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Simons M, Fisher G, Spanos S, Zurynski Y, Davidson A, Stoodley M, Rapport F, Ellis LA. Integrating training in evidence-based medicine and shared decision-making: a qualitative study of junior doctors and consultants. BMC MEDICAL EDUCATION 2024; 24:418. [PMID: 38637798 PMCID: PMC11027546 DOI: 10.1186/s12909-024-05409-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND In the past, evidence-based medicine (EBM) and shared decision-making (SDM) have been taught separately in health sciences and medical education. However, recognition is increasing of the importance of EBM training that includes SDM, whereby practitioners incorporate all steps of EBM, including person-centered decision-making using SDM. However, there are few empirical investigations into the benefits of training that integrates EBM and SDM (EBM-SDM) for junior doctors, and their influencing factors. This study aimed to explore how integrated EBM-SDM training can influence junior doctors' attitudes to and practice of EBM and SDM; to identify the barriers and facilitators associated with junior doctors' EBM-SDM learning and practice; and to examine how supervising consultants' attitudes and authority impact on junior doctors' opportunities for EBM-SDM learning and practice. METHODS We developed and ran a series of EBM-SDM courses for junior doctors within a private healthcare setting with protected time for educational activities. Using an emergent qualitative design, we first conducted pre- and post-course semi-structured interviews with 12 junior doctors and thematically analysed the influence of an EBM-SDM course on their attitudes and practice of both EBM and SDM, and the barriers and facilitators to the integrated learning and practice of EBM and SDM. Based on the responses of junior doctors, we then conducted interviews with ten of their supervising consultants and used a second thematic analysis to understand the influence of consultants on junior doctors' EBM-SDM learning and practice. RESULTS Junior doctors appreciated EBM-SDM training that involved patient participation. After the training course, they intended to improve their skills in person-centered decision-making including SDM. However, junior doctors identified medical hierarchy, time factors, and lack of prior training as barriers to the learning and practice of EBM-SDM, whilst the private healthcare setting with protected learning time and supportive consultants were considered facilitators. Consultants had mixed attitudes towards EBM and SDM and varied perceptions of the role of junior doctors in either practice, both of which influenced the practice of junior doctors. CONCLUSIONS These findings suggested that future medical education and research should include training that integrates EBM and SDM that acknowledges the complex environment in which this training must be put into practice, and considers strategies to overcome barriers to the implementation of EBM-SDM learning in practice.
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Affiliation(s)
- Mary Simons
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia.
- Australian Institute of Health Innovation, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia.
| | - Georgia Fisher
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Samantha Spanos
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Yvonne Zurynski
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Andrew Davidson
- Department of Neurosurgery, The Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Marcus Stoodley
- Department of Clinical Medicine, Macquarie University, Sydney, NSW, 2109, Australia
| | - Frances Rapport
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Louise A Ellis
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
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Brönneke JB, Müller J, Mouratis K, Hagen J, Stern AD. Regulatory, Legal, and Market Aspects of Smart Wearables for Cardiac Monitoring. SENSORS 2021; 21:s21144937. [PMID: 34300680 PMCID: PMC8309890 DOI: 10.3390/s21144937] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 01/27/2023]
Abstract
In the area of cardiac monitoring, the use of digitally driven technologies is on the rise. While the development of medical products is advancing rapidly, allowing for new use-cases in cardiac monitoring and other areas, regulatory and legal requirements that govern market access are often evolving slowly, sometimes creating market barriers. This article gives a brief overview of the existing clinical studies regarding the use of smart wearables in cardiac monitoring and provides insight into the main regulatory and legal aspects that need to be considered when such products are intended to be used in a health care setting. Based on this brief overview, the article elaborates on the specific requirements in the main areas of authorization/certification and reimbursement/compensation, as well as data protection and data security. Three case studies are presented as examples of specific market access procedures: the USA, Germany, and Belgium. This article concludes that, despite the differences in specific requirements, market access pathways in most countries are characterized by a number of similarities, which should be considered early on in product development. The article also elaborates on how regulatory and legal requirements are currently being adapted for digitally driven wearables and proposes an ongoing evolution of these requirements to facilitate market access for beneficial medical technology in the future.
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Affiliation(s)
- Jan Benedikt Brönneke
- Health Innovation Hub, Torstr. 223, 10785 Berlin, Germany; (J.H.); (A.D.S.)
- Correspondence:
| | - Jennifer Müller
- Helios Health Institute, Helios Health, Friedrichstraße 136, 10117 Berlin, Germany;
| | - Konstantinos Mouratis
- Herzzentrum Leipzig, Universitätsklinik für Kardiologie, Strümpellstraße 39, 04289 Leipzig, Germany;
- Leipzig Heart Institute, Russenstraße 69a, 04289 Leipzig, Germany
| | - Julia Hagen
- Health Innovation Hub, Torstr. 223, 10785 Berlin, Germany; (J.H.); (A.D.S.)
| | - Ariel Dora Stern
- Health Innovation Hub, Torstr. 223, 10785 Berlin, Germany; (J.H.); (A.D.S.)
- Harvard Business School, Harvard University, Morgan Hall 433, Soldiers Field Road, Boston, MA 02163, USA
- Hasso-Plattner-Institute, Prof.-Dr.-Helmert-Straße 2-3, 14482 Potsdam, Germany
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Mugerauer R. Professional judgement in clinical practice (part 2): knowledge into practice. J Eval Clin Pract 2021; 27:603-611. [PMID: 33241613 DOI: 10.1111/jep.13514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 12/16/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Though strong evidence-based medicine is assertive in its claims, an insufficient theoretical basis and patchwork of arguments provide a good case that rather than introducing a new paradigm, EBM is resisting a shift to actually revolutionary complexity theory and other emergent approaches. This refusal to pass beyond discredited positivism is manifest in strong EBM's unsuccessful attempts to continually modify its already inadequate previous modifications, as did the defenders of the Ptolemaic astronomical model who increased the number of circular epicycles until the entire epicycle-deferent system proved untenable. METHODS Narrative Review. RESULTS The analysis in Part 1 of this three part series showed epistemological confusion as strong EBM plays the discredited positivistic tradition out to the end, thus repeating in a medical sphere and vocabulary the major assumptions and inadequacies that have appeared in the trajectory of modern science. Paper 2 in this series examines application, attending to strong EBM's claim of direct transferability of EBM research findings to clinical settings and its assertion of epistemological normativity. EBM's contention that it provides the "only valid" approach to knowledge and action is questioned by analyzing the troubled story of proposed hierarchies of the quality of research findings (especially of RCTs, with other factors marginalized), which falsely identifies evaluating findings with operationally utilizing them in clinical recommendations and decision-making. Further, its claim of carrying over its normative guidelines to cover the ethical responsibilities of researchers and clinicians is questioned.
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Affiliation(s)
- Robert Mugerauer
- College of Built Environments, University of Washington, Seattle, Washington, USA
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Mugerauer R. Professional judgement in clinical practice (part 1): Recovering original, moderate evidence-based health care. J Eval Clin Pract 2021; 27:592-602. [PMID: 33241623 DOI: 10.1111/jep.13513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022]
Abstract
Evidence-based medicine announced its entry as heralding a new paradigm in health care practices, but it has been widely criticized for lacking a coherent theoretical basis. This paper presents the first part of a three-article series examining the epistemological, practical, and ethical dimensions of strong EBM, as well as considering alternatives that promise potential solutions to chronic conceptual and practical problems. While the focus is on the details of the arguments and evidence in thoughtful debates over the last 30 years, it is worthwhile to keep in mind the overall trajectory of modern thought, because strong EBM continues discredited positivist positions, thus repeating its major assumptions and inadequacies, now transferred to the medical sphere and vocabulary. Part 1 of the series examines the development of strong EBM by clarifying and critiquing its somewhat discontinuous accounts of scientific knowledge and epistemology, evidence, the differences between statistical probability in regard to populations and understanding the health of individuals, and its claims for direct transfer of research findings to clinical settings-all of which raises more questions regarding its application to provider-patient decision making, pedagogy, and policy.
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Affiliation(s)
- Robert Mugerauer
- College of Built Environments, University of Washington, Seattle, Washington, USA
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Suriani RJ, Kassam HF, Passarelli NR, Esparza R, Kovacevic D. Validation of PROMIS Global-10 compared with legacy instruments in patients with shoulder instability. Shoulder Elbow 2020; 12:243-252. [PMID: 32788929 PMCID: PMC7400719 DOI: 10.1177/1758573219843617] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 03/14/2019] [Accepted: 03/19/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Outcomes instruments are used to measure patients' subjective assessment of health status. The Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 was developed to be a concise yet comprehensive instrument that provides physical and mental health scores and an estimated EuroQol-5 Dimension (EQ-5D) score. METHODS A total of 175 prospectively enrolled patients with shoulder instability completed the PROMIS Global-10, EQ-5D, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability Index. Spearman correlations between PROMIS scores and the legacy instruments were calculated. Bland-Altman analysis assessed agreement between estimated and actual EQ-5D scores. Floor and ceiling effects were recorded. RESULTS Correlation between actual and estimated EQ-5D was excellent-good (0.64/p < 0.0005), but Bland-Altman agreement revealed high variability for estimated EQ-5D scores (95% CI: -0.30 to +0.34). Correlation of PROMIS physical scores was excellent-good with ASES (0.69/p < 0.0005), good with SANE (0.43/p<0.0005), and poor with WOSI (0.17/p = 0.13). Correlation between PROMIS mental scores and all legacy instruments was poor. CONCLUSIONS PROMIS Global-10 physical function scores show high correlation with ASES but poor correlation with other legacy instruments, suggesting it is an unreliable outcomes instrument in populations with shoulder instability. The PROMIS Global-10 cannot replace actual EQ-5D scores for cost-effectiveness assessment in this population. LEVEL OF EVIDENCE Level II, study of diagnostic test.
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Affiliation(s)
| | | | | | | | - David Kovacevic
- David Kovacevic, Department of Orthopaedics and Rehabilitation, School of Medicine, Yale University, 47 College Street, Office 221D, New Haven, CT 06510, USA.
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Lentz T, Genty S, Gergereau A, Descatha A. Health Support for a Remote Industrial Site. Front Public Health 2019; 7:180. [PMID: 31380331 PMCID: PMC6652800 DOI: 10.3389/fpubh.2019.00180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 06/14/2019] [Indexed: 11/25/2022] Open
Abstract
This publication is derived from and rooted in the authors' experience in designing the Health Support of a remote industrial site. Summarizing the main steps of this design is the purpose of the approach. As a first step devoted to “Evaluation” (Chapters 1–5) are displayed the fundamentals for designing a Project Health Plan, such as a realistic and operative definition of “patient stabilization” and the principles of tactical reasoning for Medevacs, specifying how pathophysiology and logistic constraints should be correlated. A core element of the conceptual work consists in partnering these two domains, which usually each go their own way. Both should be considered in terms of delays: in life threatening situations, pathophysiology allows for a (maximum) delay before effective stabilization, while logistics dictates a (minimum) delay for reaching a stabilization facility. Ensuring that these two delays match is the desired result. Clearly, this conceptual work will unfold its full potential in low sanitary level countries, where most industrial commodities Projects take place, and where these delays are the longest. Next is detailed the audit/study preparation, i.e., the data gathering needed to get a clear picture of the Project conditions and concerns, workforce headcount and pattern, evacuation vectors and delays, and reference documents. Finally, risk assessment and a review of health facilities—in the vicinity and further away—complete the evaluation work. In a second phase devoted to “Implementation” (Chapters 6–9) is detailed how contracts with health providers, and health exhibits of industrial contracts should be conceived, and how on-site health support is designed, from the necessity of a pre-employment check to the design and organization of routine and emergency medicine facilities. Emergency preparedness and response plans, as well as medical coordination, should integrate with the HSE command chart. Overall, this document strongly advocates for joint engineering between HSE officers and medical specialists. An overview of key points for hygiene—often a separate topic covered in an offprint—is proposed. Finally, forward guidance for writing the audit/study report is proposed. This audit/study report must result in conclusive recommendations. Hence, a guide is proposed so that the report becomes a matrix of the Health Plan itself, and will be ended by a summary of findings and recommendations ready-to-use in Project management. In this way, the Health Plan will be launched, and gradually evolve and be amended as a “living document” throughout the lifetime of the Project.
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Affiliation(s)
- Thierry Lentz
- AP-HP, EMS (Samu92) University Hospital of Paris West Suburb, Garches, France
| | - Sabine Genty
- FRANCE MÉDIAS MONDE, Issy-les-Moulineaux, France
| | | | - Alexis Descatha
- AP-HP, EMS (Samu92) University Hospital of Paris West Suburb, Garches, France
- AP-HP UVSQ, Occupational Health Unit, University Hospital of Paris West Suburb, Garches, France
- Versailles St-Quentin University UVSQ, UMR-S 1168, Versailles, France
- Inserm, U1168, UMS 011, Villejuif, France
- Univ Angers, CHU Angers, Univ Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)—UMR_S1085, Angers, France
- *Correspondence: Alexis Descatha
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Nicholson AD, Kassam HF, Pan SD, Berman JE, Blaine TA, Kovacevic D. Performance of PROMIS Global-10 Compared With Legacy Instruments for Rotator Cuff Disease. Am J Sports Med 2019; 47:181-188. [PMID: 30481472 PMCID: PMC6635130 DOI: 10.1177/0363546518810508] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 was recently developed to assess physical and mental health and provide an estimated EuroQol-5 Dimension (EQ-5D) score. This instrument needs to be validated for specific patient cohorts such as those with rotator cuff pathology. HYPOTHESIS There is moderate to high correlation between the PROMIS Global-10 and legacy patient-reported outcome measures; PROMIS Global-10 will not show ceiling effects; and estimated EQ-5D scores will show good correlation and low variance with actual EQ-5D scores. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 2. METHODS A total of 323 patients with rotator cuff disease were prospectively enrolled before treatment. Each patient completed the PROMIS Global-10, EQ-5D, American Shoulder and Elbow Surgeons (ASES) shoulder assessment form, and Single Assessment Numeric Evaluation (SANE), and those with known rotator cuff tears completed the Western Ontario Rotator Cuff Index (WORC). Spearman correlations were calculated. Bland-Altman agreement tests were conducted between estimated EQ-5D scores from the PROMIS and actual EQ-5D scores. Ceiling and floor effects were assessed, defined as ≥15% respondents with highest or lowest possible score. RESULTS Correlation between the PROMIS Global-10 and EQ-5D was excellent (0.70, P < .0001). Correlation of the PROMIS physical scores was excellent-good with the ASES (0.62, P < .0001), good with the WORC (0.47, P < .0001), and good with the SANE (0.41, P < .0005). Correlation between the PROMIS mental scores was poor with the ASES (0.34, P < .0001), the WORC (0.32, P = .0016), and the SANE (0.24, P < .0001). No floor or ceiling effects were found. Agreement analysis showed substantial variance in individual scores, despite the overall similarity in mean scores between the estimated and actual EQ-5D scores, indicating poor agreement. Bland-Altman 95% limits of agreement for estimated EQ-5D scores ranged from 34% below to 31% above actual EQ-5D scores. CONCLUSION Physical function scores of the PROMIS Global-10 show high correlation with legacy patient-reported outcome instruments, suggesting that it is a reliable tool for outcome assessment in a population with rotator cuff pathology. The large variability in 95% limit of agreement suggested that the estimated EQ-5D scores from the PROMIS Global-10 cannot replace traditional EQ-5D scores.
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Affiliation(s)
- Allen D. Nicholson
- Department of Orthopaedics and Rehabilitation, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Hafiz F. Kassam
- Department of Orthopaedics and Rehabilitation, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Steven D. Pan
- Department of Orthopaedics and Rehabilitation, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Jacob E. Berman
- Department of Orthopaedics and Rehabilitation, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Theodore A. Blaine
- Department of Orthopaedics and Rehabilitation, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - David Kovacevic
- Department of Orthopaedics and Rehabilitation, School of Medicine, Yale University, New Haven, Connecticut, USA.,Address correspondence to David Kovacevic, MD, Department of Orthopaedics and Rehabilitation, School of Medicine, Yale University, 47 College Street, Office 221D, New Haven, CT 06510, USA ()
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Hancock KJ, Glass N, Anthony CA, Wolf BR, Hettrich CM, Albright J, Bollier M, Amendola A. PROMIS: a valid and efficient outcomes instrument for patients with ACL tears. Knee Surg Sports Traumatol Arthrosc 2019; 27:100-104. [PMID: 29974172 DOI: 10.1007/s00167-018-5034-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 06/25/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE The current study compares the Patient Reported Outcomes Information System Physical Function Computer Adaptive Test (PROMIS PF CAT) to traditional knee PRO instruments in a healthy population undergoing surgery for ACL injuries with the following objectives: (1) identify and determine the strength of any correlations between the scores of PROMIS PF CAT and current knee PROs or their subscales that measure physical function; (2) evaluate PROMIS PF CAT's test burden; and (3) determine if PROMIS PF CAT has any floor or ceiling effects in this population. METHODS Patients indicated for ACL surgery completed the Short Form-36 Physical Function (SF-36 PF), Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Knee Activity Rating Scale (Marx), the EuroQol 5-dimensions Questionnaire (EQ-5D), and PROMIS PF CAT. Correlations between PROs were defined as follows: High (≥ 0.7); high-moderate (0.61-0.69); moderate (0.4-0.6); moderate-weak (0.31-0.39); and weak (≤ 0.3). Floor or ceiling effects were considered significant if 15% or more patients reported the lowest or highest possible total score, respectively. RESULTS 100 patients participated with a mean age of 26 years (range 11-57). The PROMIS PF CAT demonstrated high correlations with SF-36 PF (r = 0.82, p < 0.01), EQ-5D (r = - 0.70, p < 0.01) KOOS ADL (r = 0.74, p < 0.01), and KOOS Sport (r = 0.70, p < 0.01). There were no ceiling or floor effects for PROMIS PF CAT (0%). The mean number of items completed for the PROMIS PF CAT was 4.2 (median 4; range 4-11). CONCLUSIONS The PROMIS PF CAT shows a high correlation with commonly employed PROs that also measure physical function with low test burden and without ceiling effects in this relatively young and healthy population.
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Affiliation(s)
- Kyle John Hancock
- The Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242, USA.
| | - Natalie Glass
- The Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242, USA
| | - Chris A Anthony
- The Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242, USA
| | - Brian R Wolf
- The Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242, USA
| | - Carolyn M Hettrich
- The Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242, USA
| | - John Albright
- The Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242, USA
| | - Matt Bollier
- The Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA 52242, USA
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Nieman GF, Andrews P, Satalin J, Wilcox K, Kollisch-Singule M, Madden M, Aiash H, Blair SJ, Gatto LA, Habashi NM. Acute lung injury: how to stabilize a broken lung. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:136. [PMID: 29793554 PMCID: PMC5968707 DOI: 10.1186/s13054-018-2051-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The pathophysiology of acute respiratory distress syndrome (ARDS) results in heterogeneous lung collapse, edema-flooded airways and unstable alveoli. These pathologic alterations in alveolar mechanics (i.e. dynamic change in alveolar size and shape with each breath) predispose the lung to secondary ventilator-induced lung injury (VILI). It is our viewpoint that the acutely injured lung can be recruited and stabilized with a mechanical breath until it heals, much like casting a broken bone until it mends. If the lung can be "casted" with a mechanical breath, VILI could be prevented and ARDS incidence significantly reduced.
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Affiliation(s)
- Gary F Nieman
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA
| | - Penny Andrews
- Department of Biological Sciences, SUNY Cortland, Cortland, NY, USA
| | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.
| | - Kailyn Wilcox
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA
| | - Michaela Kollisch-Singule
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA
| | - Maria Madden
- Department of Biological Sciences, SUNY Cortland, Cortland, NY, USA
| | - Hani Aiash
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA
| | - Sarah J Blair
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA
| | - Louis A Gatto
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.,Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nader M Habashi
- Department of Biological Sciences, SUNY Cortland, Cortland, NY, USA
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10
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Hancock KJ, Glass N, Anthony CA, Hettrich CM, Albright J, Amendola A, Wolf BR, Bollier M. Performance of PROMIS for Healthy Patients Undergoing Meniscal Surgery. J Bone Joint Surg Am 2017; 99:954-958. [PMID: 28590381 DOI: 10.2106/jbjs.16.00848] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed as an extensive question bank with multiple health domains that could be utilized for computerized adaptive testing (CAT). In the present study, we investigated the use of the PROMIS Physical Function CAT (PROMIS PF CAT) in an otherwise healthy population scheduled to undergo surgery for meniscal injury with the hypotheses that (1) the PROMIS PF CAT would correlate strongly with patient-reported outcome instruments that measure physical function and would not correlate strongly with those that measure other health domains, (2) there would be no ceiling effects, and (3) the test burden would be significantly less than that of the traditional measures. METHODS Patients scheduled to undergo meniscal surgery completed the PROMIS PF CAT, Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Knee Activity Rating Scale, Short Form-36 (SF-36), and EuroQol-5 Dimension (EQ-5D) questionnaires. Correlations were defined as high (≥0.7), high-moderate (0.61 to 0.69), moderate (0.4 to 0.6), moderate-weak (0.31 to 0.39), or weak (≤0.3). If ≥15% respondents to a patient-reported outcome measure obtained the highest or lowest possible score, the instrument was determined to have a significant ceiling or floor effect. RESULTS A total of 107 participants were analyzed. The PROMIS PF CAT had a high correlation with the SF-36 Physical Functioning (PF) (r = 0.82, p < 0.01) and KOOS Sport (r = 0.76, p < 0.01) scores; a high-moderate correlation with the KOOS Quality-of-Life (QOL) (r = 0.63, p < 0.01) and EQ-5D (r = 0.62, p < 0.01) instruments; and a moderate correlation with the SF-36 Pain (r = 0.60, p < 0.01), KOOS Symptoms (r = 0.57, p < 0.01), KOOS Activities of Daily Living (ADL) (r = 0.60, p < 0.01), and KOOS Pain (r = 0.60, p < 0.01) scores. The majority (89%) of the patients completed the PROMIS PF CAT after answering only 4 items. The PROMIS PF CAT had no floor or ceiling effects, with 0% of the participants achieving the lowest and highest score, respectively. CONCLUSIONS The PROMIS PF CAT correlates strongly with currently used patient-reported outcome measures of physical function and demonstrates no ceiling effects for patients with meniscal injury requiring surgery. It may be a reasonable alternative to more burdensome patient-reported outcome measures.
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Affiliation(s)
- Kyle J Hancock
- 1Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa 2Duke Sports Sciences Institute, Durham, North Carolina
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Loughlin M, Wyer P, Tanenbaum SJ. Teaching by (bad) example: what a confused attempt to "advance" EBM reveals about its underlying problems: commentary on Jenicek, M. (2015). Do we need another discipline in medicine? From epidemiology and evidence-based medicine to cognitive medicine and medical thinking. Journal of evaluation in clinical practice, 21:1028-1034. J Eval Clin Pract 2016; 22:628-33. [PMID: 27225855 DOI: 10.1111/jep.12552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 04/04/2016] [Indexed: 01/26/2023]
Abstract
Professor Jenicek's paper is confused in that his proposal to 'integrate' what he means by 'evidence-based scientific theory and cognitive approaches to medical thinking' actually embodies a contradiction. But, although confused, he succeeds in teaching us more about the EBM debate than those who seem keen to forge ahead without addressing the underlying epistemological problems that Jenicek brings to our attention. Fundamental questions about the relationship between evidence, knowledge and reason still require resolution if we are to see a genuine advance in this debate.
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Affiliation(s)
- Michael Loughlin
- Department of Interdisciplinary Studies, MMU Cheshire, Crewe, UK
| | - Peter Wyer
- Columbia University Medical Center, New York, NY, USA.
| | - Sandra J Tanenbaum
- Department of Health Services Management and Policy College of Public Health, The Ohio State University, Columbus Ohio, USA
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Wyer P, Alves da Silva S. 'All the King's horses . . .’: the problematical fate of born-again evidence-based medicine: commentary on Greenhalgh, T., Snow, R., Ryan, S., Rees, S., and Salisbury, H. (2015) six 'biases' against patients and carers in evidence-based medicine. BioMed Central Medicine, 13:200. J Eval Clin Pract 2015; 21:E1-10. [PMID: 26710931 DOI: 10.1111/jep.12492] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The phrase ‘evidence-based medicine (EBM)’ is being used by both EBM advocates and adversaries to broadly denote the production and use of clinical research throughout the healthcare system. Recently, this trend was joined by a call for a general expansion and rebirth of EBM to encompass a diverse range of healthcare activities otherwise corresponding to person-centred care. The call asserts that EBM is to blame for anti-patient biases within clinical practice and in policy and public health domains. Effective critique of either EBM or of the healthcare system requires that EBM itself be properly identified as a research literacy movement that grew out of clinical epidemiology of the 1970’s and 1980’s. We demonstrate the ineffectiveness of inappropriately targeted critiques of healthcare under the banner of born-again EBM.We identify the strengths and weaknesses of EBM as an educational movement drawing on the concept of literacy associated with the Brazilian educator Paolo Freire. We consider the relationship of EBM to clinical epidemiology and conclude that it cannot fruitfully divorce itself from the latter.We briefly consider existing precedents for philosophically sound conceptual platforms for advocacy of person-centred healthcare and broad based critique of the healthcare system including relationship-centred care. We conclude that traditional EBM, as a framework for research literacy training of both clinicians and policy makers, must continue to play a subsidiary role within an expanding patient-centred healthcare system and that advocacy efforts on behalf of patient voice and engagement are best pursued unencumbered by subsidiary agendas.
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Affiliation(s)
- Peter Wyer
- Columbia University Medical Center; NYC NY USA
| | - Suzana Alves da Silva
- HCOR; Sao Paulo Brazil
- Amil Assistencia Medica Internacional; Rio de Janeiro Brazil
- National Institute of Cardiology; Rio de Janeiro Brazil
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Weaver RR. Reconciling evidence-based medicine and patient-centred care: defining evidence-based inputs to patient-centred decisions. J Eval Clin Pract 2015; 21:1076-80. [PMID: 26456314 PMCID: PMC5057360 DOI: 10.1111/jep.12465] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 01/06/2023]
Abstract
Evidence-based and patient-centred health care movements have each enhanced the discussion of how health care might best be delivered, yet the two have evolved separately and, in some views, remain at odds with each other. No clear model has emerged to enable practitioners to capitalize on the advantages of each so actual practice often becomes, to varying degrees, an undefined mishmash of each. When faced with clinical uncertainty, it becomes easy for practitioners to rely on formulas for care developed explicitly by expert panels, or on the tacit ones developed from experience or habit. Either way, these tendencies towards 'cookbook' medicine undermine the view of patients as unique particulars, and diminish what might be considered patient-centred care. The sequence in which evidence is applied in the care process, however, is critical for developing a model of care that is both evidence based and patient centred. This notion derives from a paradigm for knowledge delivery and patient care developed over decades by Dr. Lawrence Weed. Weed's vision enables us to view evidence-based and person-centred medicine as wholly complementary, using computer tools to more fully and reliably exploit the vast body of collective knowledge available to define patients' uniqueness and identify the options to guide patients. The transparency of the approach to knowledge delivery facilitates meaningful practitioner-patient dialogue in determining the appropriate course of action. Such a model for knowledge delivery and care is essential for integrating evidence-based and patient-centred approaches.
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Affiliation(s)
- Robert R Weaver
- Health Sciences, University of Ontario, Institute of Technology, Oshawa, Ontario, Canada
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Fernandez A, Sturmberg J, Lukersmith S, Madden R, Torkfar G, Colagiuri R, Salvador-Carulla L. Evidence-based medicine: is it a bridge too far? Health Res Policy Syst 2015; 13:66. [PMID: 26546273 PMCID: PMC4636779 DOI: 10.1186/s12961-015-0057-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 10/29/2015] [Indexed: 01/28/2023] Open
Abstract
AIMS This paper aims to describe the contextual factors that gave rise to evidence-based medicine (EBM), as well as its controversies and limitations in the current health context. Our analysis utilizes two frameworks: (1) a complex adaptive view of health that sees both health and healthcare as non-linear phenomena emerging from their different components; and (2) the unified approach to the philosophy of science that provides a new background for understanding the differences between the phases of discovery, corroboration, and implementation in science. RESULTS The need for standardization, the development of clinical epidemiology, concerns about the economic sustainability of health systems and increasing numbers of clinical trials, together with the increase in the computer's ability to handle large amounts of data, have paved the way for the development of the EBM movement. It was quickly adopted on the basis of authoritative knowledge rather than evidence of its own capacity to improve the efficiency and equity of health systems. The main problem with the EBM approach is the restricted and simplistic approach to scientific knowledge, which prioritizes internal validity as the major quality of the studies to be included in clinical guidelines. As a corollary, the preferred method for generating evidence is the explanatory randomized controlled trial. This method can be useful in the phase of discovery but is inadequate in the field of implementation, which needs to incorporate additional information including expert knowledge, patients' values and the context. CONCLUSION EBM needs to move forward and perceive health and healthcare as a complex interaction, i.e. an interconnected, non-linear phenomenon that may be better analysed using a variety of complexity science techniques.
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Affiliation(s)
- Ana Fernandez
- Brain and Mind Centre, Faculty of Health Sciences, The University of Sydney, 94 Mallett Street, Camperdown, NSW, 2050, Australia.
| | - Joachim Sturmberg
- Discipline of General Practice, School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia.
| | - Sue Lukersmith
- Centre for Disability Research and Policy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.
| | - Rosamond Madden
- Centre for Disability Research and Policy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.
| | - Ghazal Torkfar
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia.
| | - Ruth Colagiuri
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, Australia.
| | - Luis Salvador-Carulla
- Centre for Disability Research and Policy-Brain and Mind Centre, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.
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van Baalen S, Boon M. An epistemological shift: from evidence-based medicine to epistemological responsibility. J Eval Clin Pract 2015; 21:433-9. [PMID: 25394168 DOI: 10.1111/jep.12282] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2014] [Indexed: 11/26/2022]
Abstract
In decision making concerning the diagnosis and treatment of patients, doctors have a responsibility to do this to the best of their abilities. Yet we argue that the current paradigm for best medical practice - evidence-based medicine (EBM) - does not always support this responsibility. EBM was developed to promote a more scientific approach to the practice of medicine. This includes the use of randomized controlled trials in the testing of new treatments and prophylactics and rule-based reasoning in clinical decision making. But critics of EBM claim that such a scientific approach does not always work in the clinic. In this article, we build on this critique and argue that rule-based reasoning and the use of general guidelines as promoted by EBM does not accommodate the complex reasoning of doctors in clinical decision making. Instead, we propose that a new medical epistemology is needed that accounts for complex reasoning styles in medical practice and at the same time maintains the quality usually associated with 'scientific'. The medical epistemology we propose conforms to the epistemological responsibility of doctors, which involves a specific professional attitude and epistemological skills. Instead of deferring part of the professional responsibility to strict clinical guidelines, as EBM allows for, our alternative epistemology holds doctors accountable for epistemic considerations in clinical decision making towards the diagnosis and treatment plan of individual patients. One of the key intellectual challenges of doctors is the ability to bring together heterogeneous pieces of information to construct a coherent 'picture' of a specific patient. In the proposed epistemology, we consider this 'picture' as an epistemological tool that may then be employed in the diagnosis and treatment of a specific patient.
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Affiliation(s)
- Sophie van Baalen
- Department of Philosophy, University of Twente, Enschede, The Netherlands
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Wyer P, da Silva SA. 'One mission accomplished, more important ones remain': commentary on Every-Palmer, S., Howick, J. (2014) How evidence-based medicine is failing due to biased trials and selective publication. Journal of Evaluation in Clinical Practice, 20 (6), 908-914. J Eval Clin Pract 2015; 21:518-28. [PMID: 25720797 DOI: 10.1111/jep.12330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2014] [Indexed: 11/29/2022]
Abstract
Every-Palmer and Howick suggest that evidence-based medicine (EBM) is failing in its mission because of contamination of research by manufacturer and researcher-motivated bias and self-interest. They fail to define that mission and to distinguish between the EBM movement and the research enterprise it was developed to critique. An educational movement, EBM accomplished its mission to simplify and package clinical epidemiological concepts in a form accessible to clinical learners. Its wide adoption within educational circles fostered critical literacy among several generations of practitioners. Illumination of bias, subterfuge and incomplete reporting of research has been a strength of EBM. Increased uptake and use of clinical research within the health care system properly defines the failing mission that eludes Every-Palmer and Howick. Responsibility for failure to make progress towards its achievement is shared by virtually all relevant streams within the system, including policy, clinical guideline development, educational movements and the development of approaches to evidence synthesis. Discordance between the epistemological premises pervading today's research and health care community and the complex social processes that ultimately determine research use constitutes an important factor that must be addressed as part of a remedy. Enhanced emphasis on and demonstration of alternative approaches to research such as realism and realist synthesis and the momentum towards development of a learning health care system hold promise as guideposts for the rapidly evolving health care environment.
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Affiliation(s)
- Peter Wyer
- Columbia University Medical Center, NYC, NY, USA
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Pinto M, Isabel Escalona M, Pulgarín A, Uribe-Tirado A. The scientific production of Ibero-American authors on information literacy (1985–2013). Scientometrics 2014. [DOI: 10.1007/s11192-014-1498-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Whitcomb DC. Framework for interpretation of genetic variations in pancreatitis patients. Front Physiol 2012; 3:440. [PMID: 23230421 PMCID: PMC3515781 DOI: 10.3389/fphys.2012.00440] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Accepted: 11/02/2012] [Indexed: 01/28/2023] Open
Abstract
Chronic pancreatitis (CP) is defined by irreversible damage to the pancreas as a result of inflammation-driven pancreatic tissue destruction and fibrosis occurring over many years. The disorder is complex, with multiple etiologies leading to the same tissue pathology, and unpredictable clinical courses with variable pain, exocrine and endocrine organ dysfunction, and cancer. Underlying genetic variants are central CP susceptibility and progression. Three genes, with Mendelian genetic biology (PRSS1, CFTR, and SPINK1) have been recognized for over a decade, and little progress has been made since then. Furthermore, application of high-throughput genetic techniques, including genome-wide association studies (GWAS) and next generation sequencing (NGS) will provide a large volume of new genetic variants that are associated with CP, but with small independent effect that are impossible to apply in the clinic. The problem of interpretation is using the old framework of the germ theory of disease to understand complex genetic disorders. To understand these variants and translate them into clinically useful information requires a new framework based on modeling and simulation of physiological processes with or without genetic, metabolic and environmental variables considered at the cellular and organ levels, with integration of the immune system, nervous system, tissue injury and repair system, and DNA repair system. The North American Pancreatitis Study 2 (NAPS2) study was designed to capture this type of date and construct a time line to understand and later predict rates of disease progression from the initial symptom to end-stage disease. This effort is needed to target the etiology of pancreatic dysfunction beginning at the first signs of disease and thereby prevent the development of irreversible damage and the complications of CP. The need for a new framework and the rational for implementing it into clinical practice are described.
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Affiliation(s)
- David C Whitcomb
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh and UPMC Pittsburgh, PA, USA ; Department of Human Genetics, University of Pittsburgh and UPMC Pittsburgh, PA, USA ; Department of Cell Biology and Molecular Physiology, University of Pittsburgh and UPMC Pittsburgh, PA, USA
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Dijkers MP, Murphy SL, Krellman J. Evidence-based practice for rehabilitation professionals: concepts and controversies. Arch Phys Med Rehabil 2012; 93:S164-76. [PMID: 22683207 DOI: 10.1016/j.apmr.2011.12.014] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 12/20/2011] [Accepted: 12/21/2011] [Indexed: 10/28/2022]
Abstract
This article describes evidence-based practice (EBP) in the health professions and sciences in general and in the rehabilitation disciplines specifically. It discusses the following: what counts as evidence and how that has changed over the last 4 decades, trends in the short history of evidence-based medicine and EBP, the fallacious nature of most criticisms of EBP, (perceived) shortcomings of clinical research and the resulting evidence in rehabilitation, resources available to clinicians who want their practice to be evidence-based, and the barriers these clinicians face in keeping up with the evidence and applying it in practice. Lastly, it describes how the development of a new art and science, knowledge translation, may play a role in truly making EBP feasible in rehabilitation services.
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Affiliation(s)
- Marcel P Dijkers
- Department of Rehabilitation Medicine, Mount Sinai School of Medicine, New York, NY 10029-6574, USA.
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Abstract
Personalized medicine is a new framework for medical care that involves modelling and simulation of a disease on the basis of its underlying mechanisms. This strategy must replace the 20(th) century paradigm of defining disease by pathology or associated signs and symptoms and conducting outcomes research that is based on the presence or absence of the disease syndrome. New technologies, including next-generation sequencing, the 'omics' and powerful computers provide massive amounts of accurate data. However, attempts to understand complex disorders by applying these new technologies within the 20(th) century framework have failed to produce the expected medical advances. To help physicians embrace a paradigm shift, the limitations of the old framework and major advantages of the new framework must be demonstrated. Chronic pancreatitis is an ideal complex disorder to study to consider the pros and cons of the two frameworks, because the pancreas is such a simple organ for disease modelling, and the advantages of personalized medicine are so profound.
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Affiliation(s)
- David C. Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Department of Cell Biology & Molecular Physiology, and Human Genetics, University of Pittsburgh, Medical Arts Building, 3708 Fifth Avenue, Suite 401.5, Pittsburgh, PA 15213, USA
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Sestini P. Epistemology and ethics of evidence-based medicine: a response to comments. J Eval Clin Pract 2011; 17:1002-3; discussion 1004-5. [PMID: 21951935 DOI: 10.1111/j.1365-2753.2011.01736.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Piersante Sestini
- Department of Clinical Medicine and Immunological Sciences, Section of Respiratory Diseases, University of Siena, Siena, Italy.
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Charles C, Gafni A, Freeman E. The evidence-based medicine model of clinical practice: scientific teaching or belief-based preaching? J Eval Clin Pract 2011; 17:597-605. [PMID: 21087367 DOI: 10.1111/j.1365-2753.2010.01562.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
RATIONALE Evidence-based medicine (EBM) is commonly advocated as a 'gold standard' of clinical practice. A prominent definition of EBM is: the integration of best research evidence with clinical expertise and patient values. Over time, various versions of a conceptual model or framework for implementing EBM (i.e. how to practice EBM) have been developed. AIMS AND OBJECTIVES This paper (i) traces the evolution of the different versions of the conceptual model; (ii) tries to make explicit the underlying goals, assumptions and logic of the various versions by exploring the definitions and meaning of the components identified in each model, and the methods suggested for integrating these into clinical practice; and (iii) offers an analytic critique of the various model iterations. METHODS A literature review was undertaken to identify, summarize, and compare the content of articles and books discussing EBM as a conceptual model to guide physicians in clinical practice. RESULTS Our findings suggest that the EBM model of clinical practice, as it has evolved over time, is largely belief-based, because it is lacking in empirical evidence and theoretical support. The model is not well developed and articulated in terms of defining model components, justifying their inclusion and suggesting ways to integrate these in clinical practice. CONCLUSION These findings are significant because without a model that clearly defines what constitutes an EBM approach to clinical practice we cannot (i) consistently teach clinicians how to do it and (ii) evaluate whether it is being done.
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Affiliation(s)
- Cathy Charles
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
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Silva SA, Charon R, Wyer PC. The marriage of evidence and narrative: scientific nurturance within clinical practice. J Eval Clin Pract 2011; 17:585-93. [PMID: 21062389 DOI: 10.1111/j.1365-2753.2010.01551.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Published elaborations of evidence-based medicine (EBM) have failed to materially integrate the domains of interpersonal sensibility and relationship with tools intended to facilitate attention to biomedical research and knowledge within clinical practice. Furthermore, the elaboration of EBM skills has been confined to a narrow range of clinical research. As a result, crucial tools required to connect much clinically relevant research and practice remain hidden, and explorations of the deeper challenges faced by practitioners in their struggle to integrate sound science and shared clinical action remain elusive. METHODS We developed a model for scientifically informed, individualized, medical practice and learning that embraces the goals, resources and skills of EBM within a larger framework of practice defined by narrative process: 'attention', 'representation' and 'affiliation'. We drew from published elaborations of EBM, narrative medicine (NM) and the results of a project to develop tools for assessment of the cognitive skills embedded within a practice based EBM domain. RESULTS Within the resulting model, a tool of representation, whose components are Problem delineation, Actions, Choices and Targets, enables the clinical problem to be delineated and the patient and practitioner perspectives to be concretely defined with reference to four classes of clinical interaction: 'therapy', 'diagnosis', 'prognosis' and 'harm'. As a result, the 'information literacy' skills required to access, evaluate and apply clinical research using electronic resources are well defined but subordinated to shared appreciation of patient need. The model acknowledges the relevance of the full range and scope of scientifically derived medical knowledge. CONCLUSION A model based on integration of NM and EBM can lead to instructional tools that integrate clinical epidemiological knowledge with enforced consideration of differing patient and practitioner perspectives. It also may inform avenues for qualitative research into the processes through which such differing perspectives can be productively identified and shared.
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Lim SM, Shin ES, Lee SH, Seo KH, Jung YM, Jang JE. Tools for assessing quality and risk of bias by levels of evidence. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2011. [DOI: 10.5124/jkma.2011.54.4.419] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Sun Mi Lim
- Research Institute for Healthcare Policy, Korean Medical Association, Korea
| | - Ein Soon Shin
- Department of Preventive Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Sun Hee Lee
- Department of Preventive Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyung Hwa Seo
- Research Institute for Healthcare Policy, Korean Medical Association, Korea
| | - Yu Min Jung
- Department of Preventive Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Ji Eun Jang
- Department of Preventive Medicine, Ewha Womans University School of Medicine, Seoul, Korea
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Chatterji M, Graham MJ, Wyer PC. Mapping cognitive overlaps between practice-based learning and improvement and evidence-based medicine: an operational definition for assessing resident physician competence. J Grad Med Educ 2009; 1:287-98. [PMID: 21975994 PMCID: PMC2931258 DOI: 10.4300/jgme-d-09-00029.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
PURPOSE The complex competency labeled practice-based learning and improvement (PBLI) by the Accreditation Council for Graduate Medical Education (ACGME) incorporates core knowledge in evidence-based medicine (EBM). The purpose of this study was to operationally define a "PBLI-EBM" domain for assessing resident physician competence. METHOD The authors used an iterative design process to first content analyze and map correspondences between ACGME and EBM literature sources. The project team, including content and measurement experts and residents/fellows, parsed, classified, and hierarchically organized embedded learning outcomes using a literature-supported cognitive taxonomy. A pool of 141 items was produced from the domain and assessment specifications. The PBLI-EBM domain and resulting items were content validated through formal reviews by a national panel of experts. RESULTS The final domain represents overlapping PBLI and EBM cognitive dimensions measurable through written, multiple-choice assessments. It is organized as 4 subdomains of clinical action: Therapy, Prognosis, Diagnosis, and Harm. Four broad cognitive skill branches (Ask, Acquire, Appraise, and Apply) are subsumed under each subdomain. Each skill branch is defined by enabling skills that specify the cognitive processes, content, and conditions pertinent to demonstrable competence. Most items passed content validity screening criteria and were prepared for test form assembly and administration. CONCLUSIONS The operational definition of PBLI-EBM competence is based on a rigorously developed and validated domain and item pool, and substantially expands conventional understandings of EBM. The domain, assessment specifications, and procedures outlined may be used to design written assessments to tap important cognitive dimensions of the overall PBLI competency, as given by ACGME. For more comprehensive coverage of the PBLI competency, such instruments need to be complemented with performance assessments.
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Affiliation(s)
- Madhabi Chatterji
- Corresponding author: Madhabi Chatterji, PhD, Teachers College, Columbia University, 525 W 120th Street, New York, NY 10027, 212.678.3357,
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Silva SA, Wyer PC. Where is the wisdom? II - Evidence-based medicine and the epistemological crisis in clinical medicine. Exposition and commentary on Djulbegovic, B., Guyatt, G. H. & Ashcroft, R. E. (2009) Cancer Control, 16, 158-168. J Eval Clin Pract 2009; 15:899-906. [PMID: 20367680 DOI: 10.1111/j.1365-2753.2009.01324.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Suzana A Silva
- Coordinator of Clinical Research, The Teaching and Research Center of Pró-Cardíaco/PROCEP, Rio de Janeiro, Brazil
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Miles A. Evidence-based medicine: requiescat in pace? A commentary on Djulbegovic, B., Guyatt, G. H. & Ashcroft, R. E. (2009) Cancer Control, 16, 158-168. J Eval Clin Pract 2009; 15:924-9. [PMID: 20367685 DOI: 10.1111/j.1365-2753.2009.01349.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Andrew Miles
- Professor of Public Health Education and Policy and Associate Dean of Medicine, Medical School, University of Buckingham (London Campus), London, UK
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