asked of that study.

– Archi

Getting from the diamond to the drug chart

9 Oct, 15 | by Bob Phillips

“Come out of the dark and into the light – use systematic reviews in your clinical practice.” (OK, so that’s probably NOT a direct quote.)

It’s been battered on about for a while in this blog that systematic reviews give you – probably – the best idea of if a treatment, diagnostic test or prognostic factor is real/effective/truthful.

But it’s also true that the same, wonderful, complex and sometimes frankly unreadable pieces of research don’t tell you how to take that Truth and get the pharmacy to dispense it, or the physio team to do it, or the lab to tell you the answer.

The answer might be here, beautifully written by Paul Glasziou, an enormously wise practical theorist on evidence-based practice, and colleagues.


Clashing concepts

2 Oct, 15 | by Bob Phillips

One thing I meet (fairly often) is the clash between the RCT and the patient ‘preference’. (I have to use ‘quotes’ because I know it’s the wrong phrase but I can’t find the right one.)

Take an example – topical anaesthesia for accessing implanted central lines in children & young people with cancer. For those who don’t know, nearly every child who needs chemo in Western Europe, North America and Australasia will have a surgically placed central line to enable venous access for blood taking and drug delivery. For some, it will be a ‘wiggly’ one, like a Hickman or Broviac. For some it will be an implanted one, like a Port-a-Cath or Pass-port. more…

Evidence free yet evidence based; guidelines again.

29 Sep, 15 | by Bob Phillips

2211526355_d11a0e29be_mIn a paper that I’d have never seen if it wasn’t for Twitter, Loes Knaapen of the Université de Montréal Public Health Research Institute reports the scholarly musings on a bunch of conversations with ‘EBM’ guideline developers, attendance at conference events, and a lot of reading around the subject of Guideline Creation. At the heart of these musings is the dilemma

‘how to address the challenges of providing evidence-based advice to address questions for which the evidence is lacking, of poor quality, immature or incomplete’


Sleep tight

18 Sep, 15 | by Bob Phillips

Every so often you bump into something that you didn’t know you didn’t know. That might make a massive difference to your (or someone else’s) life.

Well recently I was directed at this survival guide encouraging sleep to survive shift working and do it safely and securely.

For us.

The key points are:


But what if you miss a malignancy?

15 Sep, 15 | by Bob Phillips

There’s a big push in the UK to make ‘early diagnosis’ of cancer happen more often. The assumption is that diagnosis earlier will mean the disease has not spread, is more treatable, and will lead to a better outcome.

For many conditions, the stage at presentation does indeed link to outcome. In some conditions, there’s a clear natural history that allows you to ‘catch it early’ (cervical neoplasia for example). In others, the biology doesn’t work like that, and early doesn’t mean anything (take the example of neuroblastoma screening).

But what about acute leukaemia?



8 Sep, 15 | by Bob Phillips

That was the repeated phrase of my middle child’s obsessive bedtime reading for a while. Picture of police bikes, fire engines, ambulances, mountain rescue 4×4 and lifeboats.

In not one frame was the rescued individual entered into a clinical trial of therapy or diagnostics.

I guess that might have been asking a bit much, but is it also a bit much to ask for signed, informed consent with an appropriate time to reflect between information delivery and accession? If we worry about risk of bias in non-randomised trials, should the acuity of emergency studies make this even more important to get right?


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