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Wilson MG, Palmer E, Asselbergs FW, Harris SK. Integrated rapid-cycle comparative effectiveness trials using flexible point of care randomisation in electronic health record systems. J Biomed Inform 2023; 137:104273. [PMID: 36535604 DOI: 10.1016/j.jbi.2022.104273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 10/13/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Whilst the Randomised Controlled Trial remains the gold standard for deriving robust causal estimates of treatment efficacy, too often a traditional design proves prohibitively expensive or cumbersome when it comes to assessing questions regarding the comparative effectiveness of routinely used treatments. As a result, patients experience variation in practice as clinicians lack the evidence needed to personalise treatments effectively. This variation may be classified as unwarranted, where existing evidence is ignored, or legitimate where in the absence of evidence, clinicians rely on experience, expert opinion, and inferred principles from basic science to make decisions. We argue that within the right ethical and technological framework, legitimate variation can be transformed into a mechanism for evidence generation and learning. Learning Health Systems which harness existing variation in practice, represent a novel approach for generating evidence from everyday clinical practice. The development of these systems has gained traction due to the increased availability of modern Electronic Health Record Systems. However, despite their promise, overcoming hurdles to successfully integrating clinical trials within Learning Health Systems has proven challenging. This article describes the origins of integrated clinical trials and explores two main barriers to their further implementation - how best to obtain informed consent from patients to participate in routine comparative effectiveness research, and how to automate and integrate randomisation into a clinical workflow. Having described these barriers, we present a potential solution in the form of a research pipeline using a novel form of flexible point-of-care randomisation to allow clinicians and patients to participate in studies where there is clinical equipoise.
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Affiliation(s)
- Matthew G Wilson
- Institute of Health Informatics, Faculty of Population Health Sciences, University College London, UK.
| | - Edward Palmer
- Bloomsbury Institute of Intensive Care Medicine, University College London, UK; Whittington Hospital NHS Trust, UK
| | - Folkert W Asselbergs
- Institute of Cardiovascular Science and Institute of Health Informatics, Faculty of Population Health Sciences, University College London, UK; Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Steve K Harris
- Institute of Health Informatics, Faculty of Population Health Sciences, University College London, UK; Critical Care Department, University College London Hospital, UK
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Shanahan EM, Glaezter K, Gill T, Hill C, Graf S, Allcroft P. A case series of suprascapular nerve block (with an historical comparator) for shoulder pain in motor neurone disease. Palliat Med 2020; 34:1127-1133. [PMID: 32469625 DOI: 10.1177/0269216320929553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Shoulder pain is a distressing but under-reported and poorly managed symptom in people with motor neurone disease. OBJECTIVES This study aimed to assess the efficacy of suprascapular nerve block for the management of shoulder pain in patients with motor neurone disease. METHODS A total of 27 patients with motor neurone disease and shoulder pain were offered a suprascapular nerve block. Ten of these patients had bilateral shoulder pain and both were injected, making a total of 37 shoulders. The patients were followed up for a total of 3 months, or until death. Shoulder pain was measured using the pain scale (out of 100) of the shoulder pain and disability index and compared with baseline scores and a placebo control group from an earlier study using the same methodology (ACTRN12619000353190). RESULTS Following the nerve block there was a significant improvement of pain scores from baseline (58.4) at week 1 (20.8, p < 0.000), week 6 (17.6, p < 0.000) and week 12 (30.4, p = 0.001) and a significant improvement compared with the control group across each time interval. CONCLUSION Suprascapular nerve block is a safe, effective therapy for patients with chronic shoulder pain.
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Affiliation(s)
- E Michael Shanahan
- Department of Rheumatology, Flinders University and Flinders Medical Centre, Adelaide, SA, Australia.,Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Karen Glaezter
- Department of Rheumatology, Flinders University and Flinders Medical Centre, Adelaide, SA, Australia.,Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Tiffany Gill
- Discipline of Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - Catherine Hill
- Discipline of Medicine, The University of Adelaide, Adelaide, SA, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville South, SA, Australia.,Rheumatology Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Scott Graf
- Department of Rheumatology, Flinders University and Flinders Medical Centre, Adelaide, SA, Australia
| | - Peter Allcroft
- Southern Adelaide Local Health Network, Adelaide, SA, Australia
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Napoli V, Berchiolli R, Carboncini MC, Sartucci F, Marconi M, Bocci T, Perrone O, Mannoni N, Congestrì C, Benedetti R, Morganti R, Caramella D, Cioni R, Ferrari M. Percutaneous Venous Angioplasty in Patients with Multiple Sclerosis and Chronic Cerebrospinal Venous Insufficiency: A Randomized Wait List Control Study. Ann Vasc Surg 2019; 62:275-286. [PMID: 31445091 DOI: 10.1016/j.avsg.2019.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/18/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Venous percutaneous transluminal angioplasty (vPTA) in patients with multiple sclerosis (MS) and chronic cerebrospinal venous insufficiency (CCSVI) have shown contradictory results. The aim of the study is to evaluate the efficacy of the procedure in a randomized wait list control study. METHODS 66 adults with neurologist-confirmed diagnosis of MS and sonographic diagnosis of CCSVI were allocated into vPTA-yes group (n = 31) or vPTA-not group (n = 35, control group). vPTA was performed immediately 15 days after randomization in the PTA-yes group and 6 months later in the control group. Evoked potentials (EPs), clinical-functional measures (CFMs), and upper limb kinematic measures (ULKMs) were measured at baseline (T0) and six months after in both groups, just before the venous angioplasty in the vPTA-not group (T1). RESULTS Comparing the vPTA-yes and vPTA-not group, the CFM-derived composite functional outcome showed 11 (37%) versus 7 (20%) improved, 1 (3%) versus 3 (8%) stable, 0 versus 7 (20%) worsened, and 19 (61%) versus 18 (51%) mixed patients (χ2 = 8.71, df = 3, P = 0.03). Unadjusted and adjusted (for baseline confounding variables) odds ratio at 95% confidence interval were, respectively, 1.93 (1.3-2.8), P value 0.0007, and 1.85 (1.2-1.7), P value 0.002. EP- and ULKM-derived composite functional outcome showed no significant difference between the two groups. CONCLUSIONS Venous angioplasty can positively impact a few CFMs especially for the quality of life but achieving disability improvement is unlikely.
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Affiliation(s)
- Vinicio Napoli
- Unit of Diagnostic and Interventional Radiology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Raffaella Berchiolli
- Unit of Vascular Surgery, Department of Traslational Research and New Technologies in Medicine and Surgery, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Maria Chiara Carboncini
- Section of Severe Acquired Brain Injuries, Department of Traslational Research and New Technologies in Medicine and Surgery, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Ferdinando Sartucci
- Section of Neurology, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Michele Marconi
- Unit of Vascular Surgery, Department of Traslational Research and New Technologies in Medicine and Surgery, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy.
| | - Tommaso Bocci
- Section of Neurology, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Orsola Perrone
- Unit of Diagnostic and Interventional Radiology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Nicola Mannoni
- Section of Neurology, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Claudia Congestrì
- Section of Neurology, Department of Clinical and Experimental Medicine, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Roberta Benedetti
- Section of Severe Acquired Brain Injuries, Department of Traslational Research and New Technologies in Medicine and Surgery, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Davide Caramella
- Unit of Diagnostic Radiology, Department of Traslational Research and New Technologies in Medicine and Surgery, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Roberto Cioni
- Unit of Diagnostic and Interventional Radiology, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Mauro Ferrari
- Unit of Vascular Surgery, Department of Traslational Research and New Technologies in Medicine and Surgery, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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Abstract
There has been a paradigm shift in medicine away from tradition, anecdote and theoretical reasoning from the basic sciences towards evidence-based medicine (EBM). In palliative care however, statistically significant benefits may be marginal and may not be related to clinical meaningfulness. The typical treatment vs. placebo comparison necessitated by ‘gold standard’ randomised controlled trials (RCTs) is not necessarily applicable. The complex multimorbidity of end of life care involves considerations of the patient’s physical, psychological, social and spiritual needs. In addition, the field of palliative care covers a heterogeneous group of chronic and incurable diseases no longer limited to cancer. Adequate sample sizes can be difficult to achieve, reducing the power of studies and high attrition rates can result in inadequate follow up periods. This review uses examples of the management of cancer-related fatigue and death rattle (noisy breathing) to demonstrate the current state of EBM in palliative care. The future of EBM in palliative care needs to be as diverse as the patients who ultimately derive benefit. Non-RCT methodologies of equivalent quality, validity and size conducted by collaborative research networks using a ‘mixed methods approach’ are likely to pose the correct clinical questions and derive evidence-based yet clinically relevant outcomes.
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Affiliation(s)
- Claire Visser
- 1 Harris Manchester College, University of Oxford, Oxford OX3 9DU, UK ; 2 Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Gina Hadley
- 1 Harris Manchester College, University of Oxford, Oxford OX3 9DU, UK ; 2 Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Bee Wee
- 1 Harris Manchester College, University of Oxford, Oxford OX3 9DU, UK ; 2 Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
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Walthouwer MJL, Oenema A, Lechner L, de Vries H. Use and Effectiveness of a Video- and Text-Driven Web-Based Computer-Tailored Intervention: Randomized Controlled Trial. J Med Internet Res 2015; 17:e222. [PMID: 26408488 PMCID: PMC4642388 DOI: 10.2196/jmir.4496] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 06/23/2015] [Accepted: 07/08/2015] [Indexed: 12/19/2022] Open
Abstract
Background Many Web-based computer-tailored interventions are characterized by high dropout rates, which limit their potential impact. Objective This study had 4 aims: (1) examining if the use of a Web-based computer-tailored obesity prevention intervention can be increased by using videos as the delivery format, (2) examining if the delivery of intervention content via participants’ preferred delivery format can increase intervention use, (3) examining if intervention effects are moderated by intervention use and matching or mismatching intervention delivery format preference, (4) and identifying which sociodemographic factors and intervention appreciation variables predict intervention use. Methods Data were used from a randomized controlled study into the efficacy of a video and text version of a Web-based computer-tailored obesity prevention intervention consisting of a baseline measurement and a 6-month follow-up measurement. The intervention consisted of 6 weekly sessions and could be used for 3 months. ANCOVAs were conducted to assess differences in use between the video and text version and between participants allocated to a matching and mismatching intervention delivery format. Potential moderation by intervention use and matching/mismatching delivery format on self-reported body mass index (BMI), physical activity, and energy intake was examined using regression analyses with interaction terms. Finally, regression analysis was performed to assess determinants of intervention use. Results In total, 1419 participants completed the baseline questionnaire (follow-up response=71.53%, 1015/1419). Intervention use declined rapidly over time; the first 2 intervention sessions were completed by approximately half of the participants and only 10.9% (104/956) of the study population completed all 6 sessions of the intervention. There were no significant differences in use between the video and text version. Intervention use was significantly higher among participants who were allocated to an intervention condition that matched their preferred intervention delivery format. There were no significant interaction terms for any of the outcome variables; a match and more intervention use did not result in better intervention effects. Participants with a high BMI and participants who felt involved and supported by the intervention were more likely to use the intervention more often. Conclusions Video delivery of tailored feedback does not increase the use of Web-based computer-tailored interventions. However, intervention use can potentially be increased by delivering intervention content via participants’ preferred intervention delivery format and creating feelings of relatedness. Because more intervention use was not associated with better intervention outcomes, more research is needed to examine the optimum number of intervention sessions in terms of maximizing use and effects. Trial Registration Nederlands Trial Register: NTR3501; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3501 (Archived by WebCite at http://www.webcitation.org/6b2tsH8Pk)
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Aoun SM, Nekolaichuk C. Improving the evidence base in palliative care to inform practice and policy: thinking outside the box. J Pain Symptom Manage 2014; 48:1222-35. [PMID: 24727305 DOI: 10.1016/j.jpainsymman.2014.01.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 01/23/2014] [Accepted: 02/07/2014] [Indexed: 02/01/2023]
Abstract
The adoption of evidence-based hierarchies and research methods from other disciplines may not completely translate to complex palliative care settings. The heterogeneity of the palliative care population, complexity of clinical presentations, and fluctuating health states present significant research challenges. The aim of this narrative review was to explore the debate about the use of current evidence-based approaches for conducting research, such as randomized controlled trials and other study designs, in palliative care, and more specifically to (1) describe key myths about palliative care research; (2) highlight substantive challenges of conducting palliative care research, using case illustrations; and (3) propose specific strategies to address some of these challenges. Myths about research in palliative care revolve around evidence hierarchies, sample heterogeneity, random assignment, participant burden, and measurement issues. Challenges arise because of the complex physical, psychological, existential, and spiritual problems faced by patients, families, and service providers. These challenges can be organized according to six general domains: patient, system/organization, context/setting, study design, research team, and ethics. A number of approaches for dealing with challenges in conducting research fall into five separate domains: study design, sampling, conceptual, statistical, and measures and outcomes. Although randomized controlled trials have their place whenever possible, alternative designs may offer more feasible research protocols that can be successfully implemented in palliative care. Therefore, this article highlights "outside the box" approaches that would benefit both clinicians and researchers in the palliative care field. Ultimately, the selection of research designs is dependent on a clearly articulated research question, which drives the research process.
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Affiliation(s)
- Samar M Aoun
- School of Nursing and Midwifery, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia.
| | - Cheryl Nekolaichuk
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
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Williams KB, Glaros A, Walker MP, Cobb CM. Randomized clinical trials: is periodontal research good for patients? Periodontol 2000 2012; 59:32-40. [DOI: 10.1111/j.1600-0757.2011.00430.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vandelanotte C, Duncan MJ, Plotnikoff RC, Mummery WK. Do participants' preferences for mode of delivery (text, video, or both) influence the effectiveness of a Web-based physical activity intervention? J Med Internet Res 2012; 14:e37. [PMID: 22377834 PMCID: PMC3374539 DOI: 10.2196/jmir.1998] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 01/29/2012] [Accepted: 02/06/2012] [Indexed: 12/04/2022] Open
Abstract
Background In randomized controlled trials, participants cannot choose their preferred intervention delivery mode and thus might refuse to participate or not engage fully if assigned to a nonpreferred group. This might underestimate the true effectiveness of behavior-change interventions. Objective To examine whether receiving interventions either matched or mismatched with participants’ preferred delivery mode would influence effectiveness of a Web-based physical activity intervention. Methods Adults (n = 863), recruited via email, were randomly assigned to one of three intervention delivery modes (text based, video based, or combined) and received fully automated, Internet-delivered personal advice about physical activity. Personalized intervention content, based on the theory of planned behavior and stages of change concept, was identical across groups. Online, self-assessed questionnaires measuring physical activity were completed at baseline, 1 week, and 1 month. Physical activity advice acceptability and website usability were assessed at 1 week. Before randomization, participants were asked which delivery mode they preferred, to categorize them as matched or mismatched. Time spent on the website was measured throughout the intervention. We applied intention-to-treat, repeated-measures analyses of covariance to assess group differences. Results Attrition was high (575/863, 66.6%), though equal between groups (t863 =1.31, P =.19). At 1-month follow-up, 93 participants were categorized as matched and 195 as mismatched. They preferred text mode (493/803, 61.4%) over combined (216/803, 26.9%) and video modes (94/803, 11.7%). After the intervention, 20% (26/132) of matched-group participants and 34% (96/282) in the mismatched group changed their delivery mode preference. Time effects were significant for all physical activity outcomes (total physical activity: F2,801 = 5.07, P = .009; number of activity sessions: F2,801 = 7.52, P < .001; walking: F2,801 = 8.32, P < .001; moderate physical activity: F2,801 = 9.53, P < .001; and vigorous physical activity: F2,801 = 6.04, P = .002), indicating that physical activity increased over time for both matched and mismatched groups. Matched-group participants improved physical activity outcomes slightly more than those in the mismatched group, but interaction effects were not significant. Physical activity advice acceptability (content scale: t368 = .10, P = .92; layout scale: t368 = 1.53, P = .12) and website usability (layout scale: t426 = .05, P = .96; ease of use scale: t426 = .21, P = .83) were generally high and did not differ between the matched and mismatched groups. The only significant difference (t621 = 2.16, P = .03) was in relation to total time spent on the website: the mismatched group spent significantly more time on the website (14.4 minutes) than the matched group (12.1 minutes). Conclusion Participants’ preference regarding delivery mode may not significantly influence intervention outcomes. Consequently, allowing participants to choose their preferred delivery mode may not increase effectiveness of Web-based interventions.
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Affiliation(s)
- Corneel Vandelanotte
- Centre for Physical Activity Studies, Institute for Health and Social Science Research, Central Queensland University, Rockhampton, Australia.
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Hanratty B, Goldacre M, Griffith M, Whitehead M, Capewell S. Making the most of routine data in palliative care research--a case study analysis of linked hospital and mortality data on cancer and heart failure patients in Scotland and Oxford. Palliat Med 2008; 22:744-9. [PMID: 18715974 DOI: 10.1177/0269216308095021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The research base of palliative care is growing rapidly, but despite methodological advances, some of the practical challenges of working with people at the end of life will persist. This means that analysis of routine data is arguably more important in studying palliative care than it is in other aspects of health services research. End-of-life researchers have been using the high-quality linked data from cancer registries for many years. This paper explores the value of a less well-known resource for palliative care research: linked mortality and hospital activity data. Two case studies are presented using information from Scotland (population 5.1 million) and the former Oxford region of England (population 2.5 million). The advantages and limitations of linked hospital and mortality data for research and service planning in palliative care are drawn out through analyses investigating hospital bed utilisation by people with cancer and heart failure and the influence of social deprivation on the use of hospital services in the last year of life. The use of such data deserves a higher profile.
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Affiliation(s)
- B Hanratty
- Division of Public Health, University of Liverpool, Liverpool, UK.
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Flemming K, Adamson J, Atkin K. Improving the effectiveness of interventions in palliative care: the potential role of qualitative research in enhancing evidence from randomized controlled trials. Palliat Med 2008; 22:123-31. [PMID: 18372377 DOI: 10.1177/0269216307087319] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Evaluating interventions in palliative care using randomized controlled trials (RCTs) has helped advance the specialty and create an evidence base for the delivery of care. RCTs, however, are notoriously difficult to conduct in palliative care, raising a variety of practical, ethical and moral dilemmas. Mixed-methods research, which combines qualitative research and RCTs, offers a potential solution to these problems. This paper begins by examining the theoretical basis for combining the two approaches, before reviewing the specific role qualitative research could play in planning, conducting and implementing trials. The paper then goes on to explore how palliative care research currently uses the mixed-methods approach, by searching the trials included in six Cochrane Systematic Reviews (n = 146) on the incorporation of qualitative research. Only one trial undertook qualitative research. These findings reflect some of the challenges facing mixed-methods research, which include lack of experience in a research team, the problems of obtaining funding and difficulties in publishing. The paper concludes that while combining qualitative and quantitative research is not a panacea for methodological problems in palliative care research, with careful planning and integration, the approach may enhance the clinical and ethical utility of trial findings, which in turn will improve patient care.
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Affiliation(s)
- Kate Flemming
- Department of Health Sciences, The University of York, York, UK
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Aoun SM, Kristjanson LJ. Evidence in palliative care research: how should it be gathered? Med J Aust 2005; 183:264-6. [PMID: 16138803 DOI: 10.5694/j.1326-5377.2005.tb07034.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2004] [Accepted: 06/23/2005] [Indexed: 11/17/2022]
Affiliation(s)
- Samar M Aoun
- School of Nursing and Public Health, Edith Cowan University, Churchlands, WA 6018, Australia.
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Abstract
This paper examines the debate about best evidence within the public health literature and proposes that similar arguments and concerns exist with respect to use of current evidence-based approaches to implementing research and evaluating the literature in palliative care. Whilst randomized controlled trials (RCTs) remain the gold standard and are appropriate in many instances of palliative care research, there is a need for an alternate research design framework that incorporates contextual and compositional effects pertinent to palliative care research. A framework, entitled Equity-Based Evidence, is discussed as an approach to evidence-based knowledge development in palliative care.
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Affiliation(s)
- Samar M Aoun
- WA Centre for Cancer and Palliative Care, School of Nursing, Midwifery and Postgraduate Medicine, Edith Cowan University, Churchlands 6018, Western Australia.
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