Insights from the Darzi Review

Clinical Decision Support for Quality Improvement: Insights from the Darzi Review

Foreword The purpose of clinical decision support is “to translate knowledge into evidence-based practice in clinical settings.” 1 Clinical decision support can improve healthcare in a range of ways. It can reduce medical errors; it can ensure that healthcare professionals follow guidelines; and it can also save costs. 2

within BMJ Best Practice can be put into practice to drive quality improvement. The BMJ Best Practice Comorbidities Manager outlines how to better care for the growing number of people with multiple illnesses. Our physical and mental healthcare content gives clear guidance on how to achieve holistic care. The content on cancer helps healthcare professionals avoid the twin perils of over and underdiagnosis. The topics on cardiology and infectious disease cover diagnosis, management, and follow-up, and of course prevention. Our new content on frailty gives guidance on how to come to shared decisions with patients and their families and how to proactively manage this condition. Lastly, the technology underpinning BMJ Best Practice should enable it to be available to healthcare professionals where and when they need it - on a mobile, on an app, and increasingly integrated into the electronic healthcare record. These are current areas of emphasis for BMJ Best Practice. But we are interested in your views also. We have built BMJ Best Practice with our users – and we plan to continue to develop it with people like you. If there are other areas that you feel we should focus on, we would be delighted to hear from you. BMJ Best Practice is freely available in the NHS in England, Scotland, and Wales. Please get in touch if you would like to find out how to make it available in your organisation.

There is a growing research base as to what works in clinical decision support. Such support must provide knowledge that is evidence-based, continually updated and at the same time practical and actionable. Clinical decision support must be fast; it must fit with the clinical workflow; and it must deliver in real-time. 3 It must be available online and offline (via an app) and must work on whatever electronic device that the healthcare professional uses. Ideally, clinical decision support must be usable at the point of care and must be integrated with other relevant resources - from drug formularies to medical calculators. This is a brief summary of where clinical decision support is today. But another important point is that clinical decision support should not stand alone. It should be based on the needs of patients and populations, and the needs of healthcare professionals who serve those patients and populations. The Independent Investigation of the National Health Service in England by Lord Darzi gives a comprehensive outline of the needs of the health service in England. 4 The Darzi review touches on a wide range of topics - but certain issues stand out such as multimorbidity, mental health, and cancer care. This short briefing paper shows how BMJ Best Practice can help with these problems. It gives straightforward examples of how the knowledge

Dr Kieran Walsh. Clinical Director, BMJ Group

Sources: 1. Khong PC, Holroyd E, Wang W. A Critical Review of the Theoretical Frameworks and the Conceptual Factors in the Adoption of Clinical Decision Support Systems. Comput Inform Nurs. 2015 Dec;33(12):555-70. 2. Castillo RS, Kelemen A. Considerations for a successful clinical decision support system. Comput Inform Nurs. 2013 Jul;31(7):319-26. 3. Bates DW, Kuperman GJ, Wang S, Gandhi T, Kittler A, Volk L, Spurr C, Khorasani R, Tanasijevic M, Middleton B. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc. 2003 Nov-Dec;10(6):523-30. 4. Independent Investigation of the National Health Service in England. Lord Darzi. September 2024 Competing interests, KW works for BMJ.

We also have a podcast available

BMJ Best Practice Podcast and The Darzi Review The Darzi report states that “ a recurring theme is that the recommendations of previous reviews have not been universally adopted .” So can we do better this time? In this podcast, Professor Martyn Patel discusses how healthcare professionals can use BMJ Best Practice to improve care in areas where Darzi says that it needs to improve. In things like comorbidities, cardiovascular care, and emergency medicine. Martyn works for Norwich Medical School, Norfolk and Norwich University Hospital, and is also an expert panel member of BMJ Best Practice.

Don’t miss this insightful conversation Stream the episode now!

Contents Click on the headings below to read how BMJ Best Practice can help with the issues covered in the Darzi report.

Comorbidities

Mental health

Cancer care

Heart disease

Frailty

Infectious diseases

Technology

About BMJ Best Practice

Comorbidities

“a recurring theme is that the recommendations of previous reviews have not been universally adopted.” Darzi review

This is in the context of reviews of maternity care. But the same is true of many reviews of the NHS.

So can we do better this time? The eternal optimist in me hopes that we can. Here is one small part of the report and how we could help.

The Darzi review is strong on comorbidities. It states that “between 2017 and 2022, the number of people with two or more long- term conditions increased at an annual rate of 6.1 per cent. This matters because multiple conditions can interact with each other, which increases complexity and makes their management more challenging.” I am a geriatrician by background and I know that comorbidities are more common in older people. But we will never have enough geriatricians in the NHS to cope with a 6% increase every year.

So how can we help? We need all healthcare professionals to think a bit more about holistic care. And to think about caring for the patient rather than just a disease. To think about managing complexity. We are trying to do our bit through the BMJ Best Practice Comorbidities Manager. This is free in the NHS in England. Its purpose is to help healthcare professionals to better manage patients with multiple conditions. It covers many of the conditions mentioned in the review - from diabetes to depression. Most importantly it now covers frailty.

Mental health

“While psychiatric liaison exists in acute physical hospitals, there is no physical health liaison in mental health wards.” Darzi review

This is a fresh perspective. Can we refresh the way we provide care for physical and mental health conditions?

Can we refresh the way we provide care for physical and mental health conditions? We certainly need to. Because the Darzi review is full of look-away-now stats on mental healthcare. Such as.

“The prevalence of depression has shot up from 5.8 per cent in 2012 to 13.2 percent a decade later in 2022”. “Some 343,000 referrals for children and young people under the age of 18 are waiting for mental health services, including around 109,000 referrals waiting for more than a year.” “At the start of 2024, 2.8m people were economically inactive due to long-term sickness. That is an 800,000 increase on pre-pandemic levels with most of the rise accounted for by mental health conditions.” “In 2016, around 2.6 million people were in contact with mental health services; by 2024, this had increased to 3.6 million people.”

So how can we help? The BMJ Best Practice Comorbidities Manager gives guidance on managing patients with both physical and mental conditions. Here is one example of how to manage patients with a common combination - stroke and depression. • Prescribe the patient’s usual antidepressants, unless there are good reasons to change. • If antidepressants are stopped abruptly, the patient may develop discontinuation symptoms. • There is some evidence that selective serotonin- reuptake inhibitors (SSRIs) may cause spontaneous intracranial haemorrhage. But absolute risk is low. • SSRIs with anticoagulants and NSAIDs may increase the risk of spontaneous haemorrhage. • Certain antidepressants may cause respiratory depression – which can be a problem in stroke. • SSRIs and drugs used for hypertension can cause hyponatraemia. • Depression is very common after stroke and often missed.

Cancer care

“The 62-day target for referral to first definitive treatment for cancer has not been met since December 2015” Darzi review

Can we turn things around by December 2025?

There is an emphasis on cancer care in the Darzi review. Here are some highlights. Lowlights might be a better word.

• “The number of cancer cases in England has risen at a rate of 1.7 per cent a year from 2001 to 2021” • “The UK has appreciably higher cancer mortality rates than other countries.” • “When it comes to systemic anti- cancer therapies, there continue to be significant disparities in how quickly patients are able to access new treatments” • “No progress whatsoever was made in diagnosing cancer at stage I and II between 2013 and 2021.”

Not so great really. And not so easy to turn around. Especially because it is not easy to diagnose cancer early - for lots of reasons. Such as • Diverse and subtle presentations • Most people with suspicious symptoms have benign and self-limited conditions • GPs have limited time • Some patients may minimise symptoms • Fears of over-investigation, over-diagnosis, and over-treatment So how can we help? The purpose of BMJ Best Practice is to help get the balance right. To further explore subtle symptoms. To avoid the twin perils of under and over-diagnosis. To do all of this in a short time frame. Because there are no easy answers

Heart disease

“The ‘call-to-balloon’ time for higher risk STEMI heart attack patients in England, Wales and Northern Ireland has risen by 28 per cent.” Darzi review

How can we help these patients?

When I was young, the important target was the “door to needle” time. Things have moved on and now it is “call to balloon”. What both targets have in common is that they are about getting treatment to patients with a heart attack without delay.

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Unfortunately, we are going in the wrong direction.

So how can we help? Here are some tips from BMJ Best Practice Comorbidities on how to manage a patient with myocardial infarction and diabetes • Monitor blood glucose closely in your patient with acute coronary syndrome • Keep blood glucose <11 mmol/L while avoiding hypoglycaemia • Do not routinely use a variable rate intravenous insulin infusion but consider it if a target blood glucose <11 mmol/L is not achieved • Refer patients with ACS and diabetes early to the diabetes in-hospital specialist team or available experts in diabetes management. • Check baseline kidney function as you would on admission for any acutely ill patient and monitor particularly closely if your patient has a history of CKD, diabetes, and/or heart failure. • Be aware that certain medications (such as some beta-blockers and thiazides) may be associated with hyperglycaemia and may need to be reviewed • Check the patient’s feet.

• According to Lord Darzi, “the ‘call-to- balloon’ time for higher risk STEMI heart attack patients in England, Wales and Northern Ireland has risen by 28 per cent.” • There is a lot to this sentence. One of the key phrases is high risk. And one of the things that makes people high risk is comorbidities.

Frailty

“In emergency departments, ‘older people have endured particularly long waits. The average waits for people over the age of 65 have nearly doubled over the past 15 years from just over three hours to nearly seven.” Darzi review

How can we help these older and often frail patients? Hint: we can educate ourselves about frailty just

We launched the BMJ Best Practice Comorbidities Manager with ten comorbidities. People really liked it and thought that the comorbidities we had included were just about right. But lots of people told us there was something missing. And that thing was frailty. So we added it in.

Now you can use the BMJ Best Practice Comorbidities Manager to find out how to manage patients with common combinations of conditions plus frailty. Lots of these patients are the ones waiting for hours in emergency departments - and so they really need any help we can give.

Here are some things about frailty that many healthcare professionals miss out on. • Frailty is often associated with ageing, but it’s not an inevitable part of ageing. Young people can be frail too. • Cognitive frailty means physical frailty and cognitive decline. • You should not give up on frail patients. Physiotherapy, nutrition, and addressing social determinants of health can make a difference. • Frail patients are often on multiple medications. And they are prone to adverse effects of multiple medications. • There is an association between chronic low-grade inflammation and frailty. • People worry about having a heart attack or getting cancer. But frailty is often just as serious. Despite all of this, frailty is underdiagnosed. And undertreated. And not taken into account when making treatment decisions. If you want to do better, have a look at BMJ Best Practice. Go to “acute exacerbation of COPD”. Add frailty. You will find guidance on assessing frailty, ceilings of intervention,

and resus status. On coming to shared decisions. This is just one combination - there are many more.

Infectious diseases

“Well known infectious diseases could be on the rise as vaccination rates fall: measles cases in 2024 have been the highest this century.” Darzi review

What’s worse, herd immunity needs to be really high for measles. 95% high.

The examiner pointed at the ceiling. So I said 90%. He pointed up again. So I said 95%. He said that was correct and that the level was remarkably high. He said never forget it. But I did. Until I was reminded by the Darzi review. The review states that “well-known infectious diseases could be on the rise as vaccination rates fall: measles cases in 2024 have been the highest this century”. I remember being asked about measles in an oral exam at medical school. The examiner asked what herd immunity levels are needed to prevent outbreaks of measles. I guessed 80%.

We need to get vaccinating to push up herd immunity levels. Because measles is a serious disease. • Complications such as pneumonia or encephalitis are common. • Measles is one of the most contagious diseases in the world - there is a super high transmission rate. • Adults are at higher risk for severe disease. • Measles can suppress the immune system for months.

Technology

Technology “always seems to add to the workload of clinicians rather than releasing more time to care by simplifying the inevitable administrative tasks that arise.” Darzi review

This still happens. Despite all the promise of technology. How can we do better?

At BMJ Best Practice, we are doing all we can to give you a quick and easy digital experience.

This includes •

Chunking up the content

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Optimising the content for mobile devices

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Creating tabular and semi-structured content Ensuring the content is tagged with SNOMED-CT and ICD-10 Supporting all levels of integration including single sign-on link, search widget, and HL7 infobutton

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Putting everything onto an offline app

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Ensuring the search and browse are built for speed Ensuring the content fits with the clinical workflow

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Ranked one of the best clinical decision support tools for health professionals worldwide 2 , BMJ Best Practice takes you quickly and accurately to the latest evidence-based information, whenever and wherever you need it. Our step by step guidance on diagnosis, prognosis, treatment and prevention is updated daily using robust evidence based methodology and expert opinion. We are the only point of care tool to support the management of single conditions and patients with more complex comorbidities.

We support you to treat the whole patient.

2. Kwag KH, González-Lorenzo M, Banzi R, Bonovas S, Moja L. Providing Doctors With High-Quality Information: An Updated Evaluation of Web-Based Point-of-Care Information Summaries. J Med Internet Res 2016;18(1):e15

Includes:

Comorbidities Manager to manage patients with multiple conditions

Whole topic PDFs available for download

Over 5,000 case reports covering rare conditions and uncommon presentations

The highest-rated CDS app for instant access anywhere, anytime – even offline

Automatic CME/CPD activity tracking and certificates

Differential diagnoses and treatment algorithms

Over 250 medical calculators and more than 500 patient leaflets

Guidance videos on common clinical procedures

A local guidance tool to easily add links to local clinical information

‘Important Update’ alerts for evidence changes

Contact us If you would like more information or a free trial, please contact sales@bmj.com or visit bestpractice.bmj.com

BMJ produces the only point of care tool to support the management of single conditions and patients with more complex comorbidities.

Accessed in over 100 countries worldwide throughout 2022

BMJ Best Practice is the highest rated clinical decision support tool app in the world, rated 4.8/5 in Apple and Google Play

99.5% surge in sessions seen with electronic health record (EHR) integration 1

1. 99.5% surge in BMJ Best Practice sessions with electronic health record (EHR) integration: Q1 2023 vs same period in 2022.

Providing clinical decision support for institutional subscribers in over 50 countries

~ 850,000 NHS clinicians across England and Wales now benefit from access to the Comorbidities Manager integration

Accredited by over 60 institutions across the world 2

“Topics are practical, clear, concise, comprehensive, digestible, and updated for all physicians.” Physician, Bahrain

2. BMJ Best Practice users can now claim CPD/CME points for time spent reading topics.