Future prospects for evidence-based child health

Evidence-Based Occupational Therapy

“Is evidence-based health care just a passing fad, promoted by managers and purchasers enjoying their influence over clinical practice, but doomed to fail as a far too cumbersome method for dealing with the complexity and imprecision of real-life clinical decisions? ”

The use of evidence-based medicine in the management of acutely ill children

OBJECTIVES

To determine the extent to which emergency medicine physicians are exposed to and implement evidence-based medicine (EBM).

METHODS

A 2-part, self-administered questionnaire was sent to 375 randomly selected emergency physicians (125 PEM Fellows, 125 AAP Section of Emergency Medicine, 125 American College of Emergency Physicians). The first part focused on the physician's experience with EBM and the second part included 2 clinical scenarios to determine their decision-making process. Respondents were considered either junior physicians (practicing <5 years since residency training) or senior physicians (practicing for > or =5 years).

RESULTS

Of the 375 questionnaires sent, 22 were not eligible for analysis. Two-hundred ten of the remaining 353 (59%) questionnaires were returned.Ninety-five percent of all respondents have been exposed to EBM. There was no significant difference between junior and senior physicians in their familiarity and application of secondary EBM summaries. Although more junior physicians believe that greater than half of their clinical practice is evidenced based compared with senior physicians [49% (95% CI 41-58%) vs. 27% (95% CI 19-38%)], in responding to the clinical scenarios, there was no difference in the use of an EBM resource between junior and senior physicians in the use of intravenous magnesium sulfate for status asthmaticus [50% (95% CI 41-59%) vs. 48% (95% CI 37-59%)] or in the workup of fever in a 10-month-old [62% (95% CI 53-70%) vs. 54% (95% CI 44-64%)]. Ninety-three percent of respondents felt "time constraints in a busy ED" was the most prominent obstacle to the use of EBM.

CONCLUSIONS

Although a majority of emergency medicine physicians report having been exposed to EBM, respondents tended not to use EBM in the management of acutely ill children, regardless of years of experience.

EBM in practice: paediatrics

There is a substantial gap between what we "need to know" and what we "actually know" to practise evidence-based paediatrics. Good evidence from primary research studies about effective child healthcare strategies (for individuals or populations) for a broad range of important issues is lacking. Systematic reviews of existing good-quality research evidence, or evidence-based clinical practice guidelines relevant to child health, are often not readily available or accessible to practising clinicians. Recent initiatives to supply the information needs of paediatricians should lead to improvements in the availability, accessibility and applicability of the "evidence-base". These efforts need wider commitment and further resources. The gap between what we already "know" and what we "actually do" in daily practice is even wider. We need to improve our efforts to implement existing research knowledge, using strategies with demonstrated effectiveness, to promote the timely transfer of research evidence into actual practice. The health outcomes of these efforts need to be systematically evaluated.

Evidence based primary care? A multi-tier, multiple stakeholder perspective from Chile

A new challenge in health policy is the implementation of evidence-based practice. It is useful to look at international experiences which go beyond the conventional USA and UK examples. Health sector restructuring in Chile has as its goals: using evidence-based decision-making to reduce variations of practice, contain costs and increase the effectiveness of clinical practice. A key area of change is within primary health care. But how does the implementation of evidence-based health care proceed in reality? In order to understand this, it was decided to assess the policy environment using stakeholder analysis.

METHODS

Fifteen stakeholders from the public health sector were interviewed in depth using a snowball strategy for sampling. Material relating to perceptions, thoughts and aspirations about evidence-based innovations in primary health care was collected. Content analysis of the material produced a matrix of criteria and indicators of operational power.

RESULTS

Concepts of evidence and effectiveness are different according to the role of each stakeholder in the health system. Most innovations proposed by government are related to management and stakeholders considered them as not being evidence-based. Informal mechanisms of decision-making predominated over the formal. Political issues are more important than formal evidence. All stakeholders felt they had power to define policy criteria but not to implement them. Implementation difficulties are related to how the system is organized and the culture within each organization. Most stakeholders indicated the need for human resources with appropriate knowledge and personal skills in order to implement these changes. These findings reveal again the importance of human factors within organizations. Policy-making should consider such processual aspects in order to implement changes in practices in Chilean health care system more effectively.

Evidence-based medicine as Bayesian decision-making

We review two recent trends: the emergence of evidence-based medicine and the growing use of Bayesian statistics in medical applications. Evidence-based medicine requires an integrated assessment of the available evidence, and associated uncertainty, but there is also an emphasis on decision-making, for individual patients, or at other points in the health-care system. This demands consideration of the values and costs associated with potential outcomes. We argue that the natural statistical framework for evidence-based medicine is a Bayesian approach to decision-making that incorporates an integrated summary of the available evidence and associated uncertainty with assessment of utilities. We outline a practical agenda for further development.

Evidence and outcomes: agendas, presuppositions and power

This paper explores philosophical and methodological issues involved in determining 'What counts as making a meaningful difference?'--the fundamental question in health outcomes research and evidence-based practice. Eight diverse stakeholders are identified along with the competing agendas they bring to the debate. The power to define what counts as meaningful change in health status is typically rooted in disciplinary socialization, linguistic traditions and an orthodox consensus that circumscribes acceptable research foci and methods. The various implicit assumptions and sites of definitional authority have consequences both for health researchers and for the public being served. For researchers, their designs may be driven by available instrumentation, short political time lines, and statistical rather than clinical significance. Because methods to capture salient health outcomes are still being developed, failure to capture significant outcomes may be methodological in origin. The public may experience the consequences of subsequent programmatic funding decisions and the exclusionary potential of different categorization schemes. Despite this, the public seldom has a voice in deciding what constitutes a meaningful health outcome. Researchers are urged to involve their target population in designing studies to help rebalance relative stakeholder power, and to consider the consequences of their methodological decisions.

Systematic review of the treatment of upper respiratory tract infection

OBJECTIVES

To assess the risks and benefits of antibiotic treatment in children with symptoms of upper respiratory tract infection (URTI).

DESIGN

Quantitative systematic review of randomised trials that compare antibiotic treatment with placebo.

DATA SOURCES

Twelve trials retrieved from a systematic search (electronic databases, contact with authors, contact with drug manufacturers, reference lists); no restriction on language.

MAIN OUTCOME MEASURES

The proportion of children in whom the clinical outcome was worse or unchanged; the proportion of children who suffered complications or progression of illness; the proportion of children who had side effects.

RESULTS

1699 children were randomised in six trials that contributed to the meta-analysis. Six trials were not used in the meta-analysis because of different outcomes or incomplete data. Clinical outcome was not improved by antibiotic treatment (relative risk 1.01, 95% confidence interval (CI) 0.90 to 1.13), neither was the proportion of children suffering from complications or progression of illness (relative risk 0.71, 95% CI 0.45 to 1.12). Complications from URTI in the five trials that reported this outcome was low (range 2-15%). Antibiotic treatment was not associated with an increase in side effects compared with placebo (relative risk 0.8, 95% CI 0.54 to 1.21).

CONCLUSIONS

In view of the lack of efficacy and low complication rates, antibiotic treatment of children with URTI is not supported by current evidence from randomised trials.

La pratique de l'ergothérapie fondée sur l'évidence scientifique

«Le concept d'un système de santé fondé sur l'évidence scientifique ne représente-t-il qu'une mode transitoire, défendue par des gestionnaires et des clients exer♣ant une influence sur la pratique clinique? Un concept voué à l'échec parce qu'il constitue une méthode par trop encombrante pour aborder la complexité et l'imprécision des décisions cliniques dans des situations réelles? »