1. We had the experience but missed the meaning:
can we balance patient choice, evidence based practice and
quality improvement?
Professor Jonathan Richards
General Practitioner, Morlais Medical Practice
Locality Clinical Director, Cwm Taf HB
Visiting Professor of Primary Care, University of Glamorgan

2. Our values:
‘the universality of the best’
A critique of Utilitarian rational choice ways
of thinking:
• Commensurability:
how do we measure things?
• Aggregation: pooling choices
• Maximising:
will every person want more?
• Exogenous:
preferences taken for granted

3. Life on the boundaries
The boundary is the best place for acquiring
knowledge. At almost every point I have had
to stand between alternative possibilities of
existence, to be completely at home in
neither. This position is fruitful for thought; but
it is difficult and dangerous in life, which
again and again demands decisions and thus
the exclusion of alternatives.
Paul Tillich, On the Boundary 1967

4. VREONABA
Evidence-
based practice
Citizen Performance
choice Management

5. Nussbaum
Context Evidence-based
practice
Values
Candidacy
Genomics
Surrogate markers
Citizen choice
ent
Managem
ce
Performan

6. Gaps between the evidence and
the real world
Evidence- Lag times between the evidence
based
practice and the performance review
Whose priorities?
Surrogate markers
Citizen
Performance
Management
choice

7. Do we tell the citizen why we are doing
something?
Who does the data belong to?
What really matters andEvi whom?
to
den
Gaming and informed choice.
ce
-
Surrogate markers pra
Insights from Ariely, Kahneman and Haidt
ctic
e
Citizen Performance
choice Management

8. Data from the real world
35%
30%
25%
20%
15%
10%
5%
0%
<100 >100 >110 >120 >130 >140 >150 >160 >170 >180 >190
well bp only 2007 BP only 2008 BP 2010

9. Blood Pressure distribution
35%
30%
25%
20%
15%
10%
5%
0%
BP <100 last BP 100- last BP 110- last BP 120- last BP 130- last BP 140- last BP 150 last BP>160
109 119 129 139 149 -159
low risk intermediate risk high risk very high risk

10. Work to be done if the citizens agree
70% 4500
4000
60%
3500
50%
3000
40% 2500
30% 2000
1500
20%
1000
10%
500
0% 0
no BP reading no smoking history no measure of BMI no record of FH
numbers 20% 16% 44% 65%
proportions 1300 1017 2847 4224

11. Missing data
80%
70%
60%
50%
40%
30%
20%
10%
0%
blood pressure smoking history BMI Family History recorded
low risk intermediate risk high risk very high risk

12. A worked example

13. Resources
TS Eliot Dry Salvages part II from The Four Quartets Faber 1944
MC Nussbaum Poetic Justice Beacon Press 1995
P Tillich Life on the Boundaries 1967
http://www.ted.com/talks/dan_ariely_on_our_buggy_moral_code.html
http://www.nytimes.com/2011/10/21/opinion/brooks-who-you-are.html
http://blog.ted.com/2009/09/27/the_healthcare/
CM Micheel (Ed), JR. Ball (Ed) Evaluation of Biomarkers and Surrogate
Endpoints in Chronic Disease 2010