The evolving paradigm of evidence-based medicine

Accounting for complexity in healthcare innovation debates: Professional views on the use of new IVF treatments

Social scientists have long been interested in the forces and values driving healthcare innovation. The simultaneous rise of 20th century healthcare reforms, increased importance of evidence and upsurge in lay health activism have shaped modern medicine. On this backdrop, fertility care emerged in the 1970s. Recent developments reveal a contentious relationship between new fertility treatments and clinical evidence, with emerging technologies being used without conclusive evidence of effectiveness despite being sold to patients. Initial critiques of this phenomenon emphasise commercial interests as the culprit, suggesting that the problematic use of unproven treatments is mainly driven by the private sector. Here, we challenge this over-simplified view of IVF care. Drawing on a qualitative analysis of key documents and 43 in-depth professional interviews, this article identifies three main stakeholder approaches to new treatment adoption. We argue that viewpoints are anchored within three critical overarching 'modes of coordination' or core values in modern healthcare: efficiency, effectiveness and patient-centeredness. This analysis encourages a more contextualised overview of fertility care than previous literatures have afforded. The IVF case shows that an emphasis on private versus public clinic practices obscure similarities between the two along with the values motivating healthcare professionals' approaches to new treatments.

Chronic disease management: time for consultant physicians to take more leadership in system redesign

There is a need for system redesign to meet the needs of individuals with chronic disease. New models of chronic disease care include team-based paradigms that focus on continuous and patient-centred care. In such models the roles of providers and patients must change. In this article we focus on new roles for consultant physicians, as well as barriers and incentives to these roles.

Entangled evidence: knowledge making in systematic reviews in healthcare

As the volume of biomedical information escalates and its uses diversify, systematic reviews and meta-analyses - the compilation, selection and statistical analysis of pooled results from similar studies - are becoming an increasingly accepted method in the evaluation of healthcare technologies and interventions. We thus observe a proliferation of laboratories conducting this type of research. How is knowledge constructed in systematic reviews and meta-analysis in healthcare? Drawing on ethnographic data collected during 18 months of fieldwork in a research centre devoted to the development of evidence-based clinical-practice guidelines and systematic reviews, the paper argues that knowledge construction in secondary research in healthcare is structured upon a parallel process of disentanglement and qualification of data. In disentanglement, knowledge practices attempt to extricate data from the milieus in which they are commonly found (databases, texts, other research centres, etc.). In qualification, the focus of activities is on endowing data with new qualities - such as precision, unbiasness or 'fairness'- through the use of templates, graphical platforms and techno-political debates. The accomplishment of these two processes is fundamental to establishing the persuasive power that meta-analyses appear to have in contemporary healthcare politics.

Taking stock of evidence-based medicine: opportunities for its continuing evolution

Tough but constructive criticisms of evidence-based medicine (EBM) have without doubt informed the evolution and serial reconstitutions of this approach to clinical decision making and behaviour. Yet, concerns about EBM persist and as EBM changes in response to reflection and criticism, so too do the criticisms themselves. This paper describes our current understanding of EBM and, to identify opportunities for the continuing evolution of EBM, discusses some key attributes of EBM that still or now cause us concern. Specifically, these attributes are the nature of evidence in EBM; the unknown effectiveness of EBM; the clinician-centric focus of EBM; and the potential of EBM to harm patients.

Ultrasonography and diagnosis of venous thromboembolism

Venous thromboembolism (VTE) consists of two related conditions: pulmonary embolism (PE) and deep vein thrombosis (DVT). Objective testing for VTE is crucial because the clinical diagnosis is nonspecific and insensitive, and the consequences of a missed diagnosis are serious. The purpose of this review is to discuss the utility of venous ultrasonography as the foundation for diagnosis of acute lower extremity DVT. The effectiveness and practicality of venous ultrasonography as a stand-alone examination versus theoretically attractive, but perhaps less practical, combined approaches of ultrasonography with clinical probability assessment and D-dimer testing in the diagnosis of acute DVT is also addressed. Finally, the role of venous ultrasonography in a diagnostic algorithm for suspected PE is discussed.

Evidence-based practice in mental health: practical weaknesses meet political strengths

RATIONALE, AIMS, AND OBJECTIVES: Evidence-based medicine (EBM) has given rise to evidence-based practice (EBP) in the field of mental health. EBP too is predicated on an evidence hierarchy and has the goal of using the "best evidence" (usually randomized controlled trials) to improve practice. EBP is increasingly influential in mental health care in the U.S. Growing numbers of researchers and public officials endorse its claims and pursue its benefits. The rationale for this paper is to examine the potential of EBP for the field of mental health-and public mental health care specifically. Is it likely to contribute to improved lives for mentally ill people? If so, how?

METHODS

This qualitative study relies on archival, and to a much lesser extent, informant interview data. Informants were mostly public mental health officials because they are in a position to implement EBP on a large scale and their policies are a matter of public record. Interviews were semi-structured, held in person and on the telephone, and lasted one to two hours. Archival research included the substantial literature on EBM and EBP plus studies and articles on the practice and policy of U.S. public mental health care.

RESULTS

The results of this study were that there exists an extensive, coherent literature critical of EBM and of EBP specifically. Attempts to implement EBP will falter on epistemological and organizational barriers. Still, as a public idea--that more science will bring about better mental health practice--EBP may well serve political purposes, especially in the U.S. public mental health system, where more overtly ideological policies have been inadequate in the past. EBP, as a public idea, has the advantage of ambiguity, accountability, quantifiability, etc.

CONCLUSIONS

This paper concludes that EBP is growing more influential in public mental health care in the U.S. Its practical strengths, i.e., its improvement of mental health practice, may turn out to be less than its strengths as a public idea in the formulation and dissemination of mental health policy.

Many a slip between cup and lip. Process evaluation of a program to promote and support evidence-based public health practice

The main aims of this study are to document whether an intervention for promoting evidence-based public health practice had been delivered as intended and to explore the reasons for its lack of impact. Process data from the implementation of the program and data from interviews with 40 public health physicians are analyzed. Although they expressed satisfaction with the service, the doctors experienced the program as rather irrelevant for their daily work. They did not perceive that they dealt with many issues relevant for the use of research information, and if they did, referring to research would not make any difference to the way others perceived their advice. There is a need to develop more overlying strategies for integrating evidence into decision making than addressing the individual level.