Getting there from here: evidentiary quandaries of the US outcomes movement

"Strangers in the ER": Quality indicators and third party interference in Dutch emergency care

RATIONALE, AIMS, AND OBJECTIVES

This paper examines a remarkable dispute between Dutch insurers, hospitals, doctors, and patients about a set of quality indicators. In 2013, private insurers planned to drastically reform Dutch emergency care using quality indicators they had formulated drawing from clinical guidelines, RCTs, and systematic reviews. Insurers' plans caused much debate in the field of emergency care. As quality indicators have come to play a more central role in health care governance, the questions what constitutes good evidence for them, how they ought to be used, and who controls them have become politically and morally charged. This paper is a case study of how a Dutch public knowledge institution, the National Health Care Institute, intervened in this dispute and how they addressed these questions.

METHOD

We conducted ethnographic research into the knowledge work of the National Health Care Institute. Research entailed document analysis, participant observation, in-depth conversations, and formal interviews with 5 key-informants.

RESULTS

The National Health Care Institute problematized not only the evidence supporting insurers' indicators, but also-and especially-the scope, purpose, and use of the indicators. Our analysis shows the institute's struggle to reconcile the technical rationality of quality indicators with their social and political implications in practice. The institute deconstructed quality indicators as national standards and, instead, promoted the use of indicators in dialogue with stakeholders and their local and contextual knowledge.

CONCLUSIONS

Even if quality indicators are based on scientific evidence, they are not axiomatically good or useful. Both proponents and critics of Evidence-based Medicine always feared uncritical use of evidence by third parties. For non-medical parties who have no access to primary care processes, the type of standardized knowledge professed by Evidence-based Medicine provides the easiest way to gain insights into "what works" in clinical practice. This case study reminds us that using standardized knowledge for the management of health care quality requires the involvement of stakeholders for the development and implementation of indicators, and for the interpretation of their results.

Reasoning, evidence, and clinical decision-making: The great debate moves forward

When the editorial to the first philosophy thematic edition of this journal was published in 2010, critical questioning of underlying assumptions, regarding such crucial issues as clinical decision making, practical reasoning, and the nature of evidence in health care, was still derided by some prominent contributors to the literature on medical practice. Things have changed dramatically. Far from being derided or dismissed as a distraction from practical concerns, the discussion of such fundamental questions, and their implications for matters of practical import, is currently the preoccupation of some of the most influential and insightful contributors to the on-going evidence-based medicine debate. Discussions focus on practical wisdom, evidence, and value and the relationship between rationality and context. In the debate about clinical practice, we are going to have to be more explicit and rigorous in future in developing and defending our views about what is valuable in human life.

Evidence-Based Medicine: Toward a New Definition of `Rational' Medicine

Evidence-based medicine (EBM) promises to make the practice of medicine more fully `rational', thereby increasing medicine's reliability and improving patient health outcomes. However, intractable ethical and epistemic problems with applying a model of rationality that privileges quantifiable `evidence' in medical practice - evidence often at odds with nonquantifiable patient experiences, values and preferences - have prompted some within the medical community to condemn EBM. This article analyzes textual evidence from the medical literature as the medical community's effort to rhetorically renegotiate a new model of rationality, one which both preserves rationality's promise to protect medical decision making from the dogmatic, subjective and arbitrary and permits nonquantifiable patient experiences, values and preferences to play a legitimate role in rational diagnostic and therapeutic decision making.

Health-related quality of life in patients undergoing palmar fasciectomy for Dupuytren's disease

BACKGROUND

The present study was undertaken to assess the health-related quality of life in patients with Dupuytren's disease who undergo palmar fasciectomy.

METHODS

A prospective cohort of patients with Dupuytren's disease undergoing palmar and/or digital fasciectomy was recruited from the practice of three plastic surgeons in Hamilton, Ontario, Canada. After written informed consent was obtained, participants were asked to complete three health-related quality-of-life questionnaires (i.e., Short Form-36, Michigan Hand Outcomes Questionnaire, and Health Utility Index Mark 3) at five time points: at 1 week and 1 day preoperatively, and at 1, 3, 6, and 12 months postoperatively. Ranges of motion and grip strength measurement were also recorded.

RESULTS

For the 26 patients in the study, the multiattribute scores of the Health Utility Index Mark 3 improved from 0.80 before surgery to 0.83 at 12 months postoperatively (p > 0.05). There was no difference in the Short Form-36 scores, but the Michigan Hand Outcomes Questionnaire scores improved from 74 at 1 week preoperatively to 90 at the 12-month postoperative visit (p < 0.001).

CONCLUSIONS

Patients who undergo palmar fasciectomy for Dupuytren's disease experience a substantial improvement in their health-related quality of life 12 months after surgery. In the authors' study population, a benefit of 0.85 quality-adjusted life-year within 12 months was observed. This can be translated as follows: the average patient who undergoes palmar fasciectomy gains the equivalent of approximately 14.4 days (0.48 months) in perfect health by undergoing palmar fasciectomy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Mechanisms: what are they evidence for in evidence-based medicine?

Even though the evidence-based medicine (EBM) movement labels mechanisms a low quality form of evidence, consideration of the mechanisms on which medicine relies, and the distinct roles that mechanisms might play in clinical practice, offers a number of insights into EBM itself. In this paper, I examine the connections between EBM and mechanisms from several angles. I diagnose what went wrong in two examples where mechanistic reasoning failed to generate accurate predictions for how a dysfunctional mechanism would respond to intervention. I then use these examples to explain why we should expect this kind of mechanistic reasoning to fail in systematic ways, by situating these failures in terms of evolved complexity of the causal system(s) in question. I argue that there is still a different role in which mechanisms continue to figure as evidence in EBM: namely, in guiding the application of population-level recommendations to individual patients. Thus, even though the evidence-based movement rejects one role in which mechanistic reasoning serves as evidence, there are other evidentiary roles for mechanistic reasoning. This renders plausible the claims of some critics of EBM who point to the ineliminable role of clinical experience. Clearly specifying the ways in which mechanisms and mechanistic reasoning can be involved in clinical practice frames the discussion about EBM and clinical experience in more fruitful terms.

Evidence and expertise

This paper evaluates attempts to defend established concepts of expertise and clinical judgement against the incursions of evidence-based practice. Two related arguments are considered. The first suggests that standard accounts of evidence-based practice imply an overly narrow view of 'evidence', and that a more inclusive concept, incorporating 'patterns of knowing' not recognised by the familiar evidence hierarchies, should be adopted. The second suggests that statistical generalisations cannot be applied non-problematically to individual patients in specific contexts, and points out that this is why we need clinical judgement. In evaluating the first argument, I propose a criterion for what counts as evidence. It is a minimalist criterion but the 'patterns of knowing', referred to in the literature, still fail to meet it. In evaluating the second argument, I will outline the powerful empirical reasons we have for thinking that decisions based on research evidence are usually better than decisions based on clinical judgement; and show that current efforts to rehabilitate clinical judgement seriously underestimate the strength of these reasons. By way of conclusion, I will sketch the ways in which the concept of expertise will have to be modified if we accept evidence-based practice as a template for health-care.

Evidence-based ethics? On evidence-based practice and the "empirical turn" from normative bioethics

Background

The increase in empirical methods of research in bioethics over the last two decades is typically perceived as a welcomed broadening of the discipline, with increased integration of social and life scientists into the field and ethics consultants into the clinical setting, however it also represents a loss of confidence in the typical normative and analytic methods of bioethics.

Discussion

The recent incipiency of "Evidence-Based Ethics" attests to this phenomenon and should be rejected as a solution to the current ambivalence toward the normative resolution of moral problems in a pluralistic society. While "evidence-based" is typically read in medicine and other life and social sciences as the empirically-adequate standard of reasonable practice and a means for increasing certainty, I propose that the evidence-based movement in fact gains consensus by displacing normative discourse with aggregate or statistically-derived empirical evidence as the "bottom line". Therefore, along with wavering on the fact/value distinction, evidence-based ethics threatens bioethics' normative mandate. The appeal of the evidence-based approach is that it offers a means of negotiating the demands of moral pluralism. Rather than appealing to explicit values that are likely not shared by all, "the evidence" is proposed to adjudicate between competing claims. Quantified measures are notably more "neutral" and democratic than liberal markers like "species normal functioning". Yet the positivist notion that claims stand or fall in light of the evidence is untenable; furthermore, the legacy of positivism entails the quieting of empirically non-verifiable (or at least non-falsifiable) considerations like moral claims and judgments. As a result, evidence-based ethics proposes to operate with the implicit normativity that accompanies the production and presentation of all biomedical and scientific facts unchecked.

Summary

The "empirical turn" in bioethics signals a need for reconsideration of the methods used for moral evaluation and resolution, however the options should not include obscuring normative content by seemingly neutral technical measure.

Survival analysis in quality improvement: the Diabetic Kidney Disease Project extrapolation group estimates

Survival analysis is used in a wide variety of research settings to maximize the information extracted from a group of timed observations. Measures employed in continuous quality improvement (CQI) efforts often involve such observations. Yet to date, survival analysis has not been widely used to guide CQI efforts. This article presents the features of survival analysis that are most applicable to CQI efforts and illustrates the application of these techniques to a quality improvement project focused on diabetic kidney disease. Results are compared with those from a "standard" analysis. The interpretation of results is discussed in the context of constraints typical of CQI efforts. The article concludes with a recommendation for broader application of this valuable analytic methodology.

Evidentiary challenges to evidence-based medicine

The evidence-based medicine (EBM) movement has exerted a strong influence on contemporary medicine. It has been used to define the hierarchy of knowledge in clinical medicine by classifying clinical findings according to the perceived relevance and validity of the respective methodologies of studies from which evidence was collected. In the spectrum of theories of knowledge, EBM predominantly relies on findings obtained from population-derived clinical research. This reliance on knowledge obtained from population studies sharply contrasts with a physiologic model of clinical knowledge advocated by basic science researchers and many clinicians. An apparent schism between proponents of physiologic and population models in the approach to the practice of medicine has been created. This dichotomy between practising physicians and EBM physicians in the approach to clinical knowledge should not be irreconcilable. We advocate a consilient approach to the interpretation of evidence and the integration of medical knowledge. This approach relies on 'linking of facts and fact-based theory across various disciplines to create a common groundwork of explanation'.

Evidence-Based Practice in Health Care

Health care practice requires managing large amounts of information. Rapid advances are occurring in available evidence regarding effectiveness and efficiency of various health care services. The health care practitioner must have information management skills plus access to resources and technology. Evidence-based medicine is a philosophy of practice and an approach to decision making that values systematic evidence. There are many similarities in evidence-based practice and the systematic approach to drug information. New information resources and informatics technologies are available, and changes are occurring in health professional education that support an evidence-based practice. Implementation of principles and tools of evidence-based medicine are expected to improve the quality, effectiveness, and efficiency of care.