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Rodríguez-Gutiérrez R, Millan-Alanis JM, Barrera FJ, McCoy RG. Value of Patient-Centered Glycemic Control in Patients with Type 2 Diabetes. Curr Diab Rep 2021; 21:63. [PMID: 34902079 PMCID: PMC8693335 DOI: 10.1007/s11892-021-01433-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Present the value of a person-centered approach in diabetes management and review current evidence supporting its practice. RECENT FINDINGS Early evidence from glycemic control trials in diabetes resulted in most practice guidelines adopting a glucose-centric intensive approach for management of the disease, consistently relying on HbA1c as a marker of metabolic control and success. This paradigm has been recently dispelled by new evidence that shows that intensive glycemic control does not provide a significant benefit regarding patient-important microvascular and macrovascular hard outcomes when compared to moderate glycemic targets. The goals of diabetes therapy are to reduce the risks of acute and chronic complications and increase quality of life while incurring least burden of treatment and disruption to the patient's life. A person-centered approach to diabetes management is achieved through shared decision making, integration of evidence-based care and patient´s needs, values and preferences, and minimally disruptive approaches to diabetes care and at the same time offer practical guidance to clinicians and patients on achieving this type of care.
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Affiliation(s)
- René Rodríguez-Gutiérrez
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, Mexico.
- Endocrinology Division, Department of Internal Medicine, University Hospital "Dr. José E. González", Universidad Autónoma de Nuevo León, Francisco I. Madero y Av. Gonzalitos s/n, Mitras Centro, Monterrey, 64460, México.
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN, USA.
| | - Juan Manuel Millan-Alanis
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Francisco J Barrera
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit México), Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Rozalina G McCoy
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN, USA
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, 200 First Street SW, Rochester, MN, 55905, USA
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Nunan D, Lindblad A, Widyahening IS, Bernardo WM, Chi CC, Cowdell F, Becker K, Constantine S, East C, Myrhaug HT, Johnson SG, Jack E, Thompson R, Achilleos H, Berg RC, Snibsøer AK, Puscasiu L, Bartelink MLE, van Peet PG, Berti F, Tilson J, Tikkinen KA, Albarqouni L, Hoegen P. Ten papers for teachers of evidence-based medicine and health care: Sicily workshop 2019. BMJ Evid Based Med 2021; 26:224-227. [PMID: 33172938 DOI: 10.1136/bmjebm-2020-111479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2020] [Indexed: 11/03/2022]
Affiliation(s)
- David Nunan
- Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Adrienne Lindblad
- Alberta College of Family Physicians (PEER) and the Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Indah S Widyahening
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Depok, Indonesia
| | | | - Ching-Chi Chi
- Department of Dermatology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Fiona Cowdell
- School of Nursing and Midwifery, Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
| | - Karen Becker
- Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Christine East
- School of Nursing and Midwifery & Mercy Health, La Trobe University College of Science Health and Engineering, Bundoora, Victoria, Australia
| | - Hilde T Myrhaug
- Division For Health Sciences, Norwegian Institute of Public Health, Oslo, Norway
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Susanne Grødem Johnson
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Edmund Jack
- Yealm Medical Centre, Yealmton, UK
- PenARC (NIHR) Applied Research Collaboration (ARC) South West Peninsula, Exeter, UK
| | - Rachel Thompson
- Office of Medical Education, University of New South Wales, Sydney, New South Wales, Australia
| | - Haris Achilleos
- Paediatrics, Royal London Hospital Barts Health NHS Trust, London, UK
| | - Rigmor C Berg
- Reviews and Health Technology Assessments, Norwegian Institute of Public Health, Oslo, Norway
| | - Anne Kristin Snibsøer
- Health and Caring Sciences, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Lucian Puscasiu
- University of Medicine Pharmacy Science and Technology of Targu Mures, Targu Mures, Romania
| | | | - Petra G van Peet
- Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Franco Berti
- Gruppo Italiano per la Medicina Basata sulle Evidenze (GIMBE), Bologna, Italy
| | - Julie Tilson
- Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, California, USA
| | - Kari Ao Tikkinen
- Departments of Urology and Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Surgery, South Karelia Central Hospital, Lappeenranta, Finland
| | - Loai Albarqouni
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Peter Hoegen
- School of Health and Social Care, Avans University of Applied Science, Breda, The Netherlands
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Research Pearls: Expert Consensus Based Evidence Using the Delphi Method. Arthroscopy 2018; 34:3278-3282. [PMID: 30509437 DOI: 10.1016/j.arthro.2018.10.004] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 02/02/2023]
Abstract
The evolution of a systematic approach to assessing pertinent investigations is known as evidence-based medicine (EBM). EBM is defined as the conscientious and judicious use of current best evidence from clinical care research and integration of clinical expertise in the management of individual patients. There is no doubt that EBM is important but may not give clinically meaningful guidance on topics with clinical equipoise for individual patient care. When EBM has been insufficiently developed for a specific topic, a consensus opinion of experts can be valuable. In principle, there are 2 consensus methods for expert opinion available: the nominal group technique and the Delphi method. The nominal group technique is a structured face-to-face meeting facilitating discussion and allows participants to voice their opinions. The key characteristics of the Delphi method are the use of panel experts to obtain data, no face-to-face discussions, the use of sequential questionnaires, the systematic emergence of a concurrent opinion, use of frequency distributions to identify patterns, and the use of at least 2 rounds with feedback between rounds. We should not dismiss the collective experience of our leading experts, and expert consensus-based evidence should be explored as another tool to improve the quality of treatment for our patients.
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Traeger AC, Hübscher M, McAuley JH. Understanding the usefulness of prognostic models in clinical decision-making. J Physiother 2017; 63:121-125. [PMID: 28342681 DOI: 10.1016/j.jphys.2017.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 10/12/2016] [Accepted: 01/24/2017] [Indexed: 12/12/2022] Open
Affiliation(s)
- Adrian C Traeger
- Neuroscience Research Australia, Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Markus Hübscher
- Neuroscience Research Australia, Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - James H McAuley
- Neuroscience Research Australia, Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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Guyatt G. Dave Sackett and the ethos of the EBM community. J Clin Epidemiol 2016; 73:75-81. [DOI: 10.1016/j.jclinepi.2016.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 02/18/2016] [Indexed: 12/01/2022]
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Depaul VG, Moreland JD, Dehueck AL. Physiotherapy needs assessment of people with stroke following discharge from hospital, stratified by acute functional independence measure score. Physiother Can 2014; 65:204-14. [PMID: 24403687 DOI: 10.3138/ptc.2012-14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine the physiotherapy-related needs of people with stroke at discharge, 6 months after discharge, and 1 year after discharge from hospital, and to examine the results stratified by participants' acute Functional Independence Measure (FIM) scores. METHODS A total of 241 adults with recent stroke were recruited into this longitudinal cohort study. As well as participating in a semi-structured interview that included questions about mobility needs and barriers, participants were asked to complete and return a closed-ended needs-assessment survey. RESULTS During the interview, participants reported needs and barriers related to motor control, walking, stairs, fatigue, prevention of falls, and access to physiotherapy services. The survey identified many more needs, including transfers, wheelchair use, higher-level balance and mobility skills, and access to physiotherapy and suitable exercise facilities. Frequencies of needs and barriers tended to be lower among participants with higher acute FIM scores. There was no consistent trend for needs and barriers to decrease over time. CONCLUSIONS Over the first year after discharge from hospital, people with stroke report a large and varied number of persistent mobility-related needs. Physiotherapists have a role to play in advocating for adequate follow-up services and informing health policy with respect to the needs of their patients with stroke.
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Affiliation(s)
- Vincent G Depaul
- Physiotherapy Department, St. Joseph's Healthcare Hamilton ; School of Rehabilitation Science, McMaster University, Hamilton
| | - Julie D Moreland
- Physiotherapy Department, St. Joseph's Healthcare Hamilton ; School of Rehabilitation Science, McMaster University, Hamilton
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Shreeve MW. Evidence-based chiropractic education: are we equipping graduates for clinical practice with improved patient outcomes? THE JOURNAL OF CHIROPRACTIC EDUCATION 2012; 26:184-187. [PMID: 23362366 PMCID: PMC3557654 DOI: 10.7899/jce-11-017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 01/02/2012] [Accepted: 01/30/2012] [Indexed: 06/01/2023]
Abstract
Evidence-based practice has emerged as a driving factor in current curriculum development in chiropractic education. This commentary discusses educational strategies incorporating evidence-based practices in the doctor of chiropractic curriculum and explores whether all five steps of the evidence-based process and patient outcomes from evidence-based practice are being assessed.
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Dunstan RW, Wharton KA, Quigley C, Lowe A. The Use of Immunohistochemistry for Biomarker Assessment—Can It Compete with Other Technologies? Toxicol Pathol 2011; 39:988-1002. [DOI: 10.1177/0192623311419163] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A morphology-based assay such as immunohistochemistry (IHC) should be a highly effective means to define the expression of a target molecule of interest, especially if the target is a protein. However, over the past decade, IHC as a platform for biomarkers has been challenged by more quantitative molecular assays with reference standards but that lack morphologic context. For IHC to be considered a “top-tier” biomarker assay, it must provide truly quantitative data on par with non-morphologic assays, which means it needs to be run with reference standards. However, creating such standards for IHC will require optimizing all aspects of tissue collection, fixation, section thickness, morphologic criteria for assessment, staining processes, digitization of images, and image analysis. This will also require anatomic pathology to evolve from a discipline that is descriptive to one that is quantitative. A major step in this transformation will be replacing traditional ocular microscopes with computer monitors and whole slide images, for without digitization, there can be no accurate quantitation; without quantitation, there can be no standardization; and without standardization, the value of morphology-based IHC assays will not be realized.
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Affiliation(s)
| | | | | | - Amanda Lowe
- Digital Pathology Consultants, LLC, Broomfield, Colorado, USA
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Amonette WE, English KL, Ottenbacher KJ. Nullius in verba: a call for the incorporation of evidence-based practice into the discipline of exercise science. Sports Med 2010; 40:449-57. [PMID: 20524711 DOI: 10.2165/11531970-000000000-00000] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Evidence-based practice (EBP) is a concept that was popularized in the early 1990s by several physicians who recognized that medical practice should be based on the best and most current available evidence. Although this concept seems self-evident, much of medical practice was based on outdated textbooks and oral tradition passed down in medical school. Currently, exercise science is in a similar situation. Due to a lack of regulation within the exercise community, the discipline of exercise science is particularly prone to bias and misinformation, as evidenced by the plethora of available programmes with efficacy supported by anecdote alone. In this review, we provide a description of the five steps in EBP: (i) develop a question; (ii) find evidence; (iii) evaluate the evidence; (iv) incorporate evidence into practice; and (v) re-evaluate the evidence. Although objections have been raised to the EBP process, we believe that its incorporation into exercise science will improve the credibility of our discipline and will keep exercise practitioners and academics on the cutting edge of the most current research findings.
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Affiliation(s)
- William E Amonette
- Preventive Medicine and Community Health, Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas 77555-0411, USA.
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Karpouzis F, Bonello R, Pollard H. Chiropractic care for paediatric and adolescent Attention-Deficit/Hyperactivity Disorder: A systematic review. CHIROPRACTIC & OSTEOPATHY 2010; 18:13. [PMID: 20525195 PMCID: PMC2891800 DOI: 10.1186/1746-1340-18-13] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 06/02/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Psychostimulants are first line of therapy for paediatric and adolescent AD/HD. The evidence suggests that up to 30% of those prescribed stimulant medications do not show clinically significant outcomes. In addition, many children and adolescents experience side-effects from these medications. As a result, parents are seeking alternate interventions for their children. Complementary and alternative medicine therapies for behavioural disorders such as AD/HD are increasing with as many as 68% of parents having sought help from alternative practitioners, including chiropractors. OBJECTIVE The review seeks to answer the question of whether chiropractic care can reduce symptoms of inattention, impulsivity and hyperactivity for paediatric and adolescent AD/HD. METHODS Electronic databases (Cochrane CENTRAL register of Controlled Trials, Cochrane Database of Systematic reviews, MEDLINE, PsycINFO, CINAHL, Scopus, ISI Web of Science, Index to Chiropractic Literature) were searched from inception until July 2009 for English language studies for chiropractic care and AD/HD. Inclusion and exclusion criteria were applied to select studies. All randomised controlled trials were evaluated using the Jadad score and a checklist developed from the CONSORT (Consolidated Standards of Reporting Trials) guidelines. RESULTS The search yielded 58 citations of which 22 were intervention studies. Of these, only three studies were identified for paediatric and adolescent AD/HD cohorts. The methodological quality was poor and none of the studies qualified using inclusion criteria. CONCLUSIONS To date there is insufficient evidence to evaluate the efficacy of chiropractic care for paediatric and adolescent AD/HD. The claim that chiropractic care improves paediatric and adolescent AD/HD, is only supported by low levels of scientific evidence. In the interest of paediatric and adolescent health, if chiropractic care for AD/HD is to continue, more rigorous scientific research needs to be undertaken to examine the efficacy and effectiveness of chiropractic treatment. Adequately-sized RCTs using clinically relevant outcomes and standardised measures to examine the effectiveness of chiropractic care verses no-treatment/placebo control or standard care (pharmacological and psychosocial care) are needed to determine whether chiropractic care is an effective alternative intervention for paediatric and adolescent AD/HD.
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Affiliation(s)
- Fay Karpouzis
- Department of Chiropractic, Faculty of Science, Macquarie University, Sydney, NSW 2109, Australia
- Macquarie Injury Management Group, Macquarie University, Sydney, NSW 2109, Australia
| | - Rod Bonello
- Department of Chiropractic, Faculty of Science, Macquarie University, Sydney, NSW 2109, Australia
- Macquarie Injury Management Group, Macquarie University, Sydney, NSW 2109, Australia
| | - Henry Pollard
- Department of Chiropractic, Faculty of Science, Macquarie University, Sydney, NSW 2109, Australia
- Macquarie Injury Management Group, Macquarie University, Sydney, NSW 2109, Australia
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Yu H, Lee M, Kaufman D, Ely J, Osheroff JA, Hripcsak G, Cimino J. Development, implementation, and a cognitive evaluation of a definitional question answering system for physicians. J Biomed Inform 2007; 40:236-51. [PMID: 17462961 DOI: 10.1016/j.jbi.2007.03.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2005] [Revised: 12/31/2006] [Accepted: 03/01/2007] [Indexed: 11/26/2022]
Abstract
The published medical literature and online medical resources are important sources to help physicians make patient treatment decisions. Traditional sources used for information retrieval (e.g., PubMed) often return a list of documents in response to a user's query. Frequently the number of returned documents from large knowledge repositories is large and makes information seeking practical only "after hours" and not in the clinical setting. This study developed novel algorithms, and designed, implemented, and evaluated a medical definitional question answering system (MedQA). MedQA automatically analyzed a large number of electronic documents to generate short and coherent answers in response to definitional questions (i.e., questions with the format of "What is X?"). Our preliminary cognitive evaluation shows that MedQA out-performed three other online information systems (Google, OneLook, and PubMed) in two important efficiency criteria; namely, time spent and number of actions taken for a physician to identify a definition. It is our contention that question answering systems that aggregate pertinent information scattered across different documents have the potential to address clinical information needs within a timeframe necessary to meet the demands of clinicians.
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Affiliation(s)
- Hong Yu
- Department of Health Sciences, University of Wisconsin-Milwaukee, Enderis Hall 939, 2400 E. Hartford Avenue, P.O. Box 413, Milwaukee, WI 53211, USA.
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Grypdonck MHF. Qualitative health research in the era of evidence-based practice. QUALITATIVE HEALTH RESEARCH 2006; 16:1371-85. [PMID: 17079799 DOI: 10.1177/1049732306294089] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Evidence-based health care (EBHC) sets the tone in health care and health care research nowadays. Qualitative health researchers have to position themselves in a world that is dominated by it. The popularity of EBHC is not due to the rationality of its tenets. In this article, the author addresses major problems in EBHC. Qualitative research is important for providing the understanding that is necessary to apply findings from quantitative research properly and safely. Basic studies about the human experience in illness and regarding human behavior and meaning in general remain of great value, even in the era of EBHC. Qualitative research also plays an important role in developing scholarship.
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Audebert FX, Büttner R, Hartmann P, Schölmerich J, Bollheimer LC. [Clinical pathways--practical aid for the physician? Example: clarification of the suspicion of tuberculosis]. Internist (Berl) 2006; 47:713-9. [PMID: 16718513 DOI: 10.1007/s00108-006-1643-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Guidelines, clinical pathways and clinical algorithms are popular instruments nowadays to ensure quality as well as the economic efficiency of medical work. These terms themselves, however, are frequently defined only in a diffuse way. Thus, medical standard procedures often complicate clinical workflows more than to facilitate decision making in everyday life. In our department, feasible standardized approaches have been generated in the form of structured text documents, which on the one hand can aid clinical decision making at the bedside and on the other hand serve as medical sketches for the generation of operational treatment paths on an interdisciplinary level. Structure and content of such an instructional text are exemplified here using our standardized document for the diagnostic approach when tuberculosis is suspected.
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Affiliation(s)
- F X Audebert
- Klinik und Poliklinik für Innere Medizin I, Universitätsklinikum Regensburg, 93042, Regensburg
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Abstract
Teaching EBM is to impart the process of asking the question, acquiring and appraising the literature and applying it to the care of the patient, while weighing the risks, benefits and considering patient values. Teaching this process and its necessary content requires as with everything else, dedication, knowledge and practice. The best way to teach both patient care and EBM is by example.
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Affiliation(s)
- Brad A Petrisor
- Division of Orthopaedics, Department of Surgery, McMaster University, Hamilton, Ont., Canada
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Staunton M, Dodd JD, McCormick PA, Malone DE. Finding evidence-based answers to practical questions in radiology: which patients with inoperable hepatocellular carcinoma will survive longer after transarterial chemoembolization? Radiology 2005; 237:404-13. [PMID: 16244249 DOI: 10.1148/radiol.2372040058] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
To some, evidence-based practice (EBP) means the identification of centers that produce evidence reports and technology assessments to support guideline development. To others, EBP is the best research evidence integrated with clinical expertise and patient values. Inherent in the first approach is the implication that only central academic organizations can produce valid, reliable analyses of existing literature, which will then be distributed to ordinary practitioners. The second approach implies that ordinary practitioners can learn to use a stepwise approach and a preprepared set of rules and tools to effectively find the best current literature, appraise it, and then apply local circumstances to these rules and tools in their hospital. Paul Glasziou, director of the Centre for Evidence-based Practice in Oxford, England, has coined the phrases top-down EBP and bottom-up EBP to describe these approaches. In this article, the authors describe how knowledge gaps in an ordinary radiology practice can be addressed by using stepwise bottom-up EBP techniques. The following clinical scenario is used: Your hospital's recently appointed chief hepatobiliary surgeon questions the use of transarterial chemoembolization for inoperable hepatocellular carcinoma because of his concerns after reading a recent review article suggesting that there is no clear survival benefit to using this procedure. What would you do? Here is how the authors would do it.
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Affiliation(s)
- Marie Staunton
- Department of Radiology, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Abstract
Low back pain has long been described as a challenge for both primary care physicians and specialists. Management of low back pain has also been criticized as frequently arbitrary, inappropriate, or ineffective. Contributing factors have been an inadequate evidence base and a need for more rigorous appraisals of the available literature. Evidence-based medicine, an approach to clinical problem solving, is predicated on the premise that high-quality health care will result from practices consistent with the best evidence. In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion, authority, and unsystematic clinical observations, evidence-based medicine emphasizes the need for rigorous critical appraisals of the scientific literature to inform medical decision making. Evidence-based medicine places strong weight on the requirement for valid studies, particularly randomized controlled trials, to appropriately evaluate the effectiveness of health care interventions. Because of the rapidly increasing volume of medical literature, however, most clinicians are unable to keep up-to-date with all the new data. Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic reviews and evidence-based clinical practice guidelines. Like primary studies, systematic reviews and clinical practice guidelines must adhere to high methodologic standards to reduce error and bias. As in other areas of medicine, the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings. In addition to more rigorous primary studies, an increasing number of high-quality systematic reviews and evidence-based clinical practice guidelines for low back pain are also available. Although some research gaps and methodologic shortcomings persist, the richer evidence base has greatly improved our understanding of what does and does not work for low back pain. Despite these advances, the best available evidence often does not inform everyday clinical decisions for low back pain. Nonetheless, there is widespread agreement that adherence to evidence-based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care. This article reviews basic principles of evidence-based medicine, discusses evidence-based medicine in the context of low back pain management, and summarizes some useful evidence-based medicine resources.
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Affiliation(s)
- Roger Chou
- The Oregon Evidence-Based Practice Center, The Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA.
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Dawes M, Summerskill W, Glasziou P, Cartabellotta A, Martin J, Hopayian K, Porzsolt F, Burls A, Osborne J. Sicily statement on evidence-based practice. BMC MEDICAL EDUCATION 2005; 5:1. [PMID: 15634359 PMCID: PMC544887 DOI: 10.1186/1472-6920-5-1] [Citation(s) in RCA: 492] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2004] [Accepted: 01/05/2005] [Indexed: 05/09/2023]
Abstract
BACKGROUND A variety of definitions of evidence-based practice (EBP) exist. However, definitions are in themselves insufficient to explain the underlying processes of EBP and to differentiate between an evidence-based process and evidence-based outcome. There is a need for a clear statement of what Evidence-Based Practice (EBP) means, a description of the skills required to practise in an evidence-based manner and a curriculum that outlines the minimum requirements for training health professionals in EBP. This consensus statement is based on current literature and incorporating the experience of delegates attending the 2003 Conference of Evidence-Based Health Care Teachers and Developers ("Signposting the future of EBHC"). DISCUSSION Evidence-Based Practice has evolved in both scope and definition. Evidence-Based Practice (EBP) requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources. Health care professionals must be able to gain, assess, apply and integrate new knowledge and have the ability to adapt to changing circumstances throughout their professional life. Curricula to deliver these aptitudes need to be grounded in the five-step model of EBP, and informed by ongoing research. Core assessment tools for each of the steps should continue to be developed, validated, and made freely available. SUMMARY All health care professionals need to understand the principles of EBP, recognise EBP in action, implement evidence-based policies, and have a critical attitude to their own practice and to evidence. Without these skills, professionals and organisations will find it difficult to provide 'best practice'.
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Affiliation(s)
- Martin Dawes
- Department of Family Medicine. McGill University, Montreal, Canada
| | | | - Paul Glasziou
- Department of Primary Health Care, Centre for Evidence-Based Practice, Oxford University, Oxford, UK
| | - Antonino Cartabellotta
- Gruppo Italiano per la Medicina Basata sulle Evidenze (GIMBE), Passaggio L. da Vinci, 16 – 90145 Palermo, Italy
| | - Janet Martin
- London Health Sciences Centre, Department of Physiology & Pharmacology, University of Western Ontario, London, Ontario, Canada
| | - Kevork Hopayian
- School of Medicine, Health Policy and Practice, University of East Anglia Norwich, UK
| | - Franz Porzsolt
- University Hospital Ulm, Clinical Economics, Ulm, Germany
| | - Amanda Burls
- Department Public Health and Epidemiology, University of Birmingham, Birmingham UK
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Kulkarni AV. The challenges of evidence-based medicine: a philosophical perspective. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2005; 8:255-60. [PMID: 16215804 DOI: 10.1007/s11019-004-7345-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Although evidence-based medicine (EBM) has gained prominence in current medical practice and research, it has also had to deal with a number of problems and inconsistencies. For example, how do clinicians reconcile discordant results of randomized trials or how do they apply results of randomized trials to individual patients? In an attempt to examine such problems in a structured way, this essay describes EBM within a philosophical framework of science. Using this approach, some of the problems and challenges faced by EBM can be explained at a more fundamental level. As well, by employing a similar description of the competing alternative research tradition of clinical medicine, this essay not only highlights the philosophical differences between these two modes of medical practice, but suggests that they, in fact, play a de facto complementary role in current clinical medicine.
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Affiliation(s)
- Abhaya V Kulkarni
- Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario M5G 1X8, Canada.
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Abstract
Recent advances in molecular pathology and other technologies such as proteomics present pathologists with the challenge of integrating the new information generated with high-throughput methods with current diagnostic models based mostly on histopathology and clinicopathologic correlations. Parallel developments in the field of medical informatics and bioinformatics provide the technical and mathematical methods to approach these problems in a rational manner. However, it remains unclear whether pathologists or other medical specialists will become primarily responsible for the development and maintenance of these multivariate and multidisciplinary diagnostic and prognostic models that are hoped to provide more accurate, individualized patient-based information. Evidence-based medicine (EBM) and medical decision analysis (MDA) are relatively new disciplines that use quantitative methods to assess the value of information, differentiate fact from myth, and integrate so-called best evidence into multivariate models for the assessment of prognosis, response to therapy, selection of laboratory tests, and other complex problems that influence individual patient care. We review from an epistemological viewpoint the current approach to information in pathology and describe some of the concepts developed by the practitioners of EBM and MDA.
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Affiliation(s)
- Alberto M Marchevsky
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Roudebush P, Allen TA, Dodd CE, Novotny BJ. Application of evidence-based medicine to veterinary clinical nutrition. J Am Vet Med Assoc 2004; 224:1765-71. [PMID: 15198260 DOI: 10.2460/javma.2004.224.1766] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Philip Roudebush
- Technical Information Service and Science and Technology Center, Hill's Pet Nutrition Inc, PO Box 1658, Topeka, KS 66601, USA
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21
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McMahon AD. Study control, violators, inclusion criteria and defining explanatory and pragmatic trials. Stat Med 2002; 21:1365-76. [PMID: 12185890 DOI: 10.1002/sim.1120] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Important differences between explanatory and pragmatic studies were originally argued by Schwartz and Lellouch. Three important differences between the two types of study involve study control, study violators and inclusion criteria. It was originally argued that explanatory studies are highly controlled, and pragmatic studies may be looser and more like 'real life'. It was argued that an explanatory study should only analyse those receiving treatment, and a pragmatic study would analyse all randomized patients. Explanatory trials are said to use homogeneous groups, and pragmatic studies have less selection (better generalizability). Some suggestions are put forward to update the original distinctions between these two attitudes for future study design. Poor study control is undesirable (but might be necessary) and should not be welcomed as pragmatic. The intention-to-treat strategy is now considered as standard for nearly all trials. Homogeneity is a red herring for studies in humans. Inclusion criteria should be minimized and they should not be used to justify claims of representativeness. Routine criticism of randomized controlled trials for being unrepresentative is unwarranted. We should accept that most trials in humans are 'explanatory'. The division line should be moved, so that pragmatic studies are in the domain of non-therapeutics and complex treatments.
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Affiliation(s)
- Alex D McMahon
- Robertson Centre for Biostatistics, University of Glasgow, Boyd Orr Building, Glasgow, G12 8QQ, Scotland, U.K.
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22
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Löbbe AS. Risks and Misconceptions of Guidelines in Medicine and Palliative Medicine in Particular. PROGRESS IN PALLIATIVE CARE 2002. [DOI: 10.1080/09699260.2002.11746643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Herbert RD. How to estimate treatment effects from reports of clinical trials. II: Dichotomous outcomes. THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY 2001; 46:309-313. [PMID: 11676816 DOI: 10.1016/s0004-9514(14)60292-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This paper, the second in a series of two, discusses how readers of clinical trials can extract simple estimates of treatment effect size from trial reports when trial outcomes are measured on a dichtomous scale. A method is given to quantify the degree of uncertainty of these estimates. Estimates of treatment effect size can be adjusted on the basis of baseline risk to determine the probability that treatment will help a particular patient. The probability that the treatment will be helpful should be weighed against the costs and risks of the treatment.
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Affiliation(s)
- Robert D Herbert
- School of Physiotherapy, The University of Sydney, Lidcombe, NSW, 1825, Australia.
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24
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Bennett S, Bennett JW. The process of evidence-based practice in occupational therapy: Informing clinical decisions. Aust Occup Ther J 2000. [DOI: 10.1046/j.1440-1630.2000.00237.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ketterer MW, Mahr G, Goldberg AD. Psychological factors affecting a medical condition: ischemic coronary heart disease. J Psychosom Res 2000; 48:357-67. [PMID: 10880658 DOI: 10.1016/s0022-3999(00)00099-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The criteria for scientific validation of the entities currently subsumed under the DSM-IV category of "Psychological Factors Affecting a Medical Condition" have never been clearly enumerated. Historically, its precursor category ("Psychophysiological Disorder") was rarely used, and predicated upon clinical observation of personality styles among patients with specific physical illnesses, or clinical observations relating psychosocial events and symptom exacerbation. Because of logical flaws with either of these methods, clarification of the most rigorous criteria for demonstrating a cause-effect relationship is necessary. With the increase in well-designed and carefully executed epidemiological and treatment studies, this diagnostic category has evolved into an arena where cutting-edge insights and therapies are becoming available for a growing variety of medical conditions, especially ischemic coronary heart disease. The present article reviews the nature of the scientific evidence necessary to accept an etiological or aggravating role for psychological events.
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Affiliation(s)
- M W Ketterer
- Consultation/Liaison Psychiatry, Henry Ford Health Sciences Center, CFP3, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
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Casali P, Licitra L, Tondini C, de Braud F, Bruzzi P, Costa A, Cavalli F. START: a European state-of-the-art on-line instrument for clinical oncologists. Ann Oncol 1999; 10:769-73. [PMID: 10470422 DOI: 10.1023/a:1008318029326] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
START ('State-of-the-Art Oncology in Europe'), a freely available resource on the Internet, is a European 'information base' of current clinical approaches to human tumours. Its aim is to help clinical oncologists make appropriate clinical decisions by providing them with updated information reflecting state-of-the-art cancer treatment as perceived by the European oncology community. It is based upon contributions from authors and internal reviewers from all over Europe as selected by START's editorial board under the supervision of an advisory board and a scientific committee. Close collaborations with the main European cancer societies are ongoing. An external feedback process augments the mechanisms for rendering START a truly European instrument. START is concerned with evidence-based cancer medicine, and the main clinical options are thus codified and their bases indicated in accord with a scale worked out from the perspective of clinical decision-making. Therapeutic options may be 'standard', 'investigational', or 'suitable for individual clinical use' (within the context of a decision made jointly by the patient and the physician). The goal of instruments such as START is to improve the quality of patient care. In addition, START hopes to make contributions to the methodology by which medical research is transformed into clinical decisions.
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Affiliation(s)
- P Casali
- Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy.
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