Evidence-based Medicine Toolkit

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70 Evidence-based Medicine Toolkit8 What is the perspective of the analysis?The evaluation should state the perspective from which it was carriedout. Costs and benefits may be different from a patient’s perspectivethan from a health care provider’s. For example, creatinga primary care ‘drop-in’ centre may increase costs from the perspectiveof the health care provider, but could reduce costs fromthe perspective of individuals, employers and society as a wholeby making it easier for people to access services without takingtime off work.Can an analysis from this perspective help you to answer yourquestion?DiscountingEconomists use discounting to account for the fact that a cost orbenefit we get now is worth more than the same benefit in thefuture. It is standard practice to discount costs at 6% per year andbenefits at 1.5% per year.This means that if a drug costs £1000 per year over two years, itscost in year 2 is (1000 – 6% =) £940 when evaluated in year one.9 Does the evaluation include an appropriate sensitivityanalysis?Because costs and benefits can be different in different settingsand at different times, the study should report a sensitivity analysisto show how much the findings would be affected by changes inthe cost or benefit data.So, for example, increases in the price of drugs or in the cost ofdelivering a service might reduce the overall cost-effectiveness ofa new intervention.10 Can the result be applied to the population you areinterested in?The main points to consider here are: the similarity of the patientsin the review to the population you are interested in. Can youafford the intervention, will the money have to come from anotherservice to fund the intervention. Do you have the resources or thepersonnel to deliver a new service?
Applying the evidenceAre yourpatients similarto those in thestudy?1 Are they so different that the results can’thelp you?2 How much of the study effect can youexpect for your patients?For diagnostic testsStart with your patient’s pre-test probabilitythen use the nomogram on page 41.For therapyEstimate your patient’s expected event rate(PEER):NNT =1(PEER × RRR)Is theinterventionrealistic in yoursettings?3 Is the intervention realistic in your setting?4 Does the comparison intervention reflectyour current practice?5 What alternatives are available?Have allthe rightoutcomes beenconsidered?6 Are the outcomes appropriate to yourpatient?7 Does the intervention meet their valuesand preferences?71
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