Evidence-based Practice in Radiology: Steps 3 and 4—Appraise and Apply Interventional Radiology Literature

How to apply evidence-based principles in clinical dentistry

The primary objective of evidence-based practice is to improve the quality of health care. It helps in making a clinical decision based on recent and advanced research and the best available evidence. Evidence-based dentistry is an integration of best available evidence with clinical expertise and patient’s needs and preferences. However, there are many barriers to apply evidence-based knowledge into practice. Information overflow, inability to select appropriate evidence, and critically appraising the evidence are the main challenges a practitioner may face. The focus of this review is defining a well-structured clinical question, key principles of literature search, type of search studies, and how to appraise an evidence. Furthermore, despite the availability of good evidence, patient’s needs and preferences are crucial factors in making clinical decision. Finally, the clinician’s experience and lack of motivation to change practice is another big challenge to evidence-based practice. This article discusses the six structured steps to apply evidence-based practice in dentistry with examples. Finally, this article will help practitioners to integrate their experience and skill with modern research evidence as well as to educate their patients to reach a final clinical decision.

Evidence-based Practice of Radiology

Current health care reform in the United States is producing a shift in radiology practice from the traditional volume-based role of performing and interpreting a large number of examinations to providing a more affordable and higher-quality service centered on patient outcomes, which is described as a value-based approach to the provision of health care services. In the 1990 s, evidence-based medicine was defined as the integration of current best evidence with clinical expertise and patient values. When these methods are applied outside internal medicine, the process is called evidence-based practice (EBP). EBP facilitates understanding, interpretation, and application of the best current evidence into radiology practice, which optimizes patient care. It has been incorporated into "Practice-based Learning and Improvement" and "Systems-based Practice," which are two of the six core resident competencies of the Accreditation Council for Graduate Medical Education and two of the 12 American Board of Radiology milestones for diagnostic radiology. Noninterpretive skills, such as systems-based practice, are also formally assessed in the "Quality and Safety" section of the American Board of Radiology Core and Certifying examinations. This article describes (a) the EBP framework, with particular focus on its relevance to the American Board of Radiology certification and maintenance of certification curricula; (b) how EBP can be integrated into a residency program; and (c) the current value and likely place of EBP in the radiology information technology infrastructure. Online supplemental material is available for this article.

Loss expression of micro ribonucleic acid (miRNA)-200c induces adverse post-surgical prognosis of advanced stage non-small cell lung carcinoma and its potential relationship with ETAR messenger RNA

BACKGROUND

Non-small cell lung cancer (NSCLC) is the leading cause of cancer mortality worldwide. As micro ribonucleic acid (miRNA)-200 and ETAR may play an essential role in the process of epithelial to mesenchymal transition (EMT) simultaneously, the purpose of this study was to detect the expression of miRNA-200c and ETAR messenger (m)RNA and assess their prognostic significance in early stage NSCLC.

METHODS

Our study included 78 advanced stage (IIB, IIIA, IIIB) NSCLC patients. All patients were smokers. Using quantitative reverse transcriptase polymerase chain reaction analysis, we detected the expression of miRNA-200c and ETAR mRNA and assessed their correlation by χ(2) test. Time to progression was used as the recurrent index and was assessed by univariate and multivariate analysis in the Cox hazard model.

RESULTS

Both miRNA-200c and ETAR mRNA expression are associated with N stage and tumor node metastasis (TNM) stage in a series of advanced NSCLC patients. Among N stage and TNM stage patients, significant differences were found in IIB (P = 0.0126), IIIB (P = 0.0107) and N0 (P = 0.0023) and in N1 + N2 groups (P = 0.0133). Using both univariate and multivariate survival analyses, we found that miRNA-200c (hazard ratio [HR] = 0.352, 95% confidence interval [CI]: 0.187-0.662) and ETAR mRNA (HR = 2.500 95% CI: 1.345-4.647) were independent prognostic factors, independent of TNM stage (HR = 2.414, 95% CI: 1.600-3.642) and differentiation (HR = 1.530, 95% CI: 1.050-2230).

CONCLUSIONS

miRNA-200c induces an expedient surgical survival, whereas ETAR mRNA has the reverse prognosis in advanced stage NSCLC patients. A potential relationship exists in that miRNA-200c targets ETAR mRNA during EMT.

Value-based insurance design: barriers to implementation in radiology

Expensive and steadily rising health care costs without a concomitant increase in quality have generated a search for solutions to fund health care in the United States. Recent health care reforms and proposals on the agenda have spurred debate about alternative payment plans for health care. Much of the talk centers on imaging, which is a fast-growing and expensive component of health care. Value-based insurance design (VBID), a "clinically sensitive" means of sharing the cost of health care, has been proposed as a means to control the runaway costs of health care management including diagnostic testing. A corollary of pay-for-performance initiatives in which physician incentives are aligned with evidence-based medical practices, VBID seeks to increase patient incentives to comply with evidence-based health care consumption. We previously reviewed the principles of VBID and provided examples of VBID in practice using diabetes management as a model, as well as suggested some areas in diagnostic testing that lend themselves to VBID benefit design. In this article, we summarize the barriers to implementation and outline potential solutions, with particular regard to radiology.

Should radiology residents be taught evidence-based radiology? An experiment with "the EBR Journal Club"

RATIONALE AND OBJECTIVES

Introduce radiology residents to evidence-based radiology (EBR) using a journal club format based on the Radiology Alliance for Health Services Research/American Alliance of Academic Chief Residents in Radiology (RAHSR/A3CR2) Critical Thinking Skills sessions and EBR series of articles published in Radiology in 2007.

MATERIALS AND METHODS

The club began with a presentation outlining the process that would occur in an alternating format, with topics and articles chosen by residents. In session A, questions were rephrased in a Patient/Population, Intervention, Comparison, Outcome format, and a literature search was performed. Articles were discussed in session B, with residents assigned by year to the tasks of article summary, technology assessment, and comparison to checklists (Standards for Reporting of Diagnostic Accuracy, Consolidated Standards of Reporting Trials, or Quality of Reporting of Meta-analysis). The residents collectively assigned a level of evidence to each article, and a scribe provided a summary.

RESULTS

Twenty-two residents participated, with 12/22 (55%) of residents submitting any question, 6/22 (27.3%) submitting more than one question, and 4 residents submitting questions in more than one session. Topics included radiation risk, emergency radiology, screening examinations, modality comparisons, and technology assessment. Of the 31 articles submitted for review, 15 were in radiology journals and 5 were published before 2000. For 2/9 topics searched, no single article that the residents selected was available through our library's subscription service. The maximum level of evidence assigned by residents was level III, "limited evidence." In each session, the residents concluded that they became less confident in the "right answer." They proposed that future reading recommendations come from attendings rather than literature searches.

CONCLUSION

A journal club format is an effective tool to teach radiology residents EBR principles. Resistance comes from the difficulty in accessing good literature for review and in constructing good review questions.

Achievable outcomes in the management of proximal cholangiocarcinoma: an update prepared using "evidence-based practice" techniques

BACKGROUND

The purpose of this study is to evaluate recently reported outcomes for treatment options for proximal cholangiocarcinoma (CCA).

MATERIALS AND METHODS

Standard evidence based practice techniques were used to formulate a question, search, appraise and evaluate the retrieved literature. Our question was "In patients with CCA, how do stenting alone, stenting in addition to brachytherapy (BT) or photodynamic therapy (PDT), resection and orthotopic liver transplantation with neoadjuvant chemoradiation (OLT) compare for long-term survival?

RESULTS

Level 1b survival data was available for stenting alone (179 days), BT and metal stenting (388 days) and PDT with plastic stenting (493 days) and no survival difference was evident with metal vs. plastic stenting or unilateral vs. bilateral stenting. Five year survival data (level 3) was available for OLT (80%), formally curative trisegmentectomy with or without portal vein resection (72% and 52%) and hepatectomy (18%-23%).

CONCLUSION

All patients with proximal CCA should be reviewed by a multidisciplinary team to determine appropriate treatment. For unresectable CCA, patients should be assessed for OLT with neoadjuvant chemoradiation, while those who are unsuitable would appear to have the longest survival with PDT. Extended resection in operable candidates may improve survival over right or left hepatectomy but increased perioperative mortality is a consideration.

Which patients will benefit from percutaneous radiofrequency ablation of colorectal liver metastases? Critically appraised topic

In clinical radiology, there are numerous examples of new techniques that were initially enthusiastically promoted and then subsequently abandoned when early promise was not realized in routine patient care. Appropriateness of new or established interventional radiology techniques to specific clinical conditions must be determined from clinical experience, from communication with experts in the field and/or careful review of available medical literature, and on an individual patient basis by means of review of clinical notes and diagnostic imaging studies. For patients with liver neoplasms, regional techniques such as radiofrequency ablation (RFA) have been developed and are now the subject of ongoing research. This article describes the utilization of Evidence-Based Practice (EBP) techniques as a means of deciding the appropriateness of percutaneous RFA in treating colorectal liver metastases (CLM).

Evidence-based radiology: review and dissemination

Evidence-based radiology (EBR) is an important tool for the practice of radiology. The user of the EBR approach identifies evidence in a systematic fashion and then assimilates information through in-depth, explicit critical review of the best-designed and most recent literature on the subject in question. Clinical decision making is then based on the best current evidence, clinical expertise, and patient values. Substantial progress has been made in the review and dissemination of EBR. Dissemination of EBR within radiology has two critical aspects. The first is increased understanding of the methods required for EBR and of the appropriate use of EBR. The second important component is the dissemination of the data and critical literature reviews necessary to allow use of the EBR approach. Resources available for both EBR methods and EBR data in radiology include societies, journals, medical meetings, Web sites, and textbooks. Although radiology has made important progress in this field in recent years, the specialty is still behind other specialties that have been at the forefront of evidence-based medicine in the past decade.

Evidence-based practice in radiology: what color is your parachute?

Increasingly, constructive thought is being given to non-interpretive competencies in Radiology training and practice. Two of these are "Practice-Based Learning" and "Systems-Based Practice". These areas are evolving. It seems likely that, in some way, the paradigm of "Evidence-Based Practice" (EBP) derived from the McMaster/Centre for Evidence-Based Medicine (CEBM) methodology will form part of these new disciplines. This introductory article sets the scene for this Feature Section in Abdominal Imaging consisting entirely of short "Critically Appraised Topics" produced using EBP techniques. It is hoped that this will stimulate further discussion and consideration of the potential role of EBP in radiology education.

Technology Assessment in Radiology: Putting the Evidence in Evidence-based Radiology

In this review, which is part of a larger series on evidence-based practice in radiology, the relationship between technology assessment (TA) and the practice of evidence-based radiology (EBR) is discussed. TA guides researchers in the methods required to be reliable providers of unbiased and relevant evidence. Meanwhile, EBR equips radiologists with the skills needed to be discerning consumers of that evidence. Both paradigms aim to improve the effectiveness of health care spending. In this review, it is argued that EBR can be only as good as the TA on which it is based. However, TA is particularly complex in regard to diagnostic radiology because of the many links in the chain between the interim objective (to make the correct diagnosis) and the ultimate goal (to improve patient health). In this article, the development of TA in medicine in general and, more specifically, the TA hierarchy for the evaluation of diagnostic imaging are described. Some of the improvements in the pool of evidence during the past 30 years are documented, and some of the remaining tensions between TA and EBR are highlighted.

Evidence-based practice in radiology: step 5 (evaluate)--caveats and common questions

So far, this series has described and illustrated the first four steps of the five-step evidence-based practice (EBP) process that was originally designed and taught by the medical epidemiologists of McMaster University (Hamilton, Ontario, Canada) and the National Health Service Centre for Evidence-Based Medicine (University of Oxford, Oxford, England). This article in the series first briefly considers the fifth step (evaluate). A more detailed consideration of caveats, common questions, and challenges relevant to EBP in radiology then follows. These are issues that merit some thought by those beginning or continuing work in EBP.