Getting research findings into practice. When to act on the evidence

Patterns of Rectal Cancer Radiotherapy Adopting Evidence-Based Medicine: An Analysis of the National Database from 2005 to 2016

Purpose

Not many studies have evaluated the adoption and dissemination of evidence-based medicine in rectal cancer radiotherapy (RT). We aimed to analyze the differences by institutional characteristics and geography in adopting evidence-based care for rectal cancer RT and factors affecting the adoption in Korea.

Materials and Methods

Korean National Health Insurance Service claims database was used. All rectal cancer patients treated with radical surgery and adjuvant RT at the same institution in 2005-2016 were included in this study. RT within 3 months before and after surgery was regarded as preoperative and postoperative RT, respectively.

Results

A total of 16,827 patients treated in 83 institutions were included in the analysis. The use of preoperative RT has substantially increased over time, from 40.6% in 2005 to 84.2% in 2016 all over the nation. The proportion of preoperative RT (54.8%) exceeded that of postoperative RT (45.2%) in 2006. However, a wide range of institutional and regional variation was observed. Compared to high-volume institutions, low-volume institutions showed late adoption and variable dissemination patterns of preoperative RT. Busan–Ulsan–Gyeongsangnam-do and Gangwon-do showed slower adoption and less use of preoperative RT than other region.

Conclusion

We demonstrated gradual and steady increase in adoption of preoperative RT in rectal cancer treatment nationally from 2005 to 2016. Institutional variations between high- and low-volume institutions were observed.

Getting the Evidence into Practice: The Challenges and Successes of Action Research

In health and social care, occupational therapists are acknowledging the importance of being evidence-based practitioners. The challenge is not only how to find the evidence but also how to implement research findings or best evidence in clinical practice. Furthermore, the pressure for more effective implementation of research findings is likely to increase. This paper discusses the issues and challenges that occupational therapists may face and must overcome when doing action research from the inside. Action research can be used to improve clinical practice by identifying and solving practical problems.

The paper demonstrates the use of action research to change practice by implementing a new interprofessional discharge model with fractured neck of femur patients in an inner-London teaching hospital. The strategies used to help to overcome the challenges of action research are discussed. The main problems encountered were the difficulties in reaching amicable solutions and in empowering health care professionals who often had little or no influence on decision making. While the aims of the research project were not met, it did highlight further areas that needed to be resolved in order to enhance interprofessional working.

Mind the Gap? A Processual Reconsideration of Organizational Knowledge

On Henri Bergson's view, the flux of time is reality itself and the things we study are the things that flow. Unfortunately, popular literatures on organizational knowledge are accustomed to seeing the moving by means of the immobile. They perceive knowledge as an already organized state that can be transferred between spatially distinct points. Drawing on Bergson's theory of continual movement (Duration) and Deleuze's concept of transversal communication, I challenge the ontological concern for knowledge production and use between the discrete parts of an organized system. Instead of seeing knowledge as the integration of derived points or positions, I advocate a threefold method of creative involution in which production and use are considered as a living interpenetration of foldings and movements that connect all `things' at all places and times.

Journeying from Hippocrates with Bergson and Deleuze

The purpose of this paper is to situate the predominant medical model of Evidence Based Health Care (EBHC) in a processual framework by construing the organization of health care knowledge as non-linear, rhizomic communication. The paper is based on a theoretically driven, empirically based account of specific microprocesses of health care research and the particular settings in which those processes take place. We show how the production and appropriation of health care knowledge breaks out, cuts across and complicates simple lines of information transfer and dissemination. The boundary between research and practice is not seen simply as a frontier between two totally different realms, but rather as an interconnection between different patterns of relationality. It is this point that EBHC commentaries often miss. They typically see ‘research’ and ‘practice’ as pre-established forms, because both appear to enjoy what amounts to an independent existence, before any philosophical questions about their inherent relatedness have been asked.

An evidence-based exercise regimen for patients with mild to moderate Parkinson's disease

Parkinson’s disease (PD) is a neurological disorder that is manifested in the form of both motor and non-motor symptoms such as resting tremor, bradykinesia, muscular rigidity, depression, and cognitive impairment. PD is progressive in nature, ultimately leading to debilitating disruption of activities of daily living. Recently, a myriad of research has been focused on non-pharmacological interventions to alleviate the motor and non-motor symptoms of the disease. However, while there is a growing body of evidence supporting exercise as a viable therapy option for the treatment of Parkinson’s disease, there is a lack of literature enumerating a specific exercise sequence for patients with PD. In this literature review, we analyze the success of specific modalities of exercise in order to suggest an optimal exercise regimen for Parkinson’s disease patients.

Practice patterns for arthroscopy of osteoarthritis of the knee in the United States

BACKGROUND

Knee arthroscopy is one of the most common orthopaedic procedures performed in the United States. The publication of a randomized controlled trial of arthroscopy versus sham surgery by Moseley et al in 2002 showed no efficacy and challenged the role of arthroscopy for the treatment of osteoarthritis.

HYPOTHESIS

(1) Knee arthroscopy for osteoarthritis has decreased after the publication of the study by Moseley et al, (2) arthroscopy as a percentage of orthopaedic cases has decreased, and (3) the average age of patients undergoing arthroscopy has decreased.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

The authors examined the American Board of Orthopaedic Surgery (ABOS) database that includes 6-month case logs for each examinee sitting for the Part II board examination for 1999 to 2009. Knee arthroscopy cases were identified by CPT (Current Procedural Terminology) code and knee osteoarthritis diagnosis was defined by ICD-9 (International Classification of Diseases, 9th Revision) code. Piecewise linear regression was used to evaluate knee arthroscopy before and after the publication of the Moseley et al article in 2002.

RESULTS

The number of knee arthroscopy cases for patients with osteoarthritis had greatly decreased by 2009 after peaking in 2001 (1621 vs 966 total cases, 2.36 vs 1.40 cases per surgeon). Cases classified as chondroplasty also decreased from 10.0% to 5.8% of knee arthroscopies (P < .0001). In addition, the total number of knee arthroscopy cases per surgeon decreased from a high of 11.9 in 2003 to a low of 8.6 in 2009. As expected, knee arthroscopy as a percentage of total orthopaedic cases decreased from a high of 9.9% in 2003 to 6.6% in 2009 (P < .0001).

CONCLUSION

Knee arthroscopy for patients with osteoarthritis among orthopaedic surgeons during their ABOS examination case collection period has decreased after the publication of a highly publicized article demonstrating a lack of efficacy of this procedure. Further study is needed to determine if this change occurred in the orthopaedic community at large or if practice patterns only changed for surgeons during their board collection periods.

CLINICAL RELEVANCE

Randomized controlled trials can be effective in changing orthopaedic surgeon practice.

Exercise and motor training in people with Parkinson's disease: a systematic review of participant characteristics, intervention delivery, retention rates, adherence, and adverse events in clinical trials

There is research evidence that exercise and motor training are beneficial for people with Parkinson's disease (PD), and clinicians seek to implement optimal programs. This paper summarizes important factors about the nature and reporting of randomized controlled trials of exercise and/or motor training for people with PD which are likely to influence the translation of research into clinical practice. Searches identified 53 relevant trials with 90 interventions conducted for an average duration of 8.3 (SD 4.2) weeks. Most interventions were fully supervised (74%) and conducted at a facility (79%). Retention rates were high with 69% of interventions retaining ≥85% of their participants; however adherence was infrequently reported, and 72% of trials did not report adverse events. Overall, the labor-intensive nature of most interventions tested in these trials and the sparse reporting of adherence and adverse events are likely to pose difficulties for therapists attempting to balance benefits and costs when selecting protocols that translate to sustainable clinical practice for people with PD.

Development of pediatric wait time access targets

BACKGROUND

The effective management of wait times is a top priority for Canadians. Attention to date has largely focused on wait times for adult surgery. The purpose of this study was to develop surgical wait time access targets for children.

METHODS

Using nominal group techniques, expert panels reached consensus on prioritization levels for 574 diagnoses in 10 surgical disciplines for wait 1 (W1; time from primary care visit to surgical consultation) and wait 2 (W2; time from decision to operate to receipt of surgery).

RESULTS

A 7-stage priority classification reflects the permissible timeframe for children to receive consultation (W1) or surgery (W2). Access targets by priority were linked to 574 diagnoses in 10 pediatric surgical subspecialties.

CONCLUSION

The pediatric surgical wait time access targets are a standardized, comprehensive and consensus-based model that can be systematically applied to children's hospitals across Canada. Future research and evaluation on outcomes from this model will evaluate improved access to pediatric surgical care.

The effectiveness of cultural-competence training for health professionals in community-based rehabilitation: a systematic review of literature

AIMS

To find and review studies in which investigators evaluated cultural-competence training in community-based rehabilitation settings; critique study methods, describe clinical outcomes, and make recommendations for future research.

BACKGROUND

A review of the effectiveness of cultural-competence training for health professionals in community-based rehabilitation settings was conducted.

DATA SOURCES

Research citations from 1991-2006 in CINAHL, Medline, Pubmed, PsycInfo, SABINET, Cochrane, Google, NEXUS, and unpublished abstracts were searched.

METHODS

Searching, sifting, abstracting, and assessing quality of relevant studies by three reviewers. Studies were evaluated for sample, design, intervention, threats to validity, and outcomes. A meta-analysis was not conducted because the studies did not address the same research question.

RESULTS

Five studies and one systematic review were evaluated. Positive outcomes were reported for most training programs. Reviewed studies generally had small samples and poor design.

CONCLUSIONS/IMPLICATIONS

The paucity of studies and lack of empirical precision in evaluating effectiveness necessitate future studies that are methodologically rigorous to allow confident recommendations for practice.

Evidence-based (informed) macro practice: process and philosophy

Evidence-informed practice and policy at the macro level offers great potential for honoring ethical guidelines to integrate practice and research, to involve clients as informed participants, to respond ethically to problems of scarce resources, to enhance social and economic justice, and to empower clients. The process and philosophy of evidence-informed practice and care as described in original sources suggest a decision-making process designed to help social workers to integrate ethical, evidentiary, and application concerns. As with all innovations, objections will and should be raised. There are many challenges and obstacles to integrating evidentiary, ethical, and application concerns in practice.

Health technology assessment agencies: An international overview of organizational aspects

Objectives:The aim of the study is to make an international comparison of Health Technology Assessment (HTA) Agencies, to show their similarities and differences.

Methods:An e-mail questionnaire was sent to thirty HTA agencies internationally. Questions related to the structure of the agency, the relationship with health-related institutions, the prescriptiveness of the decisions taken, the main core and the modalities to spread the assessment, and the type of funding.

Results:Twenty-four HTA Agencies answered the questionnaire: 25 percent in America, 4.2 percent in Australia, and 70.8 percent in Europe. Fifty-four percent of HTA Agencies are governmental institutions (83.3 percent have central government funding), while 62.5 percent have relationships with health-related governmental institutions. Of the agencies, 87 percent reported that their decisions are not prescriptive, while for 20.8 percent and 8.3 percent of them stated that this was the case totally or partially, respectively, especially for the governmental and American Agencies. Seventeen agencies (70.8 percent) declared their work on multiannual programs (77 percent of the governmental HTA Agencies and 100 percent of the American ones). The assessments mainly addressed diagnostic procedures (85.7 percent) and pharmaceuticals (25 percent). The most common way to disseminate results is by means of paper report (91.7 percent), followed by the Internet (16.7 percent), and seminars to expert audiences (12.5 percent).

Conclusions:The comparative analysis of HTA Agencies showed that governmental and American Agencies have a profound impact on the prescriptiveness of their assessment, and this could be linked to the fact that these types of Agencies work on multiannual programs. European and American HTA Agencies have many similarities in terms of type of assessment, funding, and dissemination of results.

The problem of evidence-based medicine: directions for social science

Evidence-based medicine (EBM) is arguably the most important contemporary initiative committed to reshaping biomedical reason and practice. The move to establish scientific research as a fundamental ground of medical decision making has met with an enthusiastic reception within academic medicine, but has also generated considerable controversy. EBM and the broader forms of evidence-based decision making it has occasioned raise provocative questions about the relation of scientific knowledge to social action across a variety of domains. Social science inquiry about EBM has not yet reached the scale one might expect, given the breadth and significance of the phenomenon. This paper contributes reflections, critique and analysis aimed at helping to build a more robust social science investigation of EBM. The paper begins with a "diagnostics" of the existing social science literature on EBM, emphasizing the possibilities and limitations of its two central organizing analytic perspectives: political economy and humanism. We further explore emerging trends in the literature including a turn to original empirical investigation and the embrace of "newer" theoretical resources such as postmodern critique. We argue for the need to move the social inquiry of EBM beyond concerns about rationalization and the potential erasure of the patient and, to this end, suggest new avenues of exploration. The latter include analysis of clinical epidemiology and clinical reason as the discursive preconditions of EBM, the role of the patient as a site for the production of evidence, and the textually mediated character of EBM.

Traditional healing systems and the ethos of science

This paper addresses the challenge posed to traditional Chinese medicine by the ethos of science and explores three related assumptions. First, the ethos of traditional Chinese medicine is incompatible with the ethos of science. Second, the challenge of science to traditional Chinese medicine is represented by the requirement to comply with internationally recognized standards of medical research and practice applied to biomedicine, adopted and implemented by the State. The State requires that the safety and effectiveness of traditional Chinese medicine procedures and medications be ascertained following the methodology chartered by the ethos of science. Third, traditional Chinese medicine practitioners present a third ethos, the "ethos of pragmatic healing" based on the pragmatic acculturation of clinical practice, as an alternative to the ethos of science. This third ethos is an inadequate response to the challenge because it increases the divergence between health care policy requirements of scientific scrutiny and the fostering of traditional Chinese medicine as an icon of Chinese culture. The study is based on data from personal interviews with representative samples of three ethnic populations in Singapore; secondary data from other studies; relevant official data; and documents from biomedical and traditional Chinese medicine organizations. The methods include inductive analysis, multiple correlation and regression, and factor analysis among others. The analysis indicates that the pressure to comply with official health regulations and the inability to succeed under the ethos of science lead traditional Chinese medicine practitioners to respond with an ethos of pragmatic healing that eschews conceptual analysis, ignores the paradigmatic divide with biomedicine, and focuses on "using what works". This third ethos can only be a temporary response to the pressure to upgrade the practice of traditional Chinese medicine and it does not correspond to pragmatic acculturation commonly found in the population. The ethos of pragmatic healing leaves the challenge of science unresolved and it is likely to increase the level of conflict between the realm of biomedicine (including health care policy requirements of scientific scrutiny) and the ethos of traditional Chinese medicine.

Evidence, hierarchies, and typologies: horses for courses

Debate is ongoing about the nature and use of evidence in public health decision making, and there seems to be an emerging consensus that the "hierarchy of evidence" may be difficult to apply in other settings. It may be unhelpful however to simply abandon the hierarchy without having a framework or guide to replace it. One such framework is discussed. This is based around a matrix, and emphasises the need to match research questions to specific types of research. This emphasis on methodological appropriateness, and on typologies rather than hierarchies of evidence may be helpful in organising and appraising public health evidence.

Profiting from Consensus Methods in Occupational Therapy: Using a Delphi Study to Achieve Consensus on Multiprofessional Discharge Planning

In occupational therapy, there is much debate regarding many aspects of practice. In order to make effective decisions in situations where there is contradictory or insufficient information, it is important to reach a consensus decision. The Delphi technique is a survey method of research, which aims to gain consensus among a panel of experts using repeated rounds of a questionnaire.

This article is based on the first author's experience of using a Delphi survey as part of an action research project, located in a large acute National Health Service trust. This project aimed to analyse and improve multidisciplinary teamwork in discharge planning. The aim of the article is to focus on the Delphi technique as a methodological approach and, to illustrate this, examples are used from the research study. However, before using the Delphi technique, occupational therapists must understand the strengths and weaknesses of this approach.

A combination of systematic review and clinicians' beliefs in interventions for subacromial pain

The aim of the study is to determine which treatments for patients with subacromial pain are trusted by general practitioners (GPs) and physiotherapists, and to compare trusted treatments with evidence from a systematic critical review of the scientific literature. A two-step process was used: a questionnaire (written case simulation) and a systematic critical review. The questionnaire was mailed to 188 GPs and 71 physiotherapists in Sweden. The total response rate was 72% (186/259). The following treatments were trusted, ergonomics/adjustments at work, corticosteroids, non-steroidal anti-inflammatory drugs, movement exercises, acupuncture, ultrasound therapy, strengthening exercises, stretching, transcutaneous electric nerve stimulation, and superficial heat or ice therapy. The review, including efficacy studies for the treatments found to be trusted, was conducted using the CINAHL, EMBASE and MEDLINE databases. Evidence for efficacy was recorded in relation to methodological quality and to diagnostic criteria that labelled participants as having subacromial pain or a non-specific shoulder disorder. Forty studies were included. The methodological quality varied and only one treatment had definitive evidence for efficacy for non-specific patients, namely injection of corticosteroids. The trust in corticosteroids, injected in the subacromial bursa, was supported by definitive evidence for short-term efficacy. Acupuncture had tentative evidence for short-term efficacy in patients with subacromial pain. Ultrasound therapy was ineffective for subacromial pain. This is supported by tentative evidence and, together with earlier reviews, this questions both the trust in the treatment and its use. The clinicians' trust in treatments had a weak association with available scientific evidence.

Postpartum positioning and attachment education for increasing breastfeeding: a randomized trial

BACKGROUND

Although lactation experts suggest that a correct positioning and attachment technique reduces breastfeeding problems and enhances long-term breastfeeding, evidence from randomized trials is lacking. The objective of this study was to evaluate the effect of postpartum positioning and attachment education on breastfeeding outcomes in first-time mothers.

METHOD

A randomized trial was performed in a public hospital in Adelaide, South Australia, where 160 first-time mothers were randomly allocated to receive either structured one-to-one education (experimental group) or usual postpartum care (control group) within 24 hours of birth. The primary outcome was breastfeeding at 6 weeks and 3 and 6 months postpartum; other outcomes were nipple pain and trauma in hospital and at 6 weeks and 3 and 6 months, and satisfaction with breastfeeding.

RESULTS

No significant differences occurred in breastfeeding rates between the groups at each endpoint, although a trend in the direction of lower rates was seen at each endpoint in the experimental group. This group reported less nipple pain on days 2 (p = 0.004) and 3 (p = 0.04), but this was not sustained on follow-up. No differences were observed in nipple trauma in hospital or in self-reported nipple pain and/or trauma at the three endpoints. Experimental group women were less satisfied with breastfeeding at 3 and 6 months postpartum when using a one-item measure; however, a multiple-item measure showed no significant differences at the three endpoints.

CONCLUSIONS

The intervention did not increase breastfeeding duration at any assessment time or demonstrate any differences between the groups on secondary outcomes. The trend toward lower breastfeeding rates in the experimental group suggests a need for a larger trial to evaluate whether or nor postpartum positioning and attachment education may negatively affect breastfeeding.

Critique of a protocol for annual review of older people with diabetes

In this article we present a critical evaluation of the development of a protocol to support district nurses in the domiciliary annual review of older people with diabetes. We discuss the protocol's development, identifying its limitations and making recommendations for its use. We conclude that although the protocol is a useful starting point its validity is challenged by a lack of primary research regarding the care of older people with diabetes. More work is needed to identify appropriate remedial therapy following the annual review. The health education component also requires development to better reflect the different needs of older people.

What is 'best practice' in health care? State of the art and perspectives in improving the effectiveness and efficiency of the European health care systems

A framework for the classification of information on maintaining or improving effectiveness and efficiency in health care systems is proposed. Activities, disciplines and methods that are available to identify, implement and monitor the available evidence in health care are called 'best practice'. We reviewed the literature in order to (1) establish a definition for 'best practice' in the health sector, (2) develop a framework to classify relevant information, and (3) synthesise the literature on activities, disciplines and methods pertinent to the concept. Health care, public health activities and health policy should be advised by the best available evidence. Currently, the concept can be broken down into three activities (Health Technology Assessment (HTA), Evidence-Based Medicine (EBM), Clinical Practice Guidelines (CPGs)) by which evidence is synthesised either as an evidence base (EBM and most HTA) or in the form of recommendations (CPGs and some HTA) for different decision purposes in health care. These activities gain input mainly through four disciplines: clinical research, clinical epidemiology, health economics and health services research. The different disciplines are related to each other in three 'domains': (a) input, (b) dissemination/implementation and (c) monitoring/outcome. These provide evidence on (a) the (potential) effects of health care interventions and policies; (b) on ways to implement them; and (c) on ways to monitor their actual outcome. None of these separate approaches and activities exclusively forms a successful and all-embracing strategy to ascertain 'best practice'. A collective approach in the management of information is expected to add value to individual efforts. Resources should be devoted to increase quality and quantity of both primary and secondary research as well as the establishment of networks to synthesise, disseminate, implement and monitor 'best practice'.

Searching for evidence about health education and health behavior interventions

Evidence is fundamental to science, but finding the right evidence in health education and health behavior (HEHB) is often a challenge. The authors discuss some of the controversies about the types of evidence that should be considered acceptable in HEHB, the tension between the use of qualitative versus quantitative data, the need for measures of important but neglected constructs, and interpretation of data from experimental and nonexperimental research. This article discusses some of the challenges to the use of evidence and describes a number of strategies and some forces encouraging the use of evidence-based interventions. Finally, the authors suggest ways to improve the practice and dissemination of evidence-based HEHB. Ultimately, if evidence-based interventions are not disseminated, the interventions will not achieve their potential. The goal should be to develop more effective interventions and disseminate them to improve the public's health.

Common sense and figures: the rhetoric of validity in medicine (Bradford Hill Memorial Lecture 1999)

Austin Bradford Hill was once a friend to The Lancet, but, as occasionally happens, friends fall out. The great legacy of his association with the journal, however, was Principles of Medical Statistics. As each edition was succeeded by another--the first in 1937, the last in 1991--he seemed to shift his view about the influence of statistical method on clinical practice from one of assured certainty to one of modest advantage. That change paralleled a move away from an emphasis on the importance of internal validity in the randomized trial to one of understanding the inescapably practical significance of generalizability. Writers on medical research have explored notions of external validity in various ways. One view, for example, is to seek a close correlation between the participants in a clinical trial and patients seen in practice. The argument goes that such a correspondence has to be made before any decision can be taken about whether to apply the result of that trial to the clinical setting. Another view, first worked out by the American logician Charles Sanders Peirce, is that one must simply rely on the informed guess, based on a reasonable estimate of the limits of extrapolation. The tensions between and implications of these two different approaches are worked through using the example of coronary stents. A solution is, perhaps, to write explicit rules of interpretation that provide a framework for judging the strength of a claim to applicability. Five questions are posed, which try to lay a foundation for such a framework.

Diagnosis and nonoperative management of cervical radiculopathy

STUDY DESIGN

Qualitative, comprehensive literature review.

OBJECTIVE

To discuss and summarize the current peer-reviewed literature related to the management of patients with cervical radiculopathy.

BACKGROUND

Cervical radiculopathy is a lesion of the cervical spinal nerve root with a reported prevalence of 3.3 cases per 1000 people; peak annual incidence is 2.1 cases per 1000 and occurs in the fourth and fifth decades of life. Nerve root injury has the potential to produce significant functional limitations and disability.

METHODS AND MEASURES

A search of the MEDLINE, CINAHL, and Web of Science databases for the periods 1966, 1982, and 1996, respectively, to December 1999 was conducted using selected keywords and MeSH headings. The bibliography of all retrieved articles were searched and pertinent articles were obtained. The Cochrane Database of Systematic Reviews was also searched. Literature related to the diagnosis, prognosis, and treatment of cervical radiculopathy were thoroughly reviewed and summarized using a critical appraisal approach.

RESULTS

Although cervical radiculopathy remains largely a clinical diagnosis, the true diagnostic accuracy of the clinical examination for cervical radiculopathy is unknown. Imaging and electrophysiologic tests are capable of detecting clinically significant problems in many patients and each modality has inherent strengths and weaknesses; technical as well as practical factors affect the choice of procedure. The natural course of cervical radiculopathy appears to be generally favorable but no prognostic or risk factors have been firmly established and the efficacy of various nonoperative treatments for the condition is unknown.

CONCLUSION

A clear definition of terms and further research are required to establish definitive diagnostic criteria and effective treatment for the management of patients with cervical radiculopathy.

Treating individuals according to evidence: why do primary care practitioners do what they do?

Research evidence does not necessarily translate into changed management for individual patients, but that may not mean that the evidence has been ignored. Drawing on accounts from general practitioners, we use a study of non-rheumatic atrial fibrillation (NRAF) to illuminate the processes by which practitioners became aware of and assimilated research evidence. We follow that with an account of how the evidence was incorporated into practice protocols for anticoagulation and then applied to a review of individual patients' records. Practitioners used a range of sources of evidence. They reported difficulties arising from their own skills and circumstances and from the perceived quality of the evidence. Creating a protocol involved overcoming problems of scheduling, resources and managing judgements about the value of the review process. In applying the protocol practitioners drew on their knowledge of the patients' preferences, circumstances and previous specialist consultations. As a result, practitioners made judgements that evidence, combined with prior experience, did not support the initiation of anticoagulation in 52% of an unselected primary care population with NRAF. Our findings have implications for evidence-based practice and for practitioner education.

Getting evidence into clinical practice: an organisational behaviour perspective

OBJECTIVES

To study the relationship between research evidence and clinical behaviour change in the UK National Health Service (NHS) in the period 1995-1997 by examining the 'careers' of change issues designed to reshape clinical practice, the impact of such change efforts, and the factors shaping change outcomes.

METHODS

Comparative case study methods were used. Four clinical change issues were studied using semi-structured interviews (n = 119) and documentary analysis in one English NHS region. For each issue, there was an overview semi-structured interview survey of the issue at regional level, followed by an intensive analysis of its impact at local level on the practice of specific clinical groups.

RESULTS

There was a weak relationship between the evidence base and its diffusion. The diffusion and take-up of scientific evidence were shown to be socially constructed. Different forms of evidence were differentially accepted by individuals and groups. Specific organisational and social factors affected this pattern of impact. The general management hierarchy of the NHS played a very limited role in enabling evidence-based clinical change.

CONCLUSIONS

The implementation of evidence-based medicine is a complex and contested process. The results of this study confirm a professional dominance model of clinical behaviour change and identify tacit expert knowledge as a key power resource in shaping the way research evidence influences clinical practice.

Review of quality-of-life evaluations in patients with angina pectoris

Patients with angina pectoris have a reduced quality of life because of their symptoms, impaired activity and anxiety. However, there is no consensus on the best method of measuring quality of life. A systematic literature search of randomised controlled trials (RCTs) in angina showed that the most common generic questionnaire was the Nottingham Health Profile (NHP) Part 1, and the most common angina-specific measure was the Quality-of-Life after Acute Myocardial Infarction Questionnaire. A comparison of NHP scores with those of the healthy population revealed that patients with angina particularly seem to experience a lack of energy, poor sleep and decreased physical mobility. In the RCTs evaluated, antianginal drugs did not show a significant benefit over placebo in terms of quality of life. As a result of a lack of valid data from RCTs, a strong conclusion regarding the impact of revascularisation procedures on quality of life could not be derived.

Obtaining the evidence for clinically effective wound care

In tissue viability, as in other aspects of health care, there is increasing recognition of the need for healthcare interventions to be supported by good research evidence. The randomized controlled trial (RCT) is considered to provide the most accurate evidence of effectiveness. This article discusses some of the problems that arise when researchers attempt to obtain the relevant evidence. They include funding, sample selection, sample size, recruitment of patients, and mortality and attrition rates. These points are illustrated by means of a case study. In this study an RCT was undertaken to compare two dressings for the management of pressure sores. Problems arose with recruitment of patients to the study. Relevant issues associated with this are discussed and recommendations for future recruitment are presented.