Clinician interest in clinical decision support for PSA-based prostate cancer screening

OBJECTIVE

To evaluate the interest of primary care clinicians in utilizing CDS for PSA screening. Evidence suggests that electronic clinical decision support (CDS) may decrease low-value prostate-specific antigen (PSA) testing. However, physician attitudes towards CDS for PSA screening are largely unknown.

METHODS

A survey was sent to 201 primary care clinicians, including both physicians and Advanced Practice Providers (APP), within a large academic health system. Eligible clinicians cared for male patients aged 40 to 80 years and ordered ≥5 PSA tests in the past year. Respondents were stratified into 3 groups, appropriate screeners, low-value screeners, or rare-screeners, based on responses to survey questions assessing PSA screening practices. The degree of interest in electronic CDS was determined via a composite Likert score comprising relevant survey items.

RESULTS

Survey response rate was 29% (59/201) consisting of 85% MD/DO and 15% APP respondents. All clinicians surveyed were interested in CDS (P < 0.001) without significant difference between screener groups. Clinicians agreed most uniformly that CDS be evidence-based. Clinicians disagreed on whether CDS would decrease professional discretion over patient decisions.

CONCLUSIONS

Primary care clinicians are interested in CDS for PSA screening regardless of their current screening practices. Prioritizing CDS features that clinicians value, such as ensuring CDS recommendations are evidence-based, may increase the likelihood of successful implementation, whereas perceived threat to autonomy may be a hinderance to utilization.

Critically Appraising Pragmatist Critiques of Evidence-Based Medicine: Is EBM Defensible on Pragmatist Grounds?

Significant contributions to debates in the philosophy of evidence-based medicine (EBM) have come from a variety of different philosophical quarters, yet mainstream discourse in the field has been largely devoid of contributions from scholars working in the pragmatist tradition. This is a particularly conspicuous omission, given pragmatism's commitment to the melioristic view that philosophy both can, and should, be about the business of concretely bettering the human estate. Two exceptions to this oversight come from Brian Walsh and Maya Goldenberg. Unfortunately, in both cases, the misapplication of pragmatist thinking leads to the mistaken view that EBM is committed to some form of pernicious objectivism. This article aims to revise these pragmatist critiques in order to bring them more consistently in line with pragmatist values and commitments. Doing so shows that EBM is defensible on pragmatist grounds against objectivist attacks.

The (commercialised) experience of operating: Embodied preferences, ambiguous variations and explaining widespread patient harm

This article provides a detailed account of how surgeons perceived and used a device-procedure that caused widespread patient harm: transvaginal mesh for the treatment of pelvic floor disorders in women. Drawing from interviews with 27 surgeons in Canada, the UK, the United States and France and observations of major international medical conferences in North America and Europe between 2015 and 2018, we describe the commercially driven array of operative variations in the use of transvaginal mesh and show that surgeons' understanding of their hands-on, sensory experience with these variations is central to explaining patient harm. Surgeons often developed preferences for how to manage actual and anticipated dangers of transvaginal mesh procedures through embodied operative adjustments, but collectively the meaning of these preferences was fragmented, contested and deferred. We critically reflect on surgeons' understandings of their operative experience, including the view that such experience is not evidence. The harm in this case poses a challenge to some ways of thinking about uncertainty and errors in medical sociology, and calls for attention to a specific feature of surgical work: the extent and persistence of operative practices that elude classification as right or wrong but are still most certainly better and worse.

Exploring the barriers to using assistive technology for individuals with chronic conditions: a meta-synthesis review

PURPOSE

Assistive technology can provide a key tool to enabling independence, greater inclusion and participation in society for individuals with chronic conditions. This potential is currently not always realized due to barriers to accessing and using assistive technology. This review aims to identify the common barriers to acquiring and using assistive technology for users with chronic conditions through a systematic meta-synthesis. This differs from other systematic reviews by applying a transdiagnostic approach to identify if barriers are common across chronic conditions.

MATERIALS AND METHODS

A systematic literature search of five scientific databases (PubMed, SCOPUS, PsycINFO, CINAHL and Medline) was conducted to identify relevant qualitative studies. The search was conducted in November 2019. For the identified articles, thematic content analysis was conducted and the methodological quality was evaluated using the Critical Appraisal Skills Programme (CASP) checklist for qualitative research.

RESULTS

Forty papers met the inclusion criteria and were included in the analysis. Fifty-one descriptive themes grouped into six overarching analytical themes were identified from the studies. The analytical themes identified were: the design and function of the assistive technology, service provision, information and awareness, psychological barriers, support network and societal barriers.

CONCLUSIONS

The barriers are interconnected and common across different health conditions. More involvement in personalized care for developing strategies, adaptation of home technologies and provision of assistive technology could overcome the service provision and design barriers to assistive technology. Accessible information and providing greater awareness will be important to overcoming information, psychological and societal barriers to assistive technology.Implications for rehabilitationIndividuals with chronic conditions face complex barriers to acquiring and using assistive technology as a result of the devices themselves, their individual context, the healthcare context where assistive technology is provided and wider societal barriers.The provision of assistive technology needs to change away from the traditional medical model of the "expert" clinician and instead focus on more user involvement to deliver personalised care that utilises the users lived knowledge and experiences.Assistive technology provision should be considered alongside how to adapt everyday mainstream technology to meet user needs; the provision of devices should encourage creative problem solving rather then relying on pre-defined prescription lists of assistive technology.

Paragons, Mavericks and Innovators-A typology of orthopaedic surgeons' professional identities. A comparative case study of evidence-based practice

Clinical guidelines, as vehicles for evidence-based practice (EBP) attempt to standardize health-care practice, reduce variation and increase quality. However, their use for surgery has been contested, and often resisted. This article examines professional responses to EBP in hip replacement surgery using data from case study observations and interviews in three English orthopaedic departments. A professional identity perspective is adopted to explain how standardization through EBP, represents an empirical phenomenon around which surgeons enact their identities as Paragons, Mavericks or Innovators, to enhance legitimacy and stratify themselves in their response to EBP. Attention is drawn to variation between Paragon surgeons working in university (teaching) hospitals and Maverick and Innovator types located in general hospitals, and the ways this interacts with adoption of EBP. The typology shows how practice variation is related to surgeons' tendencies to align to characteristic types, with distinct social processes, power and prestige, and which are in turn influenced by organizational context. The dynamics of EBP and professional identity continues to limit attempts to standardize surgical practice. The typology contributes to the understanding of failures to follow EBP, as associated with the identities individuals create and negotiate, and with identity narratives used to legitimize differing responses to EBP.

Clinical guidelines and clinical autonomy: exploring the missing link

Purpose

This paper aims at understanding how clinical guidelines' use in the labour process relates to clinical autonomy, that is, the self-control medical professionals exercise over medical practice.

Design/methodology/approach

Drawing on a qualitative case study research strategy, this paper explores how medical professionals use clinical guidelines in the labour process in one public general hospital of the Greek National Health System. Supplemented by an extensive study of documents, semi-structured interviews were conducted with 33 doctors of several specialties.

Findings

The analysis shows (1) how clinical autonomy, as a self-control structure, mediates the use of clinical guidelines as a knowledge tool in the labour process, and (2) how employing clinical guidelines as a means towards coordinating medical work, but also towards regulating and standardising medical practice, is exercising pressure on the individualistic character of clinical autonomy.

Originality/value

Advancing the analytic value of workplace control structures, this paper contributes novel theoretical understanding of emerging tendencies characterising medical work organisation and clinical autonomy, and explains how medical professionals' non-adherence to clinical practice guidelines (CPGs) relates to CPGs' role as a resource to medical practice. Finally, this research proposes a more critical approach to health policy towards addressing the challenges associated with centrally introducing clinical guidelines in healthcare organisations.

A review of research-supported group treatments for drug use disorders

This paper reviews methodologically rigorous studies examining group treatments for interview-diagnosed drug use disorders. A total of 50 studies reporting on the efficacy of group drug use disorder treatments for adults met inclusion criteria. Studies examining group treatment for cocaine, methamphetamine, marijuana, opioid, mixed substance, and substance use disorder with co-occurring psychiatric conditions are discussed. The current review showed that cognitive behavioral therapy (CBT) group therapy and contingency management (CM) groups appear to be more effective at reducing cocaine use than treatment as usual (TAU) groups. CM also appeared to be effective at reducing methamphetamine use relative to standard group treatment. Relapse prevention support groups, motivational interviewing, and social support groups were all effective at reducing marijuana use relative to a delayed treatment control. Group therapy or group CBT plus pharmacotherapy are more effective at decreasing opioid use than pharmacotherapy alone. An HIV harm reduction program has also been shown to be effective for reducing illicit opioid use. Effective treatments for mixed substance use disorder include group CBT, CM, and women's recovery group. Behavioral skills group, group behavioral therapy plus CM, Seeking Safety, Dialectical behavior therapy groups, and CM were more effective at decreasing substance use and psychiatric symptoms relative to TAU, but group psychoeducation and group CBT were not. Given how often group formats are utilized to treat drug use disorders, the present review underscores the need to understand the extent to which evidence-based group therapies for drug use disorders are applied in treatment settings.

What prevents health policy being 'evidence-based'? New ways to think about evidence, policy and interventions in health

BACKGROUND

Evidence-based policy decision-making is a dominant paradigm in health but realizing this ideal has proven challenging.

SOURCES OF DATA

This paper conceptually maps health policy, policy studies and social science literature critically engaged with evidence and decision-making. No new data were generated or analysed in support of this review.

AREAS OF AGREEMENT

Barriers to evidence-based policy have been documented, with efforts made to increase the uptake of evidence.

AREAS OF CONTROVERSY

Evident complexities have been regarded as a problem of translation. However, this assumes that policy-making is a process of authoritative choice, and that 'evidence' is inherently valuable policy knowledge, which has been critiqued.

GROWING POINTS

Alternative accounts urge consideration of how evidence comes to bear on decisions made within complex systems, and what counts as evidence.

AREAS TIMELY FOR DEVELOPING RESEARCH

An 'evidence-making intervention' approach offers a framework for conceptualizing how evidence and interventions are made relationally in practices, thus working with the politics and contingencies of implementation and policy-making.

From anatomy to patient experience in pelvic floor surgery: Mindlines, evidence, responsibility, and transvaginal mesh

Beginning in the late 1990s, surgeons around the world widely adopted the transvaginal placement of permanent synthetic mesh for the treatment of several common pelvic floor disorders in women. By 2012 it had become the subject of extensive litigation, including one of the biggest mass-tort cases in U.S. history, with litigants reporting debilitating and unexpected complications. Based on qualitative research that includes interviews with surgeons, observations of medical conferences, and analysis of archival materials, we argue the adoption of transvaginal mesh cannot be fully explained without recognizing the role of mindlines, or collective moral-epistemological ways of knowing and acting responsibly. The adoption of mesh was anchored in a mindline focused on repairing anatomy. The harms that resulted from transvaginal mesh necessitated a shift to a focus on patient experience. We analyze the role of evidence-based medicine (EBM) in the re-organization of these surgeons' mindlines, showing that mindlines are not reducible to evidence as defined by EBM and that evidence thus defined facilitated the adoption of transvaginal mesh.

The trouble with IVF and randomised control trials: Professional legitimation narratives on time-lapse imaging and evidence-informed care

Focusing on the case of time-lapse imaging (TLI), this paper analyses how medical professionals negotiate the use of new 'add-on' fertility treatments in light of the limited evidence available. The data produced by TLI technologies is meant to help professionals identify the best embryo to be implanted. Embryo selection is essential in IVF practice for increasing pregnancy rates and reducing the negative effects of repeated failures. More than 5 years after the introduction of TLI in IVF labs, however, there has been no conclusive randomised control trial (RCT) evidence to show that the tools do indeed have a significant impact on pregnancy rates. Nonetheless, many public clinics in the UK have adopted such technologies. Consequently, our research asks: How is the use of TLI tools legitimised by professionals, in light of contradictory evidence? Focusing on 25 semi-structured staff interviews, we argue that professionals use several strategies to legitimise the use of TLI in the clinic without, however, challenging the tenets of evidence-based medicine (EBM) and the value it places on RCTs. Rather, professionals emphasise various advantages that TLI offers, including its use as a lab tool, its potential for knowledge production in embryology, and the role it plays in the management of patient expectations and course of treatment. This paper contributes to debates on the role of EBM in modern medicine and fertility care specifically - an area where this inter-relationship has been underexplored. We conclude by suggesting avenues towards a more nuanced understanding of EBM as it relates to IVF treatment and a rapidly changing biotechnology context.

Moral entrepreneurship, the power-knowledge nexus, and the Cochrane "crisis"

BACKGROUND

In 2018, a so-called crisis developed in the international network of systematic reviewers known as Cochrane. It was widely depicted in terms of two competing narratives-"bad behaviour" by one member of Cochrane's Governing Board and scientific and moral decline within Cochrane.

OBJECTIVE

Our goal was to distil insights on the structural issues underpinning the crisis, without taking a definitive position on the accuracy of either narrative.

APPROACH AND DATASET

In this paper, we draw on (among other theories) Becker's notion of moral entrepreneurship and Foucault's conceptualisation of power to analyse the claims and counterclaims made by different parties. Our dataset consisted of publicly available materials (blogs, journal articles, newspaper articles) to end 2018, notably those relating to the expulsion of one Governing Board member.

MAIN FINDINGS

Both narratives include strong moral claims about the science of systematic review and the governance of scientific organizations. The expelled individual and his supporters defined good systematic reviews in terms of a particular kind of methodological rigour and elimination of bias, and good governance largely in terms of measures to achieve independence from industry influence. Most of Cochrane's Governing Board and their sympathizers evaluated systematic reviews according to a broader range of criteria, incorporating factors such as attention to relationships among reviewers and reflexivity and dialogue around scientific and other judgements. They viewed governance partly in terms of accountability to an external advisory group. Power-knowledge alignments in Cochrane have emerged from, and contributed to, a particular system of meaning which is now undergoing evolution and challenge.

CONCLUSION

Polarizing Cochrane's "crisis" into two narratives, only one of which is true, is less fruitful than viewing it in terms of a duality consisting of tensions between the two positions, each of which has some validity. Having framed the conflict as primarily philosophical and political rather than methodological and procedural, we suggest how Cochrane and its supporters and critics might harness their tensions productively.

Perceptions, knowledge, and perceived barriers of Yemeni pharmacists and pharmacy technicians towards evidence-based practice

RATIONAL, AIMS, AND OBJECTIVE

The aim of this study was to assess the knowledge and perception towards evidence-based practice (EBP) and identify the perceived barriers to practicing EBP among Yemeni pharmacists and pharmacy technicians.

METHODS

A cross-sectional survey study was carried out among 153 Yemeni pharmacists and pharmacy technicians who are working in hospitals or community pharmacies. This study took place between the 15th of August and the 8th of November 2017 using a self-administered validated questionnaire. The study was approved by the ethics committee/scientific research center of Yemen University, Yemen (Reference number: ERC/2017/103).

RESULTS

Completed questionnaires were received from 153 (46.6% response rate). Most of the respondents showed a positive attitude towards EBP; however, their understanding of the basic terms used in EBP was poor (34.6%). The types of source that the respondent used in high percentage to make their decisions were own judgement and consulting the colleagues that can no longer be accurate and evidence based. The barriers to practicing EBP identified by most respondents were the limited access to EBP sources and lack of personal time.

CONCLUSION

These results reveal strong support for EBP among pharmacists and pharmacy technicians in Yemen but only a minority indicated that they understood the technical terms of EBP. Training and continuing education programs on EBP and guidelines for pharmacists are strongly needed. These findings may help in planning the use and the application of EBP process in pharmacy practice.

Exploring the solutions to the inherent perils of (the multitude of) guidelines - a focus group study of stakeholders' perceptions

Background

Hospital boards have the responsibility to ensure compliance of hospital staff with guidelines and other norms, but they have struggled to do so. The current study aims to identify possible solutions that address the whole chain of guideline and norm production, use and enforcement and that could help hospital boards and management cope with norms and guidelines.

Methods

We performed a qualitative study of three focus groups involving a total of 28 participants. In the third focus group, no new themes emerged, indicating that saturation was achieved. Focus group discussions were audiotaped and transcribed verbatim. Results were coded, and three themes emerged from the results. Thick description with selected key quotes is used to display the items in the result section.

Results

In the first instance, norm developers, norm enforcers, and norm users acknowledged and reformulated the problem before they suggested solutions. The proposed concrete solutions, such as a clear description of the division of tasks within guidelines, clarity about the purpose of guideline recommendations, a maximum number of quality indicators for hospitals and implementation of an ensuring proper Information Technology (IT) infrastructure.

Conclusions

This study aimed to find solutions for the problems that hospitals encounter in managing a multitude of norms and guidelines. Participants in this study acknowledged the fact that norms and guidelines have become difficult to manage at the hospital level and four potential solutions were identified.

Trial registration

The study was retrospectively registered on the 21st of July in 2016 in the Dutch Trial Register as NL4061.

Exploring How Evidence is Used in Care Through an Organizational Ethnography of Two Teaching Hospitals

Background

Numerous published articles show that clinicians do not follow clinical practice guidelines (CPGs). However, a few studies explore what clinicians consider evidence and how they use different forms of evidence in their care decisions. Many of these existing studies occurred before the advent of smartphones and advanced Web-based information retrieval technologies. It is important to understand how these new technologies influence the ways clinicians use evidence in their clinical practice. Mindlines are a concept that explores how clinicians draw on different sources of information (including context, experience, medical training, and evidence) to develop collectively reinforced, internalized tacit guidelines.

Objective

The aim of this paper was to explore how evidence is integrated into mindline development and the everyday use of mindlines and evidence in care.

Methods

We draw on ethnographic data collected by shadowing internal medicine teams at 2 teaching hospitals. Fieldnotes were tagged by evidence category, teaching and care, and role of the person referencing evidence. Counts of these tags were integrated with fieldnote vignettes and memos. The findings were verified with an advisory council and through member checks.

Results

CPGs represent just one of several sources of evidence used when making care decisions. Some forms of evidence were predominately invoked from mindlines, whereas other forms were read to supplement mindlines. The majority of scientific evidence was accessed on the Web, often through smartphones. How evidence was used varied by role. As team members gained experience, they increasingly incorporated evidence into their mindlines. Evidence was often blended together to arrive at shared understandings and approaches to patient care that included ways to filter evidence.

Conclusions

This paper outlines one way through which the ethos of evidence-based medicine has been incorporated into the daily work of care. Here, multiple Web-based forms of evidence were mixed with other information. This is different from the way that is often articulated by health administrators and policy makers whereby clinical practice guideline adherence is equated with practicing evidence-based medicine.

How to choose an evidence-based medicine knowledge test for medical students? Comparison of three knowledge measures

BACKGROUND

There are a few studies of alignment between different knowledge-indices for evidence-based medicine (EBM). The aim of this study was to investigate whether the type of test used to assess knowledge of EBM affects the estimation of this knowledge in medical students.

METHODS

Medical students enrolled in 1-week EBM course were tested with the Fresno, Berlin, and ACE tests at the beginning and the end of the course. We evaluated the ability of these tests to detect a change in the acquired level of EBM knowledge and compared the estimates of change with those of the Control group that was tested with the ACE and Berlin tests before and after an unrelated non-EBM course. The distributions of test scores and average item difficulty indices were compared among the tests and the groups.

RESULTS

Test scores improved on all three tests when compared with their pre-test results and the control. Students had on average a "good" performance on the ACE test, "sufficient" performance on the Berlin test, and "insufficient" performance or have "not passed" on the Fresno test. The post-test improvements in performance on the Fresno test (median 31% increase in percent scores, 95% confidence interval (CI) 25-42%) outperformed those on the ACE (13, 95% CI 13-20%) and Berlin tests (13, 95% CI 7-20%). Post-test score distributions demonstrated that the ACE test had less potential to discriminate between levels of EBM knowledge than other tests.

CONCLUSION

The use of different EBM tests resulted in different assessment of general EBM knowledge in a sample of graduate medical students, with lowest results on the Fresno and highest on the ACE test. In the light of these findings, EBM knowledge assessment should be based on the course's content and learning objectives.

Ethics, Evidence Based Sports Medicine, and the Use of Platelet Rich Plasma in the English Premier League

The use of platelet rich plasma (PRP) as a novel treatment is discussed in the context of a qualitative research study comprising 38 interviews with sports medicine practitioners and other stakeholders working within the English Premier League during the 2013-16 seasons. Analysis of the data produced several overarching themes: conservatism versus experimentalism in medical attitudes; therapy perspectives divergence; conflicting versions of appropriate evidence; subcultures; community beliefs/practices; and negotiation of medical decision-making. The contested evidence base for the efficacy of PRP is presented in the context of a broader professional shift towards evidence based medicine within sports medicine. Many of the participants while accepting this shift are still committed to casuistic practices where clinical judgment is flexible and does not recognize a context-free hierarchy of evidentiary standards to ethically justifiable practice. We also discuss a tendency in the data collected to consider the use of deceptive, placebo-like, practices among the clinician participants that challenge dominant understandings of informed consent in medical ethics. We conclude that the complex relation between evidence and ethics requires greater critical scrutiny for this emerging specialism within the medical community.

Evidence-based campaigning

Background

When promoting public health measures, such as reducing smoking, there are many different approaches, for example providing information, imposing legal restrictions, taxing products, and changing cultures. By analogy with evidence-based medicine, different approaches to campaigning for health promotion can be compared by obtaining evidence of effectiveness. However, evaluating the effectiveness of campaigning approaches is far more difficult than evaluating drugs or medical procedures, because controls are seldom possible, endpoints are difficult to specify, multiple factors influence outcomes, and the targets of campaigns are people or organizations that may resist.

Methods

Ten ideal campaigning types are proposed: positive and negative approaches to the five categories of information, attitude, arguments, authorities and incentives. To illustrate the ideal types and the complexities of evaluating approaches to campaigning, three contrasting Australian strategies to promote vaccination are examined.

Results

Each of the three vaccination-promotion strategies showed the presence of several ideal campaigning types, but with distinct differences in emphasis. With available evidence, it is difficult to assess the relative effectiveness of the three strategies.

Conclusion

Because of the difficulty in obtaining evidence, claims about the effectiveness of general approaches to health promotion should be treated with scepticism, especially when presented by partisans. There are inherent difficulties in making campaigning evidence-based.

Acute lung injury: how to stabilize a broken lung

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.

Formats of responsibility: elective surgery in the era of evidence-based medicine

This article illustrates what pragmatic sociology refers to as investments in form, by examining the formats created and used by a group of surgeons to determine when elective surgery for pelvic floor disorders could be responsibly undertaken. Drawing upon ethnographic observations of surgical consultations at an academic medical centre in Canada, we show how two specific formats - that the patient is sufficiently bothered and the patient accepts the risks of surgery - allow for justifiable action in conditions of uncertainty and contingency and in light of the demands of dominant imperatives in medicine and health care, especially evidence-based medicine (EBM). We argue that an analytic of justification is necessary for understanding when and how surgery is offered and elected for, and for considering how surgical consultations might be improved.

Decolonizing Scoping Review Methodologies for Literature With, for, and by Indigenous Peoples and the African Diaspora: Dialoguing With the Tensions

This article summarizes our deepened understanding of decolonizing research with, for, and by Indigenous peoples and peoples of African descent that emerged from conducting a scoping review of the methodological literature and reflecting on our review process. Although our review identified decolonizing methodologies as a promising approach, we questioned if our scoping review process engaged in decolonizing knowing. To unpack the epistemological tensions between decolonizing knowing and Western ways of doing scoping reviews, we engaged in individual and collective reflective processes- dialoguing with the tensions-moving from individual immersion in the literature to transformative dialogues among the team. In reflecting upon our tensions with the scoping review process, themes that emerged included (a) ontological/epistemological disjunctures, (b) tensions with concepts and language, and (c) relationships with the literature and beyond. This reflexive process provides valuable insight into ways in which review methods might be made a decolonizing research experience.

What hinders the uptake of computerized decision support systems in hospitals? A qualitative study and framework for implementation

BACKGROUND

Advanced Computerized Decision Support Systems (CDSSs) assist clinicians in their decision-making process, generating recommendations based on up-to-date scientific evidence. Although this technology has the potential to improve the quality of patient care, its mere provision does not guarantee uptake: even where CDSSs are available, clinicians often fail to adopt their recommendations. This study examines the barriers and facilitators to the uptake of an evidence-based CDSS as perceived by diverse health professionals in hospitals at different stages of CDSS adoption.

METHODS

Qualitative study conducted as part of a series of randomized controlled trials of CDSSs. The sample includes two hospitals using a CDSS and two hospitals that aim to adopt a CDSS in the future. We interviewed physicians, nurses, information technology staff, and members of the boards of directors (n = 30). We used a constant comparative approach to develop a framework for guiding implementation.

RESULTS

We identified six clusters of experiences of, and attitudes towards CDSSs, which we label as "positions." The six positions represent a gradient of acquisition of control over CDSSs (from low to high) and are characterized by different types of barriers to CDSS uptake. The most severe barriers (prevalent in the first positions) include clinicians' perception that the CDSSs may reduce their professional autonomy or may be used against them in the event of medical-legal controversies. Moving towards the last positions, these barriers are substituted by technical and usability problems related to the technology interface. When all barriers are overcome, CDSSs are perceived as a working tool at the service of its users, integrating clinicians' reasoning and fostering organizational learning.

CONCLUSIONS

Barriers and facilitators to the use of CDSSs are dynamic and may exist prior to their introduction in clinical contexts; providing a static list of obstacles and facilitators, irrespective of the specific implementation phase and context, may not be sufficient or useful to facilitate uptake. Factors such as clinicians' attitudes towards scientific evidences and guidelines, the quality of inter-disciplinary relationships, and an organizational ethos of transparency and accountability need to be considered when exploring the readiness of a hospital to adopt CDSSs.

Evidence-Based Psychotherapy: Advantages and Challenges

Evidence-based psychotherapies have been shown to be efficacious and cost-effective for a wide range of psychiatric conditions. Psychiatric disorders are prevalent worldwide and associated with high rates of disease burden, as well as elevated rates of co-occurrence with medical disorders, which has led to an increased focus on the need for evidence-based psychotherapies. This chapter focuses on the current state of evidence-based psychotherapy. The strengths and challenges of evidence-based psychotherapy are discussed, as well as misperceptions regarding the approach that may discourage and limit its use. In addition, we review various factors associated with the optimal implementation and application of evidence-based psychotherapies. Lastly, suggestions are provided on ways to advance the evidence-based psychotherapy movement to become truly integrated into practice.

O desafio da qualidade e integridade das publicações científicas

A crescente importância das ciências levanta questões relacionadas à validade, veracidade, relevância, utilidade, accountability e sustentabilidade dos produtos da prática científica. Portanto, as práticas que atentem para a integridade da pesquisa científica são fundamentais, tanto por parte dos pesquisadores quanto por parte da revistas científicas. Em 2016, a Revista Brasileira de Medicina de Família e Comunidade (RBMFC) recusou 14 trabalhos que apresentavam problemas de plagiarismo, o que representa aproximadamente 10% das submissões do ano. Consideramos este um sério problema, que exige maior atenção e cuidado por parte dos autores que pretendem contribuir com a revista. A política editorial da RBMFC preza pela qualidade de suas publicações, respeitando princípios éticos e de integridade da pesquisa científica aceitos internacionalmente.

Methodological reporting quality of randomized controlled trials: A survey of seven core journals of orthopaedics from Mainland China over 5 years following the CONSORT statement

BACKGROUND

In recent years, the number of randomized controlled trials (RCTs) in the field of orthopaedics is increasing in Mainland China. However, randomized controlled trials (RCTs) are inclined to bias if they lack methodological quality. Therefore, we performed a survey of RCT to assess: (1) What about the quality of RCTs in the field of orthopedics in Mainland China? (2) Whether there is difference between the core journals of the Chinese department of orthopedics and Orthopaedics Traumatology Surgery & Research (OTSR).

MATERIAL AND METHODS

This research aimed to evaluate the methodological reporting quality according to the CONSORT statement of randomized controlled trials (RCTs) in seven key orthopaedic journals published in Mainland China over 5 years from 2010 to 2014. All of the articles were hand researched on Chongqing VIP database between 2010 and 2014. Studies were considered eligible if the words "random", "randomly", "randomization", "randomized" were employed to describe the allocation way. Trials including animals, cadavers, trials published as abstracts and case report, trials dealing with subgroups analysis, or trials without the outcomes were excluded. In addition, eight articles selected from Orthopaedics Traumatology Surgery & Research (OTSR) between 2010 and 2014 were included in this study for comparison. The identified RCTs are analyzed using a modified version of the Consolidated Standards of Reporting Trials (CONSORT), including the sample size calculation, allocation sequence generation, allocation concealment, blinding and handling of dropouts.

RESULTS

A total of 222 RCTs were identified in seven core orthopaedic journals. No trials reported adequate sample size calculation, 74 (33.4%) reported adequate allocation generation, 8 (3.7%) trials reported adequate allocation concealment, 18 (8.1%) trials reported adequate blinding and 16 (7.2%) trials reported handling of dropouts. In OTSR, 1 (12.5%) trial reported adequate sample size calculation, 4 (50.0%) reported adequate allocation generation, 1 (12.5%) trials reported adequate allocation concealment, 2 (25.0%) trials reported adequate blinding and 5 (62.5%) trials reported handling of dropouts. There were statistical differences as for sample size calculation and handling of dropouts between papers from Mainland China and OTSR (P<0.05).

CONCLUSION

The findings of this study show that the methodological reporting quality of RCTs in seven core orthopaedic journals from the Mainland China is far from satisfaction and it needs to further improve to keep up with the standards of the CONSORT statement.

LEVEL OF EVIDENCE

Level III case control.

Reconstituting populations through evidence-based medicine: an ethnographic account of recommending procedures for diagnosing type 2 diabetes in clinical practice guidelines

This ethnographic investigation responds to calls for more social science research on - versus for or against - evidence-based medicine (EBM). It centers on the recommendations endorsed, in a set of clinical practice guidelines, by Canadian specialists in the late 1990s for diagnosing diabetes. Empirically, the article mainly relies on public presentations and discussion at the Canadian Diabetes Association Professional Conferences (1997-2001), supplemented by findings from documentary sources, direct observation, participant-observation and interviews. It confirms the importance of clinical reason and clinical epidemiology as preconditions for EBM, the textually mediated character of EBM and patients’ bodies as sites for producing knowledge crucial to EBM. Most significantly, it also demonstrates the importance of non-patients’ bodies as sites for producing knowledge that is crucial to EBM and its politics. EBM politics encompass the discursive, socio-technical and visceral reconstitution of populations.

Evidence-based medicine - an appropriate tool for evidence-based health policy? A case study from Norway

Background

Evidence-based policy (EBP), a concept modelled on the principles of evidence-based medicine (EBM), is widely used in different areas of policymaking. Systematic reviews (SRs) with meta-analyses gradually became the methods of choice for synthesizing research evidence about interventions and judgements about quality of evidence and strength of recommendations. Critics have argued that the relation between research evidence and service policies is weak, and that the notion of EBP rests on a misunderstanding of policy processes. Having explored EBM standards and knowledge requirements for health policy decision-making, we present an empirical point of departure for discussing the relationship between EBM and EBP.

Methods

In a case study exploring the Norwegian Knowledge Centre for the Health Services (NOKC), an independent government unit, we first searched for information about the background and development of the NOKC to establish a research context. We then identified, selected and organized official NOKC publications as an empirical sample of typical top-of-the-line knowledge delivery adhering to EBM standards. Finally, we explored conclusions in this type of publication, specifically addressing their potential as policy decision tools.

Results

From a total sample of 151 SRs published by the NOKC in the period 2004–2013, a purposive subsample from 2012 (14 publications) advised major caution about their conclusions because of the quality or relevance of the underlying documentation. Although the case study did not include a systematic investigation of uptake and policy consequences, SRs were found to be inappropriate as universal tools for health policy decision-making.

Conclusions

The case study demonstrates that EBM is not necessarily suited to knowledge provision for every kind of policy decision-making. Our analysis raises the question of whether the evidence-based movement, represented here by an independent government organization, undertakes too broad a range of commissions using strategies that seem too confined. Policymaking in healthcare should be based on relevant and transparent knowledge, taking due account of the context of the intervention. However, we do not share the belief that the complex and messy nature of policy processes in general is compatible with the standards of EBM.

Is There a Consensus when Physicians Evaluate the Relevance of Retrieved Systematic Reviews?

BACKGROUND

A significant challenge associated with practicing evidence-based medicine is to provide physicians with relevant clinical information when it is needed. At the same time it appears that the notion of relevance is subjective and its perception is affected by a number of contextual factors.

OBJECTIVES

To assess to what extent physicians agree on the relevance of evidence in the form of systematic reviews for a common set of patient cases, and to identify possible contextual factors that influence their perception of relevance.

METHODS

A web-based survey was used where pediatric emergency physicians from multiple academic centers across Canada were asked to evaluate the relevance of systematic reviews retrieved automatically for 14 written case vignettes (paper patients). The vignettes were derived from prospective data describing pediatric patients with asthma exacerbations presenting at the emergency department. To limit the cognitive burden on respondents, the number of reviews associated with each vignette was limited to three.

RESULTS

Twenty-two academic emergency physicians with varying years of clinical practice completed the survey. There was no consensus in their evaluation of relevance of the retrieved reviews and physicians' assessments ranged from very relevant to irrelevant evidence, with the majority of evaluations being somewhere in the middle. This indicates that the study participants did not share a notion of relevance uniformly. Further analysis of commentaries provided by the physicians allowed identifying three possible contextual factors: expected specificity of evidence (acute vs chronic condition), the terminology used in the systematic reviews, and the micro environment of clinical setting.

CONCLUSIONS

There is no consensus among physicians with regards to what constitutes relevant clinical evidence for a given patient case. Subsequently, this finding suggests that evidence retrieval systems should allow for deep customization with regards to physician's preferences and contextual factors, including differences in the micro environment of each clinical setting.

Challenges to Learning Evidence-Based Medicine and Educational Approaches to Meet These Challenges: A Qualitative Study of Selected EBM Curricula in U.S. and Canadian Medical Schools

PURPOSE

Evidence-based medicine (EBM) is a fixture in many medical school curricula. Yet, little is known about the challenges medical students face in learning EBM or the educational approaches that medical schools use to overcome these challenges.

METHOD

A qualitative multi-institutional case study was conducted between December 2013 and July 2014. On the basis of the Association of American Medical Colleges 2012 Medical School Graduation Questionnaire data, the authors selected 22 U.S. and Canadian Liaison Committee on Medical Education-accredited medical schools with graduates reporting confidence in their EBM skills. Participants were interviewed and asked to submit EBM curricular materials. Interviews were audio-recorded, transcribed, and analyzed using an inductive approach.

RESULTS

Thirty-one EBM instructors (17 clinicians, 11 librarians, 2 educationalists, and 1 epidemiologist) were interviewed from 17 medical schools (13 in the United States, 4 in Canada). Four common EBM learning challenges were identified: suboptimal role models, students' lack of willingness to admit uncertainty, a lack of clinical context, and students' difficulty mastering EBM skills. Five educational approaches to these challenges that were common across the participating institutions were identified: integrating EBM with other courses and content, incorporating clinical content into EBM training, EBM faculty development, EBM whole-task exercises, and longitudinal integration of EBM.

CONCLUSIONS

The identification of these four learner-centered EBM challenges expands on the literature on challenges in teaching and practicing EBM, and the identification of these five educational approaches provides medical educators with potential strategies to inform the design of EBM curricula.

Evidence-based medicine: is it a bridge too far?

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.

Exploring the impact of providing evidence-based medicine training to service users

PLAIN ENGLISH SUMMARY

Within health services research in the UK, there has been growing interest in evidence-based medicine (EBM) and patient and public involvement (PPI) in research. These two movements have a common goal of improving the quality and transparency of clinical decision making. So far, there has been relatively little discussion about how these two movements might relate to each other, despite their common concern. Indeed, some in the PPI movement have expressed doubts about the implications of EBM for PPI because they worry that its emphasis on evidence from clinical trials marginalises the importance of a patient's individual experiences in clinical decision making. The purpose of this paper is to examine the potential for EBM and PPI to complement one another. We analysed the feedback of 10 members of the Peninsula Public Involvement Group (PenPIG) who attended EBM workshops. These workshops trained people in the basics of EBM and were primarily attended by health professionals. We used thematic analysis, a qualitative data analysis method, to explore the responses. We found that participation in the workshops appears to have increased the ability and confidence of members of the public to actively participate as both producers and consumers of research evidence. We conclude that there is an untapped potential for EBM and PPI to complement one another in their shared desire to improve the quality and transparency of clinical decision making.

ABSTRACT

Background Within the UK, health services research in the 1990s was marked by growing interest in evidence-based medicine (EBM) and in the potential of patient and public involvement (PPI) in research. However, there has been relatively little discussion of how these two developments might relate to each other, despite their common concern to improve the quality and transparency of clinical decision making. Indeed, some in the user involvement movement have expressed doubts about the implications of EBM for PPI. The purpose of this paper is to examine the potential for EBM and PPI to complement one another. Methods We used a case study design. Fifteen EBM workshops, involving PPI members, were conducted between June 2010 and December 2014. All 13 lay participants, who attended the first five workshops, were asked to fill in a standard feedback proforma designed by a member of the NIHR Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula (PenCLAHRC) Public Involvement Group (PenPIG). Ten responses were received, and these were analysed thematically. Results Four themes emerged from the thematic analysis: research knowledge, research skills, shared clinical decision making and learning environment. Participation in the workshops appears to have increased the ability and confidence of members of the public to actively participate as both producers and consumers of research evidence. Conclusions There is an untapped potential for EBM and PPI to complement one another in their shared desire to improve the quality and transparency of clinical decision making.

A history of the term "DMARD"

The article outlines a history of the concept of “disease-modifying antirheumatic drugs” or DMARDs—from the emergence in the 1970s of the idea of drugs with decisive long-term effects on bone erosion in rheumatoid arthritis (RA), through the consolidation and popularisation in the term DMARD in 1980s and 1990s. It then examines the usage of the terms “remission-inducing drugs” (RIDs) and “slow-acting anti-rheumatic drugs” (SAARDs), which for some years offered competition to the term DMARDs, thus underscoring the contingency of the establishment of DMARD as a word. Finally, it juxtaposes the apparently spontaneous emergence of the three terms DMARD, SAARD and RID, and the disappearance of the latter two, with a failed attempt in the early 1990s to replace these terms with the new term “disease-controlling antirheumatic treatment” (DC-ART). The analysis highlights the paradoxical qualities of the DMARD concept as robust albeit tension ridden, while playing down the role of identified individuals and overarching explanations of purpose.

Being a surgeon--the myth and the reality: a meta-synthesis of surgeons' perspectives about factors affecting their practice and well-being

OBJECTIVES

Synthesize the findings from individual qualitative studies about surgeons' account of their practice.

BACKGROUND

Social and contextual factors of practice influence doctors' well-being and therapeutic relationships. Little is known about surgery, but it is generally assumed that surgeons are not affected by them.

METHODS

We searched international publications (2000-2012) to identify relevant qualitative research exploring how surgeons talk about their practice. Meta-ethnography (a systematic analysis of qualitative literature that compensates for the potential lack of generalizability of the primary studies and provides new insight by their conjoint interpretation) was used to identify key themes and synthesize them.

RESULTS

We identified 51 articles (>1000 surgeons) from different specialties and countries. Two main themes emerged. (i) The patient-surgeon relationship, described surgeons' characterizations of their relationships with patients. We identified factors influencing surgical decision making, communication, and personal involvement in the process of care; these were surgeon-related, patient-related, and contextual. (ii) Group relations and culture described perceived issues related to surgical culture (image and education, teamwork, rules, and guidelines); it highlighted the influence of a social dimension on surgical practice. In both themes, we uncovered an emotional dimension of surgeons' practice.

CONCLUSIONS

Surgeons' emphasis on technical aspects, individuality, and performance seems to impede a modern patient-centered approach to care and to act as a barrier to well-being. Our findings suggest that taking into account the relational and emotional dimensions of surgical practice (both with patients and within the institution) might improve surgical innovation, surgeons' well-being, and the attractiveness of this specialty.

Communicating "Evidence": Lifestyle, Cancer, and the Promise of a Disease-free Future

In the era of evidence-based health care, conferences aimed at disseminating scientific knowledge perform an essential role in shaping policy and research agendas and transforming physician practice. Drawing on observations at two U.S. cancer prevention conferences aimed at knowledge translation, we examine the ways that evidence regarding the relationship between cancer and lifestyle is articulated and enacted. We show that characterizations of the evidence base at the conferences far outstripped what is presently known about the relationship between cancer and lifestyle. The messages presented to conference participants were also personalized and overtly moralistic, with attendees engaged not merely as practitioners but as members of the public at risk for cancer. We conclude that conferences seeking to bring together knowledge "makers" and knowledge "users" play a potentially important role in the production of scientific facts and are worthy of further study as distinct sites of knowledge production.

Risks, dangers and competing clinical decisions on venous thromboembolism prophylaxis in hospital care

Drawing on wider sociologies of risk, this article examines the complexity of clinical risks and their management, focusing on risk management systems, expert decision-making and safety standards in health care. At the time of this study preventing venous thromboembolism (VTE) among in-patients was one of the top priorities for hospital safety in the English National Health Service (NHS). An analysis of 50 interviews examining hospital professionals' perceptions about VTE risks and prophylaxis illuminates how National Institute for Health and Clinical Excellence (NICE) guidelines influenced clinical decision-making in four hospitals in one NHS region. We examine four themes: the identification of new risks, the institutionalisation and management of risk, the relationship between risk and danger and the tensions between risk management systems and expert decision-making. The implementation of NICE guidelines for VTE prevention extended managerial control over risk management but some irreducible clinical dangers remained that were beyond the scope of the new VTE risk management systems. Linking sociologies of risk with the realities of hospital risk management reveals the capacity of these theories to illuminate both the possibilities and the limits of managerialism in health care.

Evidence and ideology as a rationale for light-therapy in Russia: from the Soviet Union to the present day

Light therapy is still used to treat a number of common diseases in Russia. The practice is firmly anchored in history: Soviet clinical practice was divorced from the emerging field of evidence-based medicine. Medical researchers were cut off from international medical research and scientific literature, with much Soviet scientific activity based on a particular socialist ideology. In this study, the use of light therapy serves as a case study to explore tensions between international evidence-based medicine and practices developed in isolation under the Soviet Union, the legacy of which is to the detriment of many patients today. We used four different search methods to uncover scientific and grey literature, both historical and contemporary. We assessed the changing frequency of publications over time and contrasted the volume of literature on light therapy with more orthodox treatments such as statins and painkillers. Our search found an increasing number and comparatively large body of scientific publications on light therapy in the Russian language, and many publications emanating from prestigious Russian institutions. Combined with our analysis of the historical literature and our appraisal of 22 full text articles, this leads us to suggest that light therapy entered mainstream Soviet medical practice before the Stalinist period and still occupies an important position in contemporary Russian clinical practice. We propose that this outdated treatment survives in Russia in part due to the political, economic and social forces that helped to popularize it during Soviet times, and by the seeming justification offered by poorly executed studies.

The craft of intensive care medicine

The practice of medicine is often represented as a dualism: is medicine a 'science' or an 'art'? This dualism has been long-lasting, with evident appeal for the medical profession. It also appears to have been rhetorically powerful, for example in enabling clinicians to resist the encroachment of 'scientific' evidence-based medicine into core areas of medical work such as individual clinical judgement. In this article I want to make the case for a more valid conceptualisation of medical practice: that it is a 'craft' activity. The case I make is founded on a theoretical synthesis of the concept of craft, combined with an analysis of ethnographic observations of routine medical practice in intensive care. For this context the craft aspects of medical work can be seen in how biomedical and other types of knowledge are used in practice, the embodied skills and practical judgement of practitioners and the technological and material environment. These aspects are brought together in two conceptual dimensions for 'craft': first, the application of knowledge; second, interaction with the material world. Some practical and political implications of a 'craft' metaphor for medical practice are noted.