The Emperor's New Clothes: a Critical Appraisal of Evidence-based Medicine

Professional responsibility between guidelines and customary practice. A conflict of interest?

In Countries with Common Law, the principles of medical liability in case of malpractice claim are based on the Bolam/Bolitho tests, that is, the opinion of a panel of average professionals of the same specialty. On the contrary, in Countries whose legal system is based on the Corpus Iustinianeum the practice of a doctor is benchmarked against established guidelines. Occasionally, the opinion of an expert panel may not overlap the formal guidelines, in particular in cases like the surgical treatment of acute diverticulitis and that of acute cholecystitis where pre-existing old-fashioned ideas are so rooted into the behaviour of doctors that they are extremely difficult to eradicate despite the growing amount of evidence. This may lead to the paradox that a doctor who followed the guidelines might be considered imprudent or negligent as his or her choice did not overlap that of the "average" professional. This is a grey area that needs clarification. We propose that the "expert panel" nominated during a medical malpractice claim should not report their personal - although shared - opinion, but should unbiasedly report all the available acceptable options. Criminal and civil courts, along with other medical panels, must consider this bias when scrutinizing the practice of a professional.

Barriers to the conduct and application of research among complementary and alternative medicine professions in Australia and New Zealand: A cross-sectional survey

INTRODUCTION

Despite the growing international popularity and use of complementary and alternative medicine (CAM), the uptake of evidence-based practice (EBP) in CAM has been slow. This cross-sectional survey aimed to further our understanding of the factors impacting EBP uptake in CAM.

METHODS

The 32-item oBSTACLES instrument was administered online using the SurveyMonkey™platform. The survey evaluated barriers to both the conduct and application of research among CAM practitioners and researchers, from multiple CAM disciplines across Australia and New Zealand. Participants were recruited via practice-based research networks, professional associations, CAM educational institutions, CAM research centres, pertinent product manufacturers and social media platforms. Data were analysed using descriptive statistics.

RESULTS

Six hundred and eighty-two CAM stakeholders responded to the survey. Barrier items were divided into two interlinked constructs, "capacity" and "culture". Capacity related to issues regarding access, competency, bias, incentives, and time, whereas culture related to values and complex systems. Under capacity, the greatest proportion of participants (>70 %) agreed that access was a barrier to the conduct and application of research, including lack of funding, institutional support, research training and collaborations. In terms of culture, the majority of participants (>60 %) agreed that values were a barrier to research conduct and application, including limited undergraduate research opportunities and diverse views of evidence.

CONCLUSION

Findings from this research suggest a multitude of barriers negatively impact the conduct and application of research in CAM. Insights gained from this research will be instrumental in developing actionable strategies aimed at mitigating the impact of these barriers to improve research engagement in CAM.

Emperor's syndrome in the COVID-19 era: Time for patient-centered nephrology?

The coronavirus disease-19 (COVID-19) pandemic has been a wake-up call in which has forced us to react worldwide. Health policies and practices have attracted particular attention in terms of human and financial cost. Before COVID-19, chronic kidney disease was already considered a risk multiplier in patients with diabetes and hypertension, the two now being the major risk factors for COVID-19 infection and adverse outcome. In contrast to the urgent need for action, the nephrology field is considered to be in a state of stagnation regarding the management of chronic kidney disease patients who still experience unacceptably high morbidity and mortality. Ironically and paradoxically in a field lacking robust clinical trials, clinical practice is driven by guidelines-based medicine on weak evidence. The Emperor's syndrome, referring to Hans Christian Andersen's fairy tale, has been described in medicine as voluntary blindness to an obvious truth, being a weak evidence-based therapeutic intervention or weak health care. A promising positive example of improving heart and kidney outcomes is the emerging treatment with sodium-glucose cotransporter 2 inhibitors. COVID-19 could boost actions for patient-centered care as a positive shift in nephrology care.

Use of online knowledge base in primary health care and correlation to health care quality: an observational study

Background

Evidence-based information available at the point of care improves patient care outcomes. Online knowledge bases can increase the application of evidence-based medicine and influence patient outcome data which may be captured in quality registries. The aim of this study was to explore the effect of use of an online knowledge base on patient experiences and health care quality.

Methods

The study was conducted as a retrospective, observational study of 24 primary health care centers in Sweden exploring their use of an online knowledge base. Frequency of use was compared to patient outcomes in two national quality registries. A socio-economic Care Need Index was applied to assess whether the burden of care influenced the results from those quality registries. Non-parametric statistical methods and linear regression were used.

Results

Frequency of knowledge base use showed two groups: frequent and non-frequent users, with a significant use difference between the groups (p < 0.001). Outcome data showed significant higher values for all seven National Primary Care Patient Survey dimensions in the frequent compared to the non-frequent knowledge base users (p < 0.001), whereas 10 out of 11 parameters in the National Diabetes Register showed no differences between the groups (p > 0.05). Adjusting for Care Need Index had almost no effect on the outcomes for the groups.

Conclusions

Frequent users of a national online knowledge base received higher ratings on patient experiences, but figures on health care quality in diabetes showed near to no correlation. The findings indicate that some effects may be attributed to the use of knowledge bases and requires a controlled evaluation.

Gaps between research and recommendations in rheumatoid arthritis

OBJECTIVES

To identify recommendations on the diagnosis and management of rheumatoid arthritis (RA) supported by low recommendation grades, to study the causes of this low grading, and to propose solutions.

METHODS

A group of six rheumatologists, with extensive experience in the development of systematic reviews, reviewed national and international RA recommendations and practice guidelines. They identified all recommendations with a low level of evidence or recommendation grade (levels equivalent to 4, 5, or grades C or D of the Oxford Levels of Evidence), classified them by areas (diagnosis, follow-up, treatment, others), and analyzed plausible causes of low graduation. A Delphi was used to select 10 recommendations where it was most important to obtain quality evidence to support them. Subsequently, actions were proposed to improve evidence and recommendation grading.

RESULTS

Fourteen documents were analyzed, in which 192 recommendations with low evidence/grade of recommendation were identified, most of which were on treatment. The two most frequent causes of this low level are the absence of studies and the discrepancy between the wording of the recommendation and the evidence used. Finally, the proposed solution to the critical recommendations is a list of unanswered research questions and possible designs to answer them.

CONCLUSIONS

We propose to design and promote research that truly supports or rectifies clinical practice and, thus, bridges the gap between existing evidence and critical recommendations.

Evidence, rationality, and ignorance: Agnotological issues in COVID-19 science

Two decades ago, Robert Proctor coined the term agnotology to refer to the study of ignorance that stems from scientific research. Amid the coronavirus disease pandemic, the world is witnessing the greatest natural experiment ever, and countries have adopted different response strategies. An evaluation of the effectiveness of different policies will play a valuable role in preparing for future public health emergencies. However, controversial issues such as the timing and pathways of viral emergence, the effectiveness of social distancing and lockdown strategies, and the use of antimalarial drugs as therapy have still not been fully resolved. This serves as a fertile breeding ground for agnotological strategies, whereby scientific studies are deliberately or unintentionally designed to create distractions or draw conclusions that are not supported by research findings. Researchers, public health authorities, and healthcare workers should be equipped to identify such agnotological strategies, distinguish them from scientific fraud, and avoid drawing misleading inferences based on an irrational adherence to hypotheses and a lack of criticism of implausible results.

[Towards excellence in hospital management. A description of strategical management model]

BACKGROUND AND OBJECTIVE

Health services are evolving from the traditional view of paternalistic medicine towards a more informed and participatory patient-provider relationship. This situation includes the empowerment and participation of patients and their families in health management, including their joint responsibility in the development of health services. The objective of this article is to describe the experience in a large teaching hospital in Spain on the application of a model that focuses on a three-fold approach to healthcare management that includes the experience of the patient.

MATERIAL AND METHODS

This approach is identified by the initials EMC2 transforming the E of excellence into 3main areas of improvement: methodology, clinical knowledge and client, or patient, experience. the model has been implemented in different areas: childbirth, asthma care, outpatient clinics, and operating theatre.

RESULTS

In the case of childbirth, there was a reduction in caesarean sections, episiotomies, induction of delivery, mean hospital stay, and number of deliveries with instrumentation. The Net Promoter Score went from 82 to 86. There was also an improvement in the areas of patient experience, hospital procedures, and clinical knowledge. Qualitative improvement results were obtained in other areas such as, asthma management, outpatient visits, and the operating room.

CONCLUSIONS

This model can be applied to different areas. It promotes patient-focused practice, as well as system sustainability, efficiency, effectiveness, and level of satisfaction with the health care process.