Comment / Clinical decision support – helping to drive quality and reduce costs

Quality improvement, patient safety, and cost efficiency are likely be on the agenda of all healthcare organisations in the UK. There are multiple interventions that can help with these issues – from better staffing levels to clinical improvement programmes to consultancies that advise about costs. These should all help to a greater or lesser extent, but they will all require financial investment. Another approach is to look for resources that are already available, but which might not be used to maximum effect locally.

Decision support tools are one way of doing this and BMJ Best Practice, which is aimed at all healthcare professionals,  is one that is freely available within NHS England, Scotland, and Wales – thanks to subscriptions from the three nations The BMJ’s clinical decision support tool is a digital clinical knowledge resource that is continually updated, evidence-based and practical. Its purpose is to drive quality improvement, ensure patient safety and also to save costs. It can enable these outcomes in a number of contexts.

At its core, it provides state-of-the art knowledge in diagnosis, investigations and clinical management. It can help ensure that appropriate clinical investigations are carried out and that inappropriate and unnecessary tests are avoided – saving money. As such it can ensure prompt and accurate diagnosis and avoid problems associated with misdiagnosis or delayed diagnosis. Similarly, it ensures high quality clinical management by providing step-by-step guidance on evidence-based care and so helps avoid use of unnecessary and wasteful treatments.

BMJ Best Practice also gives guidance on how to manage patients with multiple conditions or multimorbidity. One in three adults in the UK has two or more conditions, and so by definition have multi-morbidity. In the UK, one in three adults admitted to hospital as an emergency has five or more conditions. People with multi-morbidity have poorer quality of life and health outcomes, and are higher users of care than are those without multi-morbidity. This all places a significant burden on health systems.

When comorbidities aren't taken into account, patients get suboptimal care leading to worse clinical outcomes. Comorbidities are also associated with longer lengths of stay. So appropriate early management of such patients will save costs by shortening length of stay.

Unnecessarily prolonged length of stay is bad for patients as they can become increasingly immobilised or pick up a hospital-acquired infection. It is bad for hospitals as well – because of costs.  An evaluation of BMJ Best Practice demonstrated that it enabled junior doctors to save money – mainly by shortening length of stay or by avoiding admission completely. Managing comorbidities can also help to address health inequalities – a key current priority –as their presence is associated with socioeconomic deprivation.

BMJ Best Practice covers prevention, such as prevention of falls, reducing distress for patients and reducing length of stay. Avoiding lapses in patient safety can also result in lower litigation costs.

Patient safety incidents can occur in any specialty. However, they tend to have particularly significant impact in maternity care and emergency departments. BMJ Best Practice offers comprehensive clinical coverage of diseases relevant to both these specialties. For example it covers a wide range of presentations in emergency care – from cauda equina syndrome to hip fractures to pulmonary embolism. If healthcare professionals follow evidence-based guidelines on the diagnosis and management of such conditions, it will result in patient benefit. If they do not, it can result in harm to the patient and financial penalties for the institution.

If a patient sues as a result of misdiagnosis or delayed diagnosis, then the cost will be significant. NHS Resolution looks at certain problems such as missed diagnosis of cauda equina syndrome as a high value claim. According to NHS Resolution, the average damages awarded for a high value claim are over £2m. Cauda equina syndrome and other serious illnesses such as spinal cord compression or meningitis are covered by BMJ Best Practice.

The content can also help with the creation of local, system-wide pathways as it crosses from primary to secondary care and so might be especially helpful in system-wide pathways. It is a reliable source of evidence and could help people put their business case together for a new pathway.  

The digital agenda is increasingly important to NHS trusts. Importantly, BMJ Best Practice can be integrated into clinical systems that healthcare providers use (such as electronic healthcare records) and this integration can be done quickly and at no extra cost to the provider. Different clinical resources (from prevention of pressure ulcers to prompt management of stroke) can be promoted – depending on the clinical needs of the trust.

To find out more about BMJ Best Practice, email [email protected].

Dr Walsh is presenting a webinar for HFMA members on the BMJ Best Practice clinical decision support tool on 8 September.