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Evans B, Ekpo E. Do referral guidelines recommend chest x-rays for patients with abdominal pain? A review. J Med Imaging Radiat Sci 2021; 52:606-614. [PMID: 34903354 DOI: 10.1016/j.jmir.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/02/2021] [Accepted: 08/31/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chest X-rays (CXRs) are often requested for patients who present to emergency with abdominal pain, but its benefit to patient management remains unclear. Several guidelines have been developed to ensure that imaging investigations have the highest diagnostic impact. This study aims to compare referral guidelines to establish their recommendations and circumstances for recommendations regarding CXRs for patients with abdominal pain. METHODS A systematic search of the literature was performed using Medline (via OVID), PubMed, Google, and Google Scholar. Referral guidelines were included if they provided recommendations for imaging of abdominal pain, were based on published evidence, and were broadly utilised. Data related to their recommendations for CXR for abdominal pain was recorded and analysed. RESULTS Three guidelines supported the use of CXRs in the case of suspected perforation. Two guidelines included CXR for patients presenting with blunt abdominal trauma and severe abdominal pain requiring admission. One of the guidelines included use of CXRs for patients presenting with suspected small bowel obstruction, cholecystitis, and penetrating trauma. Two guidelines recorded no circumstances where the use of CXRs were recommended. CONCLUSION Published evidence-based guidelines allow for the use of CXRs for patients presenting with abdominal pain in very limited circumstances.
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Affiliation(s)
- Brian Evans
- Medical Image Optimisation and Perception Group (MIOPeG), Faculty of Medicine and Health, The University of Sydney, Australia; Orange Radiology, Laboratories and Research Centre, Calabar, Nigeria.
| | - Ernest Ekpo
- Medical Image Optimisation and Perception Group (MIOPeG), Faculty of Medicine and Health, The University of Sydney, Australia; Orange Radiology, Laboratories and Research Centre, Calabar, Nigeria
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White A, Kawakita K. The Evidence on Acupuncture for Knee Osteoarthritis – Editorial Summary on the Implications for Health Policy. Acupunct Med 2018. [DOI: 10.1136/aim.24.suppl.71] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Decisions on whether a health service should provide a particular treatment are based on the evidence on three questions: 1) whether the treatment can work, ie it is biologically active; 2) whether the treatment is safe and effective in daily practice; and 3) whether it is economically worthwhile. Evidence presented at the Kyoto conference shows that acupuncture for osteoarthritis of the knee has a biological effect, has a large clinical effect in practice, has negligible risk, and has a cost effectiveness which is well within the usual acceptable limit. On the present evidence, acupuncture is likely to offer an alternative to treatment with non-steroidal anti-inflammatory drugs (NSAIDs).
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Affiliation(s)
| | - Kenji Kawakita
- Department of Physiology Meiji University of Oriental Medicine Japan
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Monteiro S, Norman G, Sherbino J. The 3 faces of clinical reasoning: Epistemological explorations of disparate error reduction strategies. J Eval Clin Pract 2018. [PMID: 29532584 DOI: 10.1111/jep.12907] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
There is general consensus that clinical reasoning involves 2 stages: a rapid stage where 1 or more diagnostic hypotheses are advanced and a slower stage where these hypotheses are tested or confirmed. The rapid hypothesis generation stage is considered inaccessible for analysis or observation. Consequently, recent research on clinical reasoning has focused specifically on improving the accuracy of the slower, hypothesis confirmation stage. Three perspectives have developed in this line of research, and each proposes different error reduction strategies for clinical reasoning. This paper considers these 3 perspectives and examines the underlying assumptions. Additionally, this paper reviews the evidence, or lack of, behind each class of error reduction strategies. The first perspective takes an epidemiological stance, appealing to the benefits of incorporating population data and evidence-based medicine in every day clinical reasoning. The second builds on the heuristic and bias research programme, appealing to a special class of dual process reasoning models that theorizes a rapid error prone cognitive process for problem solving with a slower more logical cognitive process capable of correcting those errors. Finally, the third perspective borrows from an exemplar model of categorization that explicitly relates clinical knowledge and experience to diagnostic accuracy.
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Affiliation(s)
- Sandra Monteiro
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,McMaster (Faculty of Health Sciences Program) Education Research, Innovation and Theory, McMaster University, Hamilton, Ontario, Canada
| | - Geoff Norman
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada.,McMaster (Faculty of Health Sciences Program) Education Research, Innovation and Theory, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan Sherbino
- McMaster (Faculty of Health Sciences Program) Education Research, Innovation and Theory, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Ilott I, Taylor MC, Bolanos C. Evidence-Based Occupational Therapy: It's Time to Take a Global Approach. Br J Occup Ther 2016. [DOI: 10.1177/030802260606900107] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This opinion piece advocates that the time is right to adopt a worldwide strategic approach to evidence-based occupational therapy (EBOT). This means globalising the evidence and localising decision making in a context-sensitive way. The main barriers to and needs for collaborative action over the next 10 years are identified. The analysis is based on our experience and on reflections upon an international meeting on EBOT held in Washington DC in 2004. We hope to challenge readers to think about what they can do to make EBOT a reality for everyone everywhere.
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Fernandez-Llatas C, Lizondo A, Monton E, Benedi JM, Traver V. Process Mining Methodology for Health Process Tracking Using Real-Time Indoor Location Systems. SENSORS (BASEL, SWITZERLAND) 2015; 15:29821-40. [PMID: 26633395 PMCID: PMC4721690 DOI: 10.3390/s151229769] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/17/2015] [Accepted: 11/20/2015] [Indexed: 11/18/2022]
Abstract
The definition of efficient and accurate health processes in hospitals is crucial for ensuring an adequate quality of service. Knowing and improving the behavior of the surgical processes in a hospital can improve the number of patients that can be operated on using the same resources. However, the measure of this process is usually made in an obtrusive way, forcing nurses to get information and time data, affecting the proper process and generating inaccurate data due to human errors during the stressful journey of health staff in the operating theater. The use of indoor location systems can take time information about the process in an unobtrusive way, freeing nurses, allowing them to engage in purely welfare work. However, it is necessary to present these data in a understandable way for health professionals, who cannot deal with large amounts of historical localization log data. The use of process mining techniques can deal with this problem, offering an easily understandable view of the process. In this paper, we present a tool and a process mining-based methodology that, using indoor location systems, enables health staff not only to represent the process, but to know precise information about the deployment of the process in an unobtrusive and transparent way. We have successfully tested this tool in a real surgical area with 3613 patients during February, March and April of 2015.
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Affiliation(s)
- Carlos Fernandez-Llatas
- Instituto Universitario de Investigación de Aplicaciones de las Tecnologías de la Información y de las Comunicaciones Avanzadas (ITACA), Universitat Politecnica de Valencia, Camino de Vera S/N, Valencia 46022, Spain.
- Unidad Mixta de Reingeniería de Procesos Sociosanitarios (eRPSS), Instituto de Investigación Sanitaria del Hospital Universitario y Politecnico La Fe, Bulevar Sur S/N, Valencia 46026, Spain.
| | - Aroa Lizondo
- Instituto Universitario de Investigación de Aplicaciones de las Tecnologías de la Información y de las Comunicaciones Avanzadas (ITACA), Universitat Politecnica de Valencia, Camino de Vera S/N, Valencia 46022, Spain.
| | - Eduardo Monton
- My Sphera S.L. Ronda Auguste y Louis Lumiere 23, Nave 13, Parque Tecnologico, Paterna 46980, Spain.
| | - Jose-Miguel Benedi
- Pattern Recognition and Human Language Technology (PRHTL), Universitat Politecnica de Valencia, Camino de Vera S/N, Valencia 46022, Spain.
| | - Vicente Traver
- Instituto Universitario de Investigación de Aplicaciones de las Tecnologías de la Información y de las Comunicaciones Avanzadas (ITACA), Universitat Politecnica de Valencia, Camino de Vera S/N, Valencia 46022, Spain.
- Unidad Mixta de Reingeniería de Procesos Sociosanitarios (eRPSS), Instituto de Investigación Sanitaria del Hospital Universitario y Politecnico La Fe, Bulevar Sur S/N, Valencia 46026, Spain.
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Attitudes toward evidence-based clinical practice among doctors of chiropractic with diplomate-level training in orthopedics. Chiropr Man Therap 2013; 21:43. [PMID: 24314309 PMCID: PMC4029280 DOI: 10.1186/2045-709x-21-43] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 09/29/2013] [Indexed: 11/24/2022] Open
Abstract
Background Evidence-based clinical practice (EBCP) is a practice model gaining prominence within healthcare, including the chiropractic profession. The status of EBCP has been evaluated in a variety of healthcare disciplines, but little is known regarding the attitudes doctors of chiropractic (DCs) hold toward this model of healthcare. This project examines the attitudes toward EBCP within a specialty discipline of DCs. Methods We identified a survey questionnaire previously used to evaluate EBCP among non-chiropractic complementary and alternative practitioners. We adapted this questionnaire for use among DCs and pretested it in 5 chiropractic college faculty. The final version was administered to DCs with diplomate-level training in orthopedics. The survey was emailed to 299 potential participants; descriptive results were calculated. Results 144 surveys were returned, resulting in a 48% response rate. The majority of respondents perceived EBCP as an important aspect of chiropractic practice. Respondents also believed themselves to have an above average skill level in EBCP, reported that training originated from their diplomate education, and based the majority of their practice on clinical research. Conclusion Doctors of chiropractic with an orthopedic diplomate appear to have favorable attitudes toward EBCP. Further study will help understand EBCP perceptions among general field DCs. A logical next step includes validation of this questionnaire.
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Upshur REG, Tracy CS. Is evidence-based medicine overrated in family medicine?: Yes. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2013; 59:1160-1161. [PMID: 24235185 PMCID: PMC3828088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Ross E G Upshur
- Department of Family and Community Medicine, University of Toronto, 2075 Bayview Ave, Toronto, ON M4N 3M5.
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Making the improbable probable: communication across models of medical practice. HEALTH CARE ANALYSIS 2012; 22:160-73. [PMID: 22743693 DOI: 10.1007/s10728-012-0214-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cooperation and conversation in the public sphere may overcome historical and other barriers to rational argumentation. As an alternative to evidence-based medicine (EBM) and patient-centered care (PCC), the recent development of a modern version of person-centered medicine (PCM) signals an opportunity for a conversational pluralogue to replace parallel monologues between EBM and its critics, and the calls to EBM to debate its critics. This article draws upon elements of Habermas's theory of communicative action in order to suggest the kind of pluralogue that is required for stakeholders in modern medicine to benefit more from publicly conversing with each other than speaking alone or using debate to argue against each other. This reasoned perspective has lessons for all discourse when deep value-based and epistemological differences cannot be easily adjudicated.
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Batistatou A, Doulis EA, Tiniakos D, Anogiannaki A, Charalabopoulos K. The introduction of medical humanities in the undergraduate curriculum of Greek medical schools: challenge and necessity. Hippokratia 2010; 14:241-243. [PMID: 21311630 PMCID: PMC3031316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND AND AIM Medical humanities is a multidisciplinary field, consisting of humanities (theory of literature and arts, philosophy, ethics, history and theology), social sciences (anthropology, psychology and sociology) and arts (literature, theater, cinema, music and visual arts), integrated in the undergraduate curriculum of Medical schools. The aim of the present study is to discuss medical humanities and support the necessity of introduction of a medical humanities course in the curriculum of Greek medical schools. MATERIALS, METHODS AND RESULTS Through the relevant Pub-Med search as well as taking into account various curricula of medical schools, it is evident that medical education today is characterized by acquisition of knowledge and skills and development of medical values and attitudes. Clinical observation with the recognition of key data and patterns in the collected information, is crucial in the final medical decision, i.e. in the complex process, through which doctors accumulate data, reach conclusions and decide on therapy. All sciences included in medical humanities are important for the high quality education of future doctors. The practice of Medicine is in large an image-related science. The history of anatomy and art are closely related, already from the Renaissance time. Studies have shown that attendance of courses on art critics improves the observational skills of medical students. Literature is the source of information about the nature and source of human emotions and behavior and of narratives of illness, and increases imagination. Philosophy aids in the development of analytical and synthetical thinking. Teaching of history of medicine develops humility and aids in avoiding the repetition of mistakes of the past, and quite often raises research and therapeutic skepticism. The comprehension of medical ethics and professional deontology guides the patient-doctor relationship, as well as the relations between physicians and their colleagues. The Medical Humanities course, which is already integrated in the undergraduate curriculum of many medical schools of Europe, USA and Australia, includes lectures by experts and students presentations on the above-mentioned areas and could be offered, for a semester, during the first years. CONCLUSION The aim of Medical Humanities course is the development of imagination and interpretation of data through analytical complex procedures, the development of skills of close observation and careful interpretation of the patient "language" and the enhancement of empathy for the patients, as well as the development of the physician-patient relationship and finally the conceptualization/construction of personal and professional values.
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Mahajan R, Singh NR, Singh J, Dixit A, Jain A, Gupta A. Assessment of Awareness among Clinicians about Concepts in Undergraduate Pharmacology Curriculum: A Novel Cross-sectional Study. J Young Pharm 2010; 2:301-5. [PMID: 21042490 PMCID: PMC2964763 DOI: 10.4103/0975-1483.66797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE In the last 30 years, concepts in pharmacology have moved from Essential Medicines (EM) to P-drugs via the Rational Use of Medicines (RUM), but no structured study has evaluated the level of understanding among working clinicians about these concepts. The present study is designed to fulfill that lacuna. MATERIALS AND METHODS A cross-sectional study was carried out in and around the teaching hospitals attached to Medical Colleges, enrolling 504 clinicians from six centers across North India to fill-up a questionnaire containing 25 questions. The results were compiled using percentages and averages. RESULTS Only one-fourth of the participants claimed that they always prescribed Essential Medicines; no one could accurately count the number of drugs / drug combinations in the Indian Essential Drug list; only 15.1% of the clinicians used to write the generic names of drugs on a prescription slip; about one-third of the clinicians were not fully aware about the adverse effects, drug interactions, and contraindications of the drugs they prescribed; about 83% of the physicians admitted to rely on information from Medical Representatives (MRs) and the interest in research activities seemed to be lost. CONCLUSION Results show a sorry state of affairs among clinicians, as far as the level of understanding about EM, P-drugs, and RUM is concerned, and points toward arranging more continuing medical education (CME) for clinicians regarding these concepts.
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Affiliation(s)
- R Mahajan
- Department of Pharmacology, Adesh Institute of Medical Sciences and Research, Bathinda - 151 109, India
| | - NR Singh
- Department of Pharmacology, Government Medical College, Amritsar - 143 001, India
| | - J Singh
- Department of Pharmacology, Sri Guru Ramdas Institute of Medical Sciences and Research, Amritsar - 143 001, India
| | - A Dixit
- Department of Pharmacology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana - 133 203, Ambala, India
| | - A Jain
- Department of Pharmacology, Guru Gobind Singh Medical College, Faridkot - 151 203, India
| | - A Gupta
- Department of Pharmacology, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Patiala, India
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Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. CHIROPRACTIC & OSTEOPATHY 2010; 18:3. [PMID: 20184717 PMCID: PMC2841070 DOI: 10.1186/1746-1340-18-3] [Citation(s) in RCA: 274] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2009] [Accepted: 02/25/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions. METHODS The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs. RESULTS By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments. CONCLUSIONS Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.
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Affiliation(s)
- Gert Bronfort
- Northwestern Health Sciences University, Bloomington, MN, USA.
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Maskrey N, Underhill J, Hutchinson A, Shaughnessy A, Slawson D. Getting a Better Grip on Research: The Maze of the Most Busy Life. ACTA ACUST UNITED AC 2010. [DOI: 10.1093/innovait/inp108] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This is the fifth paper in a series of five describing the use of evidence to support decisions made in clinical practice. In the 21st century, health care clinicians, managers and patients expect to see the findings of research incorporated into clinical practice, taking into account the needs and wishes of individual patients. In the previous four papers in this series of five, we have examined why that happens—and often does not happen—and what clinicians and managers can do to improve the use of evidence in consultations. This, the final paper, is written as if from some point in the near future and uses a narrative approach to describe a clinician's progress on a journey to meet the real-world challenges of using evidence in practice.
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Affiliation(s)
| | | | - Andy Hutchinson
- National Prescribing Centre, Evidence Based Therapeutics, Liverpool
| | - Allen Shaughnessy
- Tufts University, Family Medicine Residency at Cambridge Health Alliance, Boston, USA
| | - Dave Slawson
- University of Virginia, Family Medicine Virginia, USA
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Sahora A, Khanna C. A Survey of Evidence in theJournal of Veterinary Internal MedicineOncology Manuscripts from 1999 to 2007. J Vet Intern Med 2010; 24:51-6. [DOI: 10.1111/j.1939-1676.2009.0394.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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Devisch I, Murray SJ. 'We hold these truths to be self-evident': deconstructing 'evidence-based' medical practice. J Eval Clin Pract 2009; 15:950-4. [PMID: 20367689 DOI: 10.1111/j.1365-2753.2009.01232.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Rationale, aims and objectives Evidence-based medicine (EBM) claims to be based on 'evidence', rather than 'intuition'. However, EBM's fundamental distinction between quantitative 'evidence' and qualitative 'intuition' is not self-evident. The meaning of 'evidence' is unclear and no studies of quality exist to demonstrate the superiority of EBM in health care settings. This paper argues that, despite itself, EBM holds out only the illusion of conclusive scientific rigour for clinical decision making, and that EBM ultimately is unable to fulfil its own structural criteria for 'evidence'. Methods Our deconstructive analysis of EBM draws on the work of the French philosopher, Jacques Derrida. Deconstruction works in the name of justice to lay bare, to expose what has been hidden from view. In plain language, we deconstruct EBM's paradigm of 'evidence', the randomized controlled trial (RCT), to demonstrate that there cannot be incontrovertible evidence for EBM as such. We argue that EBM therefore 'auto-deconstructs' its own paradigm, and that medical practitioners, policymakers and patients alike ought to be aware of this failure within EBM itself. Results EBM's strict distinction between admissible evidence (based on RCTs) and other supposedly inadmissible evidence is not itself based on evidence, but rather, on intuition. In other words, according to EBM's own logic, there can be no 'evidentiary' basis for its distinction between admissible and inadmissible evidence. Ultimately, to uphold this fundamental distinction, EBM must seek recourse in (bio)political ideology and an epistemology akin to faith.
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Affiliation(s)
- Michael Loughlin
- Reader in Applied Philosophy, Manchester Metropolitan University, Crewe, Cheshire, UK.
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Ulvenes LV, Aasland O, Nylenna M, Kristiansen IS. Norwegian physicians' knowledge of and opinions about evidence-based medicine: cross-sectional study. PLoS One 2009; 4:e7828. [PMID: 19915708 PMCID: PMC2773422 DOI: 10.1371/journal.pone.0007828] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Accepted: 10/07/2009] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To answer five research questions: Do Norwegian physicians know about the three important aspects of EBM? Do they use EBM methods in their clinical practice? What are their attitudes towards EBM? Has EBM in their opinion changed medical practice during the last 10 years? Do they use EBM based information sources? DESIGN Cross sectional survey in 2006. SETTING Norway. PARTICIPANTS 966 doctors who responded to a questionnaire (70% response rate). RESULTS In total 87% of the physicians mentioned the use of randomised clinical trials as a key aspect of EBM, while 53% of them mentioned use of clinical expertise and only 19% patients' values. 40% of the respondents reported that their practice had always been evidence-based. Many respondents experienced difficulties in using EBM principles in their clinical practice because of lack of time and difficulties in searching EBM based literature. 80% agreed that EBM helps physicians towards better practice and 52% that it improves patients' health. As reasons for changes in medical practice 86% of respondents mentioned medical progress, but only 39% EBM. CONCLUSIONS The results of the study indicate that Norwegian physicians have a limited knowledge of the key aspects of EBM but a positive attitude towards the concept. They had limited experience in the practice of EBM and were rather indifferent to the impact of EBM on medical practice. For solving a patient problem, physicians would rather consult a colleague than searching evidence based resources such as the Cochrane Library.
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Maskrey N, Greenhalgh T. Getting a Better Grip on Research: The Fate of Those Who Ignore History. ACTA ACUST UNITED AC 2009. [DOI: 10.1093/innovait/inp083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Those who ignore history are doomed to repeat it George Santayana American philosopher and poet, 1863–1952 This is the first paper in a series of five describing the use of evidence to support decisions made in clinical practice. The series covers large elements of Statement 2: The general practice consultation, Statement 3.3: Ethics and values based medicine and Statement 3.5: Evidence-based practice of the GP Curriculum.
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Affiliation(s)
- Neal Maskrey
- National Prescribing Centre, Evidence Based Therapeutics, Liverpool
| | - Trisha Greenhalgh
- Research Department of Primary Care and Population, University College London
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Care ideologies reflected in 4 conceptions of pharmaceutical care. Res Social Adm Pharm 2008; 4:332-42. [DOI: 10.1016/j.sapharm.2008.01.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2006] [Revised: 01/21/2008] [Accepted: 01/21/2008] [Indexed: 11/19/2022]
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Miles A, Loughlin M, Polychronis A. Evidence-based healthcare, clinical knowledge and the rise of personalised medicine. J Eval Clin Pract 2008; 14:621-49. [PMID: 19018885 DOI: 10.1111/j.1365-2753.2008.01094.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Winning T, Needleman I, Rohlin M, Carrassi A, Chadwick B, Eaton K, Hardwick K, Ivancakova R, Jallaludin RL, Johnsen D, Kim JG, Lekkas D, Li D, Onisei D, Pissiotis A, Reynolds P, Tonni I, Vanobbergen J, Vassileva R, Virtanen J, Wesselink P, Wilson N. Evidence-based care and the curriculum. EUROPEAN JOURNAL OF DENTAL EDUCATION : OFFICIAL JOURNAL OF THE ASSOCIATION FOR DENTAL EDUCATION IN EUROPE 2008; 12 Suppl 1:48-63. [PMID: 18289268 DOI: 10.1111/j.1600-0579.2007.00480.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
An evidence-based (EB) approach has been a significant driver in reforming healthcare over the past two decades. This change has extended across a broad range of health professions, including oral healthcare. A key element in achieving an EB approach to oral healthcare is educating our practitioners, both current and future. This involves providing opportunities integrated within simulated and actual clinical settings for practitioners to learn and apply the principles and processes of evidence-based oral healthcare (EBOHC). Therefore, the focus of this discussion will be on ways in which EBOHC and associated research activities can be implemented into curricula, with the aim of improving patient care. This paper will initially define the scope of EBOHC and research, what these involve, why they are important, and issues that we need to manage when implementing EBOHC. This will be followed by a discussion of factors that enable successful implementation of EBOHC and research into curricula. The paper concludes with suggestions on the future of EBOHC and research in curricula. Key recommendations related to curricula include strengthening of the culture of a scientific approach to education and oral healthcare provision; complete integration of EBOHC into the curriculum at all levels; and faculty development to implement EBOHC based on their needs and evidence of effective approaches. Key recommendations to support implementation and maintenance of EBOHC include recognition and funding for high-quality systematic reviews and development of associated methodologies relevant for global environments; building global capacity of EBOHC researchers; research into improving translation of effective interventions into education and healthcare practice, including patient-reported outcomes, safety and harms, understanding and incorporation of patient values into EB decision-making, economic evaluation research specific to oral healthcare and effective methods for changing practitioner (faculty) behaviours; and extend access to synthesized research in 'user friendly' formats and languages tailored to meet users' needs. Realizing these recommendations may help to improve access to effective healthcare as a basic human right.
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Affiliation(s)
- T Winning
- The University of Adelaide, Adelaide, SA, Australia.
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Lenz R, Blaser R, Beyer M, Heger O, Biber C, Bäumlein M, Schnabel M. IT support for clinical pathways—Lessons learned. Int J Med Inform 2007; 76 Suppl 3:S397-402. [PMID: 17567529 DOI: 10.1016/j.ijmedinf.2007.04.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 03/26/2007] [Accepted: 04/23/2007] [Indexed: 10/23/2022]
Abstract
Clinical pathways are an effective instrument to decrease undesired practice variability and improve clinician performance. IT-applications embedded into clinical routine work can help to increase pathway compliance. Successfully implementing such applications requires both a responsive IT infrastructure and a participatory and iterative design process aimed at achieving user acceptance and usability. Experiences from the implementation and iterative improvement of an online surgical pathway at Marburg University Medical Centre have shown that pathway conformance actually could be improved by the use of IT. An analysis of the iterative design process has shown that future pathway projects can benefit from the lessons learned during this project. Based on these lessons recommendations for developing well adapted interaction mechanisms are presented, aimed at improving process alignment. Our goal is to build up a library of tested reusable components to reduce the number of iterations for pathway implementation.
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Affiliation(s)
- R Lenz
- Department of Computer Sciences, University of Erlangen, Germany.
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Abstract
This paper puts forward the argument that there are various, competing, and antithetical evidence-based practice (EBP) definitions and acknowledges that the different EBP definitions are based on different epistemological perspectives. However, this is not enough to understand the way in which nurse professionals choose between the various EBP formations and consequently facilitate them in choosing the most appropriate for their needs. Therefore, the current article goes beyond and behind the various EBP epistemologies to identify how individuals choose an epistemology, which consequently will assist our understanding as to how an individual chooses a specific EBP formation. Individuals choose an epistemology on the mere belief that the specific epistemology offers the ideals or ideas of best explaining or interpreting daily reality. These ideals or ideas are termed by science, history, and politics as ideology. Similarly, individual practitioners choose or should choose between the different EBP formations based on their own personal ideology. Consequently, this article proceeds to analyse the various ideologies behind different EBP definitions as to conclude that there are two broad ideologies that inform the various EBP formations, namely the ideology of truth and the ideology of individual emancipation. These two ideologies are analysed and their connections to the various EBP formations are depicted. Eventually, the article concludes that the in-depth, critical, and intentional analysis by individual nurses of their own ideology will allow them to choose the EBP formation that is most appropriate and fitting for them, and their specific situation. Hence, the conscious analysis of individual ideology becomes the criterion for choosing between competing EBP formations and allows for best evidence to be implemented in practice. Therefore, the best way to teach EBP courses is by facilitating students to analyse their own ideology.
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Affiliation(s)
- Stefanos Mantzoukas
- Department of Nursing, Highest Technological Educational Institute of Epirus, Ioannina, Greece.
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Affiliation(s)
- Brendan M Reilly
- Department of Medicine, Cook County (Stroger) Hospital, Rush Medical College, Chicago IL 60612, USA.
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Affiliation(s)
- Andrew Miles
- Department of Public Health Sciences, Division of Health and Social Care Research, Medical School at Guy's, King's College and St Thomas' Hospitals, King's College School of Medicine, University of London, UK.
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Bell SC, Robinson PJ. Exacerbations in cystic fibrosis: 2 . prevention. Thorax 2007; 62:723-32. [PMID: 17687099 PMCID: PMC2117269 DOI: 10.1136/thx.2006.060897] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Accepted: 01/31/2007] [Indexed: 01/12/2023]
Abstract
The life span of people with cystic fibrosis (CF) has increased dramatically over the past 50 years. Many factors have contributed to this improvement. Respiratory exacerbations of CF lung disease are associated with the need for hospitalisation and antibiotic treatment, reduction in the quality of life, fragmented sleep and mortality. A number of preventive treatment strategies have been developed to reduce the frequency and severity of respiratory exacerbations in CF including mucolytic agents, physiotherapy and exercise, antibiotics, nutritional strategies, anti-inflammatory treatments and vaccinations against common respiratory pathogens. The evidence for each of these treatments and their potential impact is discussed.
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Affiliation(s)
- Scott C Bell
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Rode Road, Chermside, Brisbane 4032, Australia.
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Durham L, Hancock HC. Critical care outreach 1: an exploration of fundamental philosophy and underpinning knowledge. Nurs Crit Care 2006; 11:239-47. [PMID: 16983855 DOI: 10.1111/j.1478-5153.2006.00180.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Critical care outreach (Outreach) is central to the effective management of critically ill patients. Its recent, expedited and somewhat uncoordinated introduction has, however, resulted in a lack of understanding about the fundamental philosophical theories and sources of knowledge that underpin it. Furthermore, there is a lack of understanding of the context in which these are applied. It is important that we understand and are able to provide sound rationale and guidance for current and future Outreach practice, for the education of practitioners and in order to evaluate and show the impact of Outreach on patient care. The need for this is heightened in the context of current changes in roles and role boundaries, in which there are significant pressures and expectations from organizations for Outreach teams to demonstrate their effectiveness. The authors argue that the complex situations encountered and managed by Outreach are not amenable to traditional forms of measurement and that its impact on patient care is, therefore, not readily acknowledged by those external to the service. This study explores the philosophical underpinnings and types of knowledge inherent in the practice of Outreach. In doing so, it illuminates how they apply and contribute to the practice and impact of Outreach.
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Affiliation(s)
- Lesley Durham
- City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK.
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Lemarié E. La place de la pneumologie fondée sur les preuves et la pratique: la réalité de la Rive Nord. Rev Mal Respir 2006. [DOI: 10.1016/s0761-8425(06)71644-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hayashino Y, Shimbo T, Tsujii S, Ishii H, Kondo H, Nakamura T, Nagata-Kobayashi S, Fukui T. Cost-effectiveness of coronary artery disease screening in asymptomatic patients with type 2 diabetes and other atherogenic risk factors in Japan: factors influencing on international application of evidence-based guidelines. Int J Cardiol 2006; 118:88-96. [PMID: 16949690 DOI: 10.1016/j.ijcard.2006.03.086] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2005] [Revised: 02/09/2006] [Accepted: 03/24/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Screening for coronary artery disease (CAD) in asymptomatic diabetic patients with atherogenic risk factors is recommended by the American College of Cardiology/American Diabetes Association. It is not clear whether these guidelines apply to the Japanese population with a different epidemiology of CAD. This study evaluates the applicability of the U.S. guidelines to Japan, taking account of cost-effectiveness. DESIGN A cost-effectiveness analysis using a Markov model was performed to measure the clinical benefit and cost of CAD screening in asymptomatic patients with diabetes and additional atherogenic risk factors. We evaluated cohorts of patients stratified by age, gender, and atherogenic risks. The incremental cost-effectiveness of not screening, exercise electrocardiography, exercise echocardiography, and exercise single-photon emission-tomography (SPECT) was calculated. The data used were obtained from the literature. Outcomes are expressed as US dollars per quality-adjusted life year (QALY). RESULTS Compared with not screening, the incremental cost-effectiveness ratio (ICER) of exercise electrocardiography was $31,400/QALY for 60-year-old asymptomatic diabetic men, and 46,600 for 65-year-old women with hypertension and smoking. The ICER of exercise echocardiography was $31,500/QALY and of SPECT was $326,000/QALY, compared with the next dominant strategy. Sensitivity analyses found that these results varied according to age, gender, the combination of additional atherogenic risk factors, and the frequency of screening. CONCLUSION From a societal perspective the U.S. guidelines on screening for CAD in high risk diabetic patients are applicable to the Japanese population. However, the population subjected to screening should be carefully selected to obtain greatest benefit from screening.
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Affiliation(s)
- Yasuaki Hayashino
- Department of Epidemiology and Healthcare Research, Kyoto University Graduate School of Medicine, Konoe-cho, Yoshida, Sakyo-ku, Kyoto 606-8501 Japan.
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Upshur R, Buetow S, Loughlin M, Miles A. Can academic and clinical journals be in financial conflict of interest situations? The case of evidence-based incorporated. J Eval Clin Pract 2006; 12:405-9. [PMID: 16907681 DOI: 10.1111/j.1365-2753.2006.00727.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The hypothesis is advanced that scholarly journals can find themselves in conflict of interest positions when they operate business strategies which for commercial reasons may militate against the publication of articles which question the usefulness of the products being sold. It is suggested on the basis of probabilistic reasoning that the more extensive the merchandizing and the greater the commercial profits, the greater is the potential for conflict of interest. The alternative hypothesis is advanced that such a conflict of interest position cannot possibly exist. The current Hypothesis paper is published in order to stimulate debate on the subject of study. The reader is referred to the Editor's Note p. 395.
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Affiliation(s)
- Ross Upshur
- Primary Care Research Unit, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON, Canada.
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Buetow S, Upshur R, Miles A, Loughlin M. Taking stock of evidence-based medicine: opportunities for its continuing evolution. J Eval Clin Pract 2006; 12:399-404. [PMID: 16907680 DOI: 10.1111/j.1365-2753.2006.00617.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Tough but constructive criticisms of evidence-based medicine (EBM) have without doubt informed the evolution and serial reconstitutions of this approach to clinical decision making and behaviour. Yet, concerns about EBM persist and as EBM changes in response to reflection and criticism, so too do the criticisms themselves. This paper describes our current understanding of EBM and, to identify opportunities for the continuing evolution of EBM, discusses some key attributes of EBM that still or now cause us concern. Specifically, these attributes are the nature of evidence in EBM; the unknown effectiveness of EBM; the clinician-centric focus of EBM; and the potential of EBM to harm patients.
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Affiliation(s)
- Stephen Buetow
- Department of General Practice and Primary Health Care, University of Auckland, Private Bag, Auckland, New Zealand.
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Abstract
OBJECTIVES To present a framework for classifying research-practice gaps to increase clarity in the discourse on evidence-informed practice and policy as it applies to child mental health. METHOD The development of the framework was informed by the research literature about the effectiveness of clinic- and community-based interventions for the prevention and treatment of child mental health problems, patterns of uptake of these interventions, and the research literature about evidence-informed practice and policy. RESULTS Four types of research-practice gaps are proposed: (1) the failure to implement interventions found to be effective, and the implementation of interventions (2) that have been demonstrated to cause harm, (3) that have evidence of no effect, and (4) where the effectiveness is unknown because of the lack of rigorous evaluation. Examples from child mental health are provided for each type. CONCLUSIONS This framework could guide an agenda aimed at reducing research-practice gaps in child mental health. A range of strategies may be required to address the different types of gaps.
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Affiliation(s)
- John D McLENNAN
- Dr. McLennan is with the University of Calgary, Alberta, Canada; and Drs. Wathen, MacMillan, and Lavis are with McMaster University, Hamilton, Ontario, Canada.
| | - C Nadine Wathen
- Dr. McLennan is with the University of Calgary, Alberta, Canada; and Drs. Wathen, MacMillan, and Lavis are with McMaster University, Hamilton, Ontario, Canada
| | - Harriet L MacMILLAN
- Dr. McLennan is with the University of Calgary, Alberta, Canada; and Drs. Wathen, MacMillan, and Lavis are with McMaster University, Hamilton, Ontario, Canada
| | - John N Lavis
- Dr. McLennan is with the University of Calgary, Alberta, Canada; and Drs. Wathen, MacMillan, and Lavis are with McMaster University, Hamilton, Ontario, Canada
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Abstract
'Evidence based medicine' is a paradigm introduced in the 1990s in which collection of clinical data in a reproducible and unbiased way is intended to guide clinical decision-making. This paradigm has been promulgated across the spectrum of medicine, but with more limited critical analysis in the realm of pathology. The 'evidence base' in support of our practices in Anatomic Pathology is a critical issue, given the key role that such diagnoses play in patient management decisions. The question is, 'On what basis are diagnostic opinions rendered in Anatomic Pathology?' The operative question becomes, 'What is the published literature that supports our anatomic pathology interpretations?' This second question was applied to the published literature in Hepatopathology, by identifying the 'citation classics' of this discipline. Specifically, the top 150 most-cited liver pathology articles were analyzed for: authorship; journal of publication; type of publication; and year of publication. Results are as follows. First, it is indeed true that the preeminent hepatopathologists of the age are the most cited authors in the 'top 150'. Second, the most cited articles in hepatopathology are not published in the pathology literature, but are instead published in much higher impact clinical journals. Third, the pathology of viral hepatitis is demonstrated to be extraordinarily well-grounded in 'evidence based medicine'. Much of the remainder of the hepatopathology literature falls into a 'narrative based' paradigm, which is the rigorous reporting of case experience without statistical clinical outcomes validation. Finally, the years of publication reflect, on the one hand, a vigorous recent literature in the pharmaceutical treatment of viral hepatitis, and on the other, a broadly distributed set of 'narrative' articles from the 1960s, 1970s, 1980s, and 1990s. In conclusion, the discipline of hepatopathology appears to be well-grounded in 'evidence based medicine' in the realm of viral hepatitis. The remainder of our discipline rests predominantly upon the time-honored identification of disease process through the publication of narrative case series.
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Affiliation(s)
- James M Crawford
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA.
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Abstract
Low back pain has long been described as a challenge for both primary care physicians and specialists. Management of low back pain has also been criticized as frequently arbitrary, inappropriate, or ineffective. Contributing factors have been an inadequate evidence base and a need for more rigorous appraisals of the available literature. Evidence-based medicine, an approach to clinical problem solving, is predicated on the premise that high-quality health care will result from practices consistent with the best evidence. In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion, authority, and unsystematic clinical observations, evidence-based medicine emphasizes the need for rigorous critical appraisals of the scientific literature to inform medical decision making. Evidence-based medicine places strong weight on the requirement for valid studies, particularly randomized controlled trials, to appropriately evaluate the effectiveness of health care interventions. Because of the rapidly increasing volume of medical literature, however, most clinicians are unable to keep up-to-date with all the new data. Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic reviews and evidence-based clinical practice guidelines. Like primary studies, systematic reviews and clinical practice guidelines must adhere to high methodologic standards to reduce error and bias. As in other areas of medicine, the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings. In addition to more rigorous primary studies, an increasing number of high-quality systematic reviews and evidence-based clinical practice guidelines for low back pain are also available. Although some research gaps and methodologic shortcomings persist, the richer evidence base has greatly improved our understanding of what does and does not work for low back pain. Despite these advances, the best available evidence often does not inform everyday clinical decisions for low back pain. Nonetheless, there is widespread agreement that adherence to evidence-based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care. This article reviews basic principles of evidence-based medicine, discusses evidence-based medicine in the context of low back pain management, and summarizes some useful evidence-based medicine resources.
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Affiliation(s)
- Roger Chou
- The Oregon Evidence-Based Practice Center, The Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA.
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Littlewood JM. European cystic fibrosis society consensus on standards--a roadmap to "best care". J Cyst Fibros 2005; 4:1-5. [PMID: 15752676 DOI: 10.1016/j.jcf.2004.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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