The promises and pitfalls of evidence-based medicine

The impact of evidence-based medicine curricula on information literacy among clinical medical undergraduates and postgraduates in China

BACKGROUND

Information literacy (IL) is vital in health education, yet studies indicate medical students' IL might be insufficient or deficient. This study aims to evaluate the impact of an integrated Evidence-based Medicine (EBM) course in improving information literacy (IL) skills among Chinese undergraduate and postgraduate medical students.

METHODS

This study included 5-year and 7-year undergraduate students as well as postgraduate students majoring in clinical medicine from West China School of Clinical Medicine at Sichuan University who took the EBM course for the first time between January 2010 and December 2010 and participated in all sessions of the course. This study would employ a pre-and post-course comparison method to assess the impact of the integrated EBM course on the IL across different academic stages of Chinese medical students, in order to offer new and reliable strategies for the improvement of medical education of IL. The study incorporated an Evidence-Based Medicine (EBM) course intervention, followed by a comprehensive assessment of its impact. The course impact is defined as the alterations in students' self-perceived Information Literacy (IL) competencies, measured by the differences between pre-and post-course self-evaluations, along with the objectively demonstrated evidence application skills as reflected in the teacher-graded reports. Specifically, the evaluation of impact contains two parts: 1) subjective assessment, which was students' self-assessments of IL (information acquiring competency, information processing competency and information utilizing competency), conducted before and after the EBM course; 2) objective assessment, which was a teacher's assessment, conducted by having each student submit an evidence-based medical record report after the EBM course, and then the teacher assigning grades based on the records.

RESULTS

A total of 288 medical students participated in the intervention course, including 5-year undergraduates (n = 106), 7-year undergraduates (n = 57) and postgraduates (n = 125). 1) Information acquiring ability: after the course, students demonstrate a more proactive and enthusiastic inclination towards acquiring information. Their capabilities and expertise in information gathering have notably improved. 2) Information processing ability, exhibited by a 9.7% increase in the number of students who can differentiate types of information (p < 0.05), and a 9.8% decrease in students who are unable to evaluate the accuracy of information (p < 0.05) after EBM course; 3) Information utilizing ability, with the percentage of medical students who can cite references in a standard format and synthesize information effectively increased by 18% (p < 0.05) and 10.1% (p < 0.05) respectively after EBM course. And multiple aspects of the three dimensions of IL showed significant improvement in the postgraduate students. 4)Post-course evaluations of the evidence-based medical record indicate that students have demonstrated commendable proficiency in constructing PICO-based questions and applying evidence to formulate clinical decisions rooted in actual clinical scenarios. Notably, over half of the students attained an A grade in this assessment; However, students exhibit relatively weaker skills in acquiring evidence and critical appraisal, particularly among the 5-year undergraduates and postgraduates; In terms of after-effect evaluation, only 10% of the students evaluated both self-evaluation and clinical effect, while most students evaluated the clinical effect alone.

CONCLUSIONS

The integrated Evidence-based Medicine (EBM) course contributes to the improvement of information literacy (IL) skills among Chinese medical students, as is evidenced by the preliminary pre-and post-course comparative analysis. Further randomized controlled trials (RCTs) are needed for a more comprehensive and in-depth evaluation of the impact of EBM on IL. In the future, there should be a reinforced emphasis on the skills related to acquiring information and critical appraisal specifically tailored to clinical questions. Moreover, it is essential to provide differentiated curricula to meet the specific needs of students in different grade levels.

A reproducible framework for monitoring the impact of randomized clinical trials on clinical practice using large-scale real-world data: application to gynaecological surgical trials using the French national healthcare database

Background

Randomized clinical trials (RCTs) are fundamental to evidence-based medicine, but their real-world impact on clinical practice often remains unmonitored. Leveraging large-scale real-world data can enable systematic monitoring of RCT effects. We aimed to develop a reproducible framework using real-world data to assess how major RCTs influence medical practice, using two pivotal surgical RCTs in gynaecologic oncology as an example-the LACC (Laparoscopic Approach to Cervical Cancer) and LION (Lymphadenectomy in Ovarian Neoplasms) trials.

Methods

We utilized data from the French National Health Insurance Database (SNDS), covering 98.8% of France's population. We analysed patients who underwent radical hysterectomy for cervical cancer (2013-2022) and patients who underwent cytoreductive surgery for ovarian cancer (2014-2022). Bayesian structural time series analysis assessed the causal effects of the LACC and LION trials on the discontinuation of minimally invasive surgery (MIS) and lymphadenectomy, respectively. Analyses were stratified by hospital type, academic status, research mission, domain expertise, human resources, and financial condition.

Findings

Our nationwide cohorts included 7108 cervical cancer and 23,090 ovarian cancer patients treated across 596 centres. The LACC trial led to a 14.1% reduction in radical hysterectomies by MIS (275 fewer surgeries; 95% CI: -407 to -140), with academic centres showing 27.9% reduction compared to 2.5% increase in nonacademic centres. The LION trial resulted in a 22.6% reduction in lymphadenectomies (2358 fewer surgeries; 95% CI: -2708 to -2003), with academic centres achieving 31.1% reduction versus 15% in nonacademic centres. Significant variation was observed across medical settings. Centres with academic status, high research missions, substantial expertise, and robust resources were more responsive to trial outcomes, highlighting the influence of institutional and human factors on adopting new practices.

Interpretation

This study demonstrates that large-scale real-world data can effectively monitor the impact of RCTs on clinical practice. While validated here using surgical trials, this reproducible framework is adaptable to various health domains and can be implemented in any country with national electronic health databases. Systematic monitoring is essential to ensure effective implementation of RCT findings and to address disparities in the adoption of evidence-based practices.

Funding

None.

Dialogued into being: Constructing knowledge about hand osteoarthritis from a polyphony of voices in healthcare encounters

PURPOSE

Multiple knowledge sources inform healthcare. In healthcare encounters, patients and health professionals' ideas intersect to understand illness and disease. Exploring what is thought of as legitimate knowledge, and where those reflections come from is central to the process of improving and developing healthcare. Within this context, we aim to explore how knowledge about hand osteoarthritis (OA) is constructed and negotiated in clinical consultations.

METHODOLOGY

The article is based on interviews with 21 patients and 14 health professionals in combination with observation in 16 clinical consultations. Reflexive thematic analysis was used to interpret the data.

RESULTS

We generated four themes from codes to tell an interpretive story about how hand OA meaning-making is "talked into being" in patient-provider encounters: from the dominant voice of health professionals, from patients as knowers in the chronic healthcare dialogue, from health professionals and patients constructing knowledge together and from the construction of knowledge in hybrid positions when patients are health professionals and health professionals have hand OA.

CONCLUSION

New knowledge about hand OA is co-constructed in the situated context of the clinical encounter through a polyphony of voices-some of which are dominant, while others occupy the periphery-within and between the interactants in dialgue.

Publications and ranking in orthopaedics and sports medicine of European countries during the last three decades: A bibliometric analysis

Introduction

The present investigation examined the trend of publications and ranking in Orthopaedics and Sports Medicine of European countries during the years 1996 to 2022 and compared these with all the regions globally.

Methods

In September 2023, the SCOPUS data of publications in Orthopaedics and Sports Medicine from the SCImago Journal & Country Rank website were retrieved. All the data from Western and Eastern Europe were extracted from the overall data of the global countries and merged into Excel files, for each of the years 1996-2022 and 2022.

Results

Western European countries contributed significantly to the global share of publications in Orthopaedics and Sports Medicine with nearly 1/3rd of the total publications. Eastern European countries' contribution was minimal to the global publications and was almost 10 times less than the Western European countries. The total number of publications in the area of Orthopaedics and Sports Medicine from 1996 to 2022 at the European scale was led by the United Kingdom (N = 51510) and has maintained its supremacy until recently, in 2022. Amongst Western European countries, during the cumulative period of 1996-2022, the maximum contributions were made by the United Kingdom (N = 51510), and also in 2022, the United Kingdom contributed maximally (N = 3339). In the cumulative period of 1996-2022, Poland contributed maximally (N = 4049) among the Eastern European countries. In 2022, the maximum contribution from the Eastern European countries came from the Russian Federation (N = 462).

Conclusion

The European continent is the major contributor to Orthopaedics and Sports Medicine research and publications, with almost 1/3rd of the global share of publications. Western European countries are far ahead in their contributions than Eastern European countries.

Contextual influences on knowledge translation capacity in a nursing home organisation: A phenomenological hermeneutical study

INTRODUCTION

The demand for advanced clinical care in nursing homes (NHs) is increasing. Evidence-based practices and knowledge translation (KT) initiatives are growing to bridge the gap between what is known and what is done. However, research on contextual influence on KT has primarily focused on hospital settings.

AIM

To expand our understanding of contextual influences on KT capacity in a NH organisation.

DESIGN AND METHODS

Lindseth and Norberg's phenomenological hermeneutical method was used to explore and describe practice development nurses' experiences, perspectives and practices regarding how contextual factors influence KT capacity in NHs. Focus group interviews, participant observations, in-depth interviews and non-participant observations provided the data.

RESULTS

Two main themes and four subthemes were identified. (1) Continuous limited resources are a cultural condition that inhibits KT readiness; prioritising keeping the NH machinery running at all costs and having contrasting care philosophies undermines KT. (2) Organisational prioritisations leave KT as a missing cogwheel in the machinery; retaining a system of fragmented KT strategies and lacking a structure for collective KT effort.

CONCLUSION

The study showed that KT held a minor role in the fast-paced NH machinery. Contradicting values characterise the NH organisation, resulting in a lack of a common vision and priorities. Building a sustainable KT capacity and providing evidence-based practice necessitates explicit responsibilities, dedicated resources and robust organisational support. Management has a critical role in strengthening the position of KT. Incorporating KT in daily NH practice can help staff become adaptable and confident, capable of meeting the increasing challenges of advanced care that alleviates suffering and promote the health and well-being of NH patients.

Role of practice standardization in outcome optimization for CDH

Standardization of care seeks to improve patient outcomes and healthcare delivery by reducing unwanted variations in care as well as promoting the efficient and effective use of healthcare resources. There are many types of standardization, with clinical practice guidelines (CPGs), based on a stringent assessment of evidence and expert consensus, being the hallmark of high-quality care. This article outlines the history of CPGs, their benefits and shortcomings, with a specific focus on standardization efforts as it relates to congenital diaphragmatic hernia management.

'Planning for a healthy baby and a healthy pregnancy': A critical analysis of Canadian clinical practice guidelines for the treatment of opioid dependence during pregnancy

As opioid fatalities rise in North America, the need to improve the supports available to those who are dependent on opioids and pregnant has become more urgent. This paper discusses the social organisation of drug treatment supports for those who are pregnant, using Canadian clinical practice guidelines (CPGs) for methadone maintenance treatment (MMT) as a case study. Pregnant patients are a priority population for MMT, both in Canada and internationally; the regulatory bodies that oversee MMT in Canada are the provincial Colleges of Physician and Surgeons and Health Canada. The paper analyses MMT CPGs published by these agencies, comparing their general recommendations to those specific to pregnant patients. We demonstrate that the guidelines address few treatment considerations for pregnant patients, other than improved birth outcomes and child welfare, despite acknowledging their more complex needs. Drawing on social science studies of gender and drugs, we argue that MMT CPGs therefore perpetuate the intensified surveillance and foetal prioritisation that have long generated barriers to care for opiate-dependent pregnant patients. We also discuss how and why the CPGs ultimately only reinforced these current limitations in the drug treatment sector.

Good conduct in a context of rationing: A case study of how frontline professionals deal with distributive dilemmas of novel gene therapies

Classical dilemmas of how to distribute limited resources have been rekindled by the rise of advanced, high-cost therapies. Building on a case study of a novel gene therapy in neuropaediatric care, this article explores the dilemmas that explicit priority setting can create for frontline professionals and develops a typology of professionals' responses to these dilemmas. Despite political attempts to centralise priority setting and spare health professionals from having to consider treatment costs at the 'bedside', this study shows that concern for economic efficiency and budget control nonetheless need to be handled and balanced against other accountabilities in the daily work of frontline professionals. Contributing to the sociological debate on priority setting and rationing, this study develops an analytical perspective attuned to the relational aspects of frontline work and the challenges related to the balancing of diverging ideas of good conduct. Further, focussing on an empirical field at the forefront of genomic medicine, this study brings the sociological debate on priority setting and rationing up to date with current developments in precision medicine.

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

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

A systematic review of policy and clinical guidelines on positive risk management

BACKGROUND

National policies and guidelines advocate that mental health practitioners employ positive risk management in clinical practice. However, there is currently a lack of clear guidance and definitions around this technique. Policy reviews can clarify complex issues by qualitatively synthesising common themes in the literature.

AIMS

To review and thematically analyse national policy and guidelines on positive risk management to understand how it is conceptualised and defined.

METHOD

The authors completed a systematic review (PROSPERO: CRD42019122322) of grey literature databases (NICE, NHS England, UK Government) to identify policies and guidelines published between 1980 and April 2019. They analysed the results using thematic analysis.

RESULTS

The authors screened 4999 documents, identifying 7 eligible policies and 19 guidelines. Qualitative synthesis resulted in three main themes: i) the conflicting aims of positive risk management; ii) conditional positive risk management; and iii) responsible positive risk management.

CONCLUSIONS

Analysis highlighted discrepancies and tensions in the conceptualisation of positive risk management both within and between policies. Documents described positive risk management in different and contradictory terms, making it challenging to identify what it is, when it should be employed, and by whom. Five policies offered only very limited definitions of positive risk management.

Multisystem Imaging Recommendations/Guidelines: In the Pursuit of Precision Oncology

With an increasing rate of cancers in almost all age groups and advanced screening techniques leading to an early diagnosis and longer longevity of patients with cancers, it is of utmost importance that radiologists assigned with cancer imaging should be prepared to deal with specific expected and unexpected circumstances that may arise during the lifetime of these patients. Tailored integration of preventive and curative interventions with current health plans and global escalation of efforts for timely diagnosis of cancers will pave the path for a cancer-free world. The commonly encountered circumstances in the current era, complicating cancer imaging, include coronavirus disease 2019 infection, pregnancy and lactation, immunocompromised states, bone marrow transplant, and screening of cancers in the relevant population. In this article, we discuss the imaging recommendations pertaining to cancer screening and diagnosis in the aforementioned clinical circumstances.

The Role of Health Care Communication in Treatment Outcomes

The physician-patient relationship has evolved significantly in the past century. Physician authority has been reduced while patients have been empowered. This review focuses on face-to-face clinical care and argues that current physician-patient relations range from partnerships between social actors who each play critical roles in negotiating care to a more adversarial duel in which both participants advocate for goals that are not necessarily shared. While the former is the hope of increased patient involvement, the latter is increasingly common. Through our discussion of existing studies, we document that while high levels of patient participation are beneficial to treatment outcomes, this engagement also has a dark side that threatens treatment outcomes. We discuss some communication resources patients use that affect treatment outcomes, exemplify how patient engagement affects physician communication, and discuss some strategies that current research finds effective for communicating about treatment with today's engaged patients.

Enacting a depoliticised alterity: law and traditional medicine at the World Health Organization

This paper interrogates the depoliticising effects of a seemingly neutral regulatory drive at the heart of the World Health Organization (WHO)'s promotion of traditional medicine. Emerging at WHO in the late 1960s against a political backdrop of decolonisation and pan-Africanism, traditional medicine has continued to be promoted in subsequent decades, culminating in the latest global Traditional Medicine Strategy (2014 to 2023). Yet WHO's promotion and acceptance of traditional medicine have also become increasingly conditional upon its standardisation and regulation - something that appears fundamentally at odds with traditional medicine's heterogeneity. Drawing on insights from critical law and science and technology studies, we suggest that such a process at WHO has done more than simply disqualify the toxic and the dangerous. Rather, it has implicitly and explicitly marginalised and excluded those aspects of traditional medicine that deviate from scientific, biomedical ways of seeing, knowing and organising.

The (After)life of a Trial: Biocommunicability of an At-Risk Pregnancy

The publication of A Randomized Trial of Induction Versus Expectant Management (ARRIVE), conducted in the United States in 2018, heralded a paradigm shift within the obstetrical management of term pregnancy among people who have not previously given birth. ARRIVE finds its home among other canonical - and controversial - randomized controlled trials (RCTs) within obstetrics. We argue that RCTs have their own (after)life, both creating new subjects for biomedical intervention and recalibrating who reproductive health practitioners consider to be at risk of adverse health outcomes. These data have important consequences for medical social scientific engagement with RCTs to further interrogate the questions of risk and intervention within reproductive health.

Medicalising the menace? The symbiotic convergence of medicine and law enforcement in the medicalisation of marijuana in Minnesota

The medicalisation of marijuana has occurred rapidly, albeit nonuniformly, across the US and around the world over the past 3 decades. This paper centres on the medicalisation of marijuana in Minnesota-which has one of the most restrictive programs in the country-as a case for evaluating the negotiation of institutional boundaries with the shift from criminalisation to medicalisation after nearly a century of criminal prohibition. Drawing upon Foucauldian discourse analyses of the medical and law enforcement associations' position statements and legislative hearings that shaped medical marijuana policy in Minnesota, this paper demonstrates a symbiotic convergence between medicine and law enforcement through the deployment of shared discursive strategies in their opposition to medical marijuana that reinforce marijuana's criminalised status by solidifying the boundaries between proper medicine and dangerous drugs. Criminal justice and medical institutions draw upon one another's definitions, logics, and practices in a mutually constitutive manner, while still maintaining distinct user subjects and institutional interventions for each based on the user's access to state-approved forms of marijuana. The consequences for the governing of marijuana in Minnesota are explored, as well as the broader implications for the sociological study of medicalisation and criminalisation with respect to the governance of drugs and health.

The role of patients in the governance of a sustainable healthcare system: A scoping review

Patients, healthcare providers and insurers need a governance framework to establish the 'rules of use' to deliver more responsible use of services. The objective of this review was to provide an overview of frameworks and analyze the definitions of patient accountability to identify themes and potential gaps in the literature. Fifteen bibliographic databases were searched until July 2021. This included: MEDLINE, EMBASE, CINAHL, PsycINFO, SPORTDiscus, Allied and Complementary Medicine Database, Web of Science, HealthSTAR, Scopus, ABI/INFORM Global, Cochrane Library, ERIC, International Bibliography of the Social Sciences, Sociological Abstracts, Worldwide Political Science Abstracts and International Political Science Abstracts. Searches were also completed in Google Scholar. Inclusion criteria included articles focused on accountability of patients, and exclusions included articles that were not available, not written in English, with missing information, and commentaries or editorials. In total, 85530 unique abstracts were identified, and 27 articles were included based on the inclusion criteria. The results showed that patient accountability is rarely used and poorly defined. Most studies focused on what patients should be held to account for and agreed that patients should be responsible for behaviours that may contribute to adverse health outcomes. Some studies promoted a punitive approach as a mechanism of enforcement. Most studies argued for positive incentives or written agreements and contracts. While many studies recognized the value of patient accountability frameworks, there was a concern that these frameworks could further exacerbate existing socioeconomic disparities and contribute to poor health-related behaviours and outcomes (e.g., stigmatizing marginalized groups). Shared models of accountability between patients and healthcare providers or patients and communities were preferred. Before committing to a patient accountability framework for improving patient health and sustaining a healthcare system, the concept must be acceptable and reasonable to patients, providers, and society as a whole.

Impacts on Context Aware Systems in Evidence-Based Health Informatics: A Review

BACKGROUND

The application of Context Aware Computing (CAC) can be an effective, useful, feasible, and acceptable way to advance medical research and provide health services.

METHODS

This review was conducted in accordance with the principles of the development of a mixed methods review and existing knowledge in the field via the Synthesis Framework for the Assessment of Health Information Technology to evaluate CAC implemented by Evidence-Based Health Informatics (EBHI). A systematic search of the literature was performed during 18 November 2021-22 January 2022 in Cochrane Library, IEEE Xplore, PUBMED, Scopus and in the clinical registry platform Clinicaltrials.gov. The author included the articles in the review if they were implemented by EBHI and concerned with CAC technologies.

RESULTS

29 articles met the inclusion criteria and refer to 26 trials published between 2011 and 2022. The author noticed improvements in healthcare provision using EBHI in the findings of CAC application. She also confirmed that CAC systems are a valuable and reliable method in health care provision.

CONCLUSIONS

The use of CAC systems in healthcare is a promising new area of research and development. The author presented that the evaluation of CAC systems in EBHI presents positive effects on the state of health and the management of long-term diseases. These implications are presented in this article in a detailed, clear, and reliable manner.

Protocol versus practice: Deviations from guidelines in low-risk twin deliveries in the United States

BACKGROUND

Medical guidelines recommend vaginal delivery for low-risk twin pregnancies because cesareans increase the probability of maternal morbidity and mortality. Yet, vaginal delivery rates for twins are considerably lower than for comparable singletons. One explanation for this disparity argues that greater risk associated with twins warrants increased surgical intervention. An alternative explanation is that twin deliveries are more likely to deviate from protocols that advise vaginal birth.

METHODS

Using the 2017 Natality Detail File (N = 3,197,401), we measured alignment of vaginal birth and trial of labor (TOL) with the American College of Obstetricians and Gynecologists' guidelines for twin and singleton no-indicated-risk births. We calculated predicted probabilities for the population and by maternal race/ethnicity to assess whether low rates of vaginal births among twins are explained by associated risk factors, or by deviations from recommended delivery methods.

RESULTS

Overall, 31.2% of twins were born vaginally compared with 79.4% of singletons. Controlling for indicated risks, the predicted probability of vaginal birth for twins was 0.49 and 0.85 for singletons. The predicted probability of TOL for twins was 0.18 and 0.47 for singletons. Maternal race/ethnicity was only weakly associated with mode of delivery. These findings indicate that no-indicated-risk twin pregnancies, across maternal racial/ethnic categories, have lower probabilities of vaginal birth and TOL than would be expected with widespread adherence to current guidelines.

CONCLUSIONS

Given the life-threatening consequences that may result from unnecessary surgical procedures, our findings highlight the need for further research to illuminate medical and nonmedical mechanisms driving nonadherence to clinical guidelines for twin births.

Sources of Information on Medicinal Products Among Physicians - A Survey Conducted Among Primary Care Physicians in Poland

Introduction: Primary care physicians need to have access to up-to-date knowledge in various fields of medicine and high-quality information sources, but little is known about the use and credibility of sources of information on medicinal products among Polish doctors. The main goal of this study was to analyze the sources of information on medicinal products among primary care physicians in Poland.

Methods: A survey was conducted among 316 primary care physicians in Poland. The following information was collected: demographic data of participants, type and frequency of using data sources on medicinal products, barriers to access credible information, assessment of the credibility of the sources used, impact of a given source and other factors on prescription decisions.

Results: The most frequently mentioned sources of information were medical representatives (79%), medical journals (78%) and congresses, conventions, conferences, and training (76%). The greatest difficulty in finding the latest information about medicinal products was the lack of time. The surveyed doctors considered clinical guidelines to be the most credible source of information, and this source also had the greatest impact on the choice of prescribed medicinal products.

Conclusion: The study showed that clinicians consider clinical guidelines as the most credible source of information with the greatest impact on prescribing medicinal products. However, it is not the source most often mentioned by doctors for obtaining knowledge about medicinal products. There is a need to develop strategies and tools to provide physicians with credible sources of information.

Do referral guidelines recommend chest x-rays for patients with abdominal pain? A review

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.

Intervention targeted at physicians' treatment of musculoskeletal disorders and sickness certification: an interrupted time series analysis

OBJECTIVE

An intervention was carried out at the occupational healthcare services (OHS) of the City of Helsinki beginning in 2016. We investigated the association between the intervention and employee sick leaves using interrupted time series analysis.

DESIGN

Register-based cohort study with a quasi-experimental study design.

SETTING

Employees of the City of Helsinki.

PARTICIPANTS

We analysed individual-level register-based data on all employees who were employed by the city for any length of time between 2013 and 2018 (a total 86 970 employees and 3 014 075 sick leave days). Sick leave days and periods that were OHS-based constituted the intervention time series and the rest of the sick leave days and periods contributed to the comparison time series.

INTERVENTION

Recommendations provided to physicians on managing pain and prescribing sick leave for low back, shoulder and elbow pain.

OUTCOME MEASURES

Number of sick leave days per month and sick leave periods per year.

RESULTS

For all sick leave days prescribed at OHS, there was no immediate change in sick leave days, whereas a gradual change showing decreasing number of OHS-based sick leave days was detected. On average, the intervention was estimated to have saved 2.5 sick leave days per year per employee. For other sick leave days, there was an immediate increase in the level of sick leave days after the intervention and a subsequent gradual trend showing decreasing number of sick leave days.

CONCLUSIONS

The intervention may have reduced employee sick leaves and therefore it is possible that it had led to direct cost savings. However, further evidence for causal inferences is needed.

Capturing patients, missing inequities: Data standardization on sexual orientation and gender identity across unequal clinical contexts

In effort to address fundamental causes and reduce health disparities, public programs increasingly mandate sites of care to capture patient data on social and behavioral domains within Electronic Health Records (EHRs). Data reporting drawing from EHRs plays an essential role in public management of social problems, and data on social factors are commonly cited as foundational for eliminating health inequities. Yet one major shortcoming of these data-centered initiatives is their limited attention to social context, including the institutional conditions of biomedical stratification and variation of care provision across clinical settings. In this article, we leverage comparative fieldwork to examine provider and system responses to mandated data collection on patient sexual orientation and gender identity (SOGI), highlighting unequal clinical contexts as they appear across a large county safety-net institution and an LGBTQ-oriented health organization. Although point of care data collection is commonly justified for governance in the aggregate (e.g., disparity monitoring), we find standardized data on social domains presents a double-edged sword in clinical settings: formal categories promote visibility where certain issues remain hidden, yet constrain clinical utility in sites with greater knowledge and experience with related topics. We further illustrate how data standardization captures patient identities yet fundamentally misses these unequal contexts, resulting in limited attenuation of inequity despite broad expectations of clinical change. By revealing the often-invisible contexts of care that elude standard measurement, our findings underline the strengths of qualitative social science in accounting for the complex dynamics of enduring social problems. We call for deeper engagement with the unequal contexts of biomedical stratification, especially in light of increasing pressure to quantify the social amidst the rising tide of data-driven care.

Evaluation of foramen locating accuracy of an endodontic motor integrated with electronic foramen employing optimal glide path kinematics

OBJECTIVE

This study aimed to evaluate the accuracy of the auto apical function in the maintenance of the apical limit of instrumentation during glide path procedures when associated to OGP kinematics of Tri Auto ZX2, compared to the continuous rotation of the same motor, as well as Root ZX II and VDW Gold.

MATERIALS AND METHODS

Forty-eight extracted human mandibular single-rooted premolars were selected. After endodontic access, cervical pre-flaring was performed using size 30, 0.10 taper rotary instruments, and the apical foramen size was standardized to 200 μm. Teeth were randomly divided into four groups (n = 12) according to the device and kinematics. For all the groups, the Auto Apical Stop function (AAS) was set to the 0.0 mark. Glide path instruments size 25, .01 taper were activated inside the canals until the apical limit was reached. Then, the files were fixed with cyanoacrylate to the teeth and decoupled from the equipment. Data were statistically analyzed in GraphPad Prism 6.0 software with the significance set at 5% (Kruskal-Wallis tests).

RESULTS

There was no difference in the mean deviation between the groups. No significant difference was found among the groups when the distributions and percentages of differences between the file tip and the apical foramen were compared (P > 0.05).

CONCLUSION

The use of auto apical function at the 0.0 mark of all tested devices provided an adequate control of the apical limit during glide path preparation. Foramen locating accuracy of Tri Auto ZX2 in OGP kinematics was similar to those of Tri Auto ZX2, Root ZX II, and VDW Gold in continuous kinematics.

CLINICAL RELEVANCE

Clinical strategies in canal negotiation and glide path as OGP motion associated to electronic foramen locators could reduce iatrogenic risk of deviation and file fractures and create an easier initial preparation to facilitate endodontic procedures.

A systematic review of food waste audit methods in hospital foodservices: development of a consensus pathway food waste audit tool

BACKGROUND

To understand, monitor and compare the scope of food waste in hospital foodservices, it is essential to measure food waste using a standardised method. The aims of this systematic review were to: (i) describe and critique the methodological features of waste audits used in hospital foodservice settings that measure aggregate food and food-related waste and (ii) develop a consensus tool for conducting a food waste audit in a hospital foodservice setting.

METHODS

Seven electronic databases were searched for peer reviewed literature, and 17 Google Advanced searches located grey literature that described food waste audit methods previously used or developed for hospital foodservices. Study selection and quality assessment occurred in duplicate. Data describing the audit method, its feasibility, and strengths and limitations were extracted and synthesised to develop a consensus tool.

RESULTS

Eight peer reviewed and nine grey literature documents describing a variety of food waste audit methods were found. The most common practices were 2-week data collection (n = 5), foodservice staff collecting data (n = 6), measuring food waste only (n = 11), measuring food waste at main meals (n = 5) and using electronic scales to measure waste (n = 12). A consensus tool was developed that proposes a method for preparing, conducting and analysing data from a food waste audit.

CONCLUSIONS

This review used published evidence to develop the first ever food waste audit consensus tool for hospital foodservices to use and measure food and food-related waste. Future research is needed to apply and test this tool in practice.

More scientific, more ethical: The ADHD controversy and boundary-work in Taiwan

Attention-deficit/hyperactivity disorder (ADHD) is one of the most controversial childhood psychiatric condition. With the globalisation of its diagnosis and treatment, Taiwan has followed other medically advanced countries in meeting the challenge of medicalising children's problematic behaviours and encountering the resistance discourses on ADHD. To contribute to the extant literature, this study employs the social worlds framework to decipher the relational dynamics amongst these competing discourses on ADHD, namely the mainstream psychiatry, the critiques of overdiagnosis and the antipsychiatric protest, and to suggest the links between these domestic advocacies and the relevant debates abroad. In addition, the concept of boundary-work is used to analyse the strategies through which these collective actors pursue legitimacy for their respective claims. Based on the existing research of scientific and ethical boundary-work, this study argues that when it comes to clinical practices fraught with uncertainties, these two seemingly distinct forms of boundary-work may become mutually supportive in order to act as arbiters of disputes. Despite the disparity of power amongst these social worlds in this case study with seemingly predictable outcomes of the dispute, representing their heterogeneous narratives and the process of discursive struggle helps to destabilise the seemingly naturalised conceptualisation of biomedical ADHD.

Clinical practice guidelines in courts' representation of medical evidence and testimony

This article examines clinical practice guidelines (CPG) in the courtroom. The guidelines in question are Finnish national current care guidelines for brain injuries, and the case context is traffic insurance compensation cases contested in the Helsinki district court. We analyse 11 case verdicts qualitatively, drawing from earlier sociological and theoretical accounts of clinical practice guidelines and evidence-based medicine. What makes the case-type relevant for studying clinical practice guidelines is the fact that the cases, which feature a medical dispute concerning traumatic brain injury, involve highly specialized expertise and contradictory expert claims, but the cases are decided in a generalist court by non-expert judges. What we show in the article is how the guidelines structure, sequence and initiate temporal reworking in the judges' representation of medical evidence and testimony, and how the plaintiffs' delayed diagnoses complicate the application of the CPG in the evaluation. We further discuss the guidelines' epistemic authority in the verdicts and finish by comparing the 2008 and 2017 editions of Finnish CPGs for brain injuries, suggesting a multifaceted, courtroom-mediated feedback loop between the patient-plaintiffs and the clinical practice guidelines.

Standardization vs Customization: Finding the Right Balance

There is an inherent tension between standardization and customization of care delivery processes. The challenge for health care systems is to achieve the right balance. At its best, standardized work can create efficiencies that generate the additional time needed for personalized care. Similarly, at its best, customization allows the people within a system to accommodate the needs, preferences, and circumstances of the unique individuals and local communities they serve. We provide examples and offer principles to decide when standardization offers the most successful path and when customization may be preferred. We believe that, in sum, the balance has shifted too far toward standardization and that a rebalancing toward customization will benefit patients, clinicians, and the health care system.

Knowledge for Nursing Practice: Beyond Evidence Alone

OBJECTIVE

For the past 30 years there has been a growing emphasis on evidence as the primary or exclusive basis for nursing practice.

METHODS

Critical examination of literature related to evidence-based practice from the 1990s to the present.

RESULTS

This review of the nursing literature from the 1990s to the present reveals that in the midst of the movement to promote evidence-based practice as the gold standard, there have been persistent expressions of concern. These concerns are (a) lack of alignment of evidence-based practice with nursing's disciplinary perspective; (b) wrongful privileging of empirical knowledge over other sources of knowledge; (c) underappreciation of the complexity of practice and practice wisdom;(d) possibilities of evidence-based practice thwarting innovation and creativity;(e) vulnerabilities of empirical evidence to be flawed, inconsistent, and influenced by competing interests; (f) situational realities that limit access to and critical appraisal of evidence that access to and critical appraisal of evidence is not feasible or practical; and (g) lack of relationship of evidence-based practice to theory.

CONCLUSIONS

We call for a recalibrated practice epistemology that promotes a greater appreciation for the myriad sources of knowledge for nursing practice, and offer recommendations for international change in education, literature, scholarship, and public media.

Implementation of algorithms in pattern & impression evidence: A responsible and practical roadmap

Over the years, scientific and legal scholars have called for the implementation of algorithms (e.g., statistical methods) in forensic science to provide an empirical foundation to experts' subjective conclusions. Despite the proliferation of numerous approaches, the practitioner community has been reluctant to apply them operationally. Reactions have ranged from passive skepticism to outright opposition, often in favor of traditional experience and expertise as a sufficient basis for conclusions. In this paper, we explore why practitioners are generally in opposition to algorithmic interventions and how their concerns might be overcome. We accomplish this by considering issues concerning human-algorithm interactions in both real world domains and laboratory studies as well as issues concerning the litigation of algorithms in the American legal system. Taking into account those issues, we propose a strategy for approaching the implementation of algorithms, and the different ways algorithms can be implemented, in a responsible and practical manner.

Early Mobilization After Stroke: Do Clinical Practice Guidelines Support Clinicians' Decision-Making?

Importance: Early mobilization, out-of-bed activity, is a component of acute stroke unit care; however, stroke patient heterogeneity requires complex decision-making. Clinically credible and applicable CPGs are needed to support and optimize the delivery of care. In this study, we are specifically exploring the role of clinical practice guidelines to support individual patient-level decision-making by stroke clinicians about early mobilization post-stroke. Methods: Our study uses a novel, two-pronged approach. (1) A review of CPGs containing recommendations for early mobilization practices published after 2015 was appraised using purposely selected items from the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence (AGREE-REX) tool relevant to decision-making for clinicians. (2) A cross-sectional study involving semi-structured interviews with Australian expert stroke clinicians representing content experts and CPG target users. Every CPG was independently assessed against the AGREE-REX standard by two reviewers. Expert stroke clinicians, invited via email, were recruited between June 2019 to March 2020.The main outcomes from the review was the proportion of criteria addressed for each AGREE-REX item by individual and all CPG(s). The main cross-sectional outcomes were the distributions of stroke clinicians' responses about the utility of CPGs, specific areas of uncertainty in early mobilization decision-making, and suggested parameters for inclusion in future early mobilization CPGs. Results: In 18 identified CPGs, many did not adequately address the "Evidence" and "Applicability to Patients" AGREE-REX items. Out of 30 expert stroke clinicians (11 physicians [37%], 11 physiotherapists [37%], 8 nurses [26%]; median [IQR] years of experience, 14 [10-25]), 47% found current CPGs "too broad or vague," while 40% rely on individual clinical judgement and interpretation of the evidence to select an evidence-based choice of action. The areas of uncertainty in decision-making revealed four key suggestions: (1) more granular descriptions of patient and stroke characteristics for appropriate tailoring of decisions, (2) clear statements about when clinical flexibility is appropriate, (3) detailed description of the intervention dose, and (4) physical assessment criteria including safety parameters. Conclusions: The lack of specificity, clinical applicability, and adaptability of current CPGs to effectively respond to the heterogeneous clinical stroke context has provided a clear direction for improvement.

Challenges in user-driven optimization of EHR: A case study of a large Epic implementation in Denmark

BACKGROUND

Research suggests that capturing the benefits of electronic health records (EHR) requires systematic and ongoing optimization of technology configuration and use after implementation. However, little is known about EHR optimization in a hospital context.

OBJECTIVE

To explore the issues and challenges involved in organizing and managing a systematic user-driven EHR optimization program.

METHODS

A longitudinal case study of an EHR optimization program launched in two large Danish hospital systems was undertaken. It involved interviewing 28 key managers, clinicians and IT staff, participating in formal and informal meetings, and reviewing policy documents, meeting minutes, teaching materials and other relevant documents.

FINDINGS

The two hospital systems are struggling to find the best way to organize and manage the optimization program. So far, the program has been a mixed success. Involving clinicians in EHR optimization poses serious dilemmas for hospital managers, who must manage two related tensions: between standardization and adaptation, and between centralized control and local autonomy.

CONCLUSION

The findings highlight the significant challenges in designing a successful EHR optimization program and underscore the importance of developing more sophisticated strategies for clinical standardization and innovation.

Blind-sided by privacy? Digital contact tracing, the Apple/Google API and big tech's newfound role as global health policy makers

Since the outbreak of COVID-19, governments have turned their attention to digital contact tracing. In many countries, public debate has focused on the risks this technology poses to privacy, with advocates and experts sounding alarm bells about surveillance and mission creep reminiscent of the post 9/11 era. Yet, when Apple and Google launched their contact tracing API in April 2020, some of the world's leading privacy experts applauded this initiative for its privacy-preserving technical specifications. In an interesting twist, the tech giants came to be portrayed as greater champions of privacy than some democratic governments. This article proposes to view the Apple/Google API in terms of a broader phenomenon whereby tech corporations are encroaching into ever new spheres of social life. From this perspective, the (legitimate) advantage these actors have accrued in the sphere of the production of digital goods provides them with (illegitimate) access to the spheres of health and medicine, and more worrisome, to the sphere of politics. These sphere transgressions raise numerous risks that are not captured by the focus on privacy harms. Namely, a crowding out of essential spherical expertise, new dependencies on corporate actors for the delivery of essential, public goods, the shaping of (global) public policy by non-representative, private actors and ultimately, the accumulation of decision-making power across multiple spheres. While privacy is certainly an important value, its centrality in the debate on digital contact tracing may blind us to these broader societal harms and unwittingly pave the way for ever more sphere transgressions.

Population Health Science: Fulfilling the Mission of Public Health

Policy Points The historical mission of public health is to ensure the conditions in which people can be healthy, and yet the field of public health has been distracted from this mission by an excessive reliance on randomized-control trials, a lack of formal theoretical models, and a fear of politics. The field of population health science has emerged to rigorously address all of these constraints. It deserves ongoing and formal institutional support.

A scoping review of clinical decision support tools that generate new knowledge to support decision making in real time

OBJECTIVE

A growing body of observational data enabled its secondary use to facilitate clinical care for complex cases not covered by the existing evidence. We conducted a scoping review to characterize clinical decision support systems (CDSSs) that generate new knowledge to provide guidance for such cases in real time.

MATERIALS AND METHODS

PubMed, Embase, ProQuest, and IEEE Xplore were searched up to May 2020. The abstracts were screened by 2 reviewers. Full texts of the relevant articles were reviewed by the first author and approved by the second reviewer, accompanied by the screening of articles' references. The details of design, implementation and evaluation of included CDSSs were extracted.

RESULTS

Our search returned 3427 articles, 53 of which describing 25 CDSSs were selected. We identified 8 expert-based and 17 data-driven tools. Sixteen (64%) tools were developed in the United States, with the others mostly in Europe. Most of the tools (n = 16, 64%) were implemented in 1 site, with only 5 being actively used in clinical practice. Patient or quality outcomes were assessed for 3 (18%) CDSSs, 4 (16%) underwent user acceptance or usage testing and 7 (28%) functional testing.

CONCLUSIONS

We found a number of CDSSs that generate new knowledge, although only 1 addressed confounding and bias. Overall, the tools lacked demonstration of their utility. Improvement in clinical and quality outcomes were shown only for a few CDSSs, while the benefits of the others remain unclear. This review suggests a need for a further testing of such CDSSs and, if appropriate, their dissemination.

Randomized phase III trial comparing pegylated liposomal doxorubicin (PLD) at 50 mg/m² versus 40 mg/m² in patients with platinum-refractory and -resistant ovarian carcinoma: the JGOG 3018 Trial

Objective

The standard dose for pegylated liposomal doxorubicin (PLD) is 50 mg/m² every 4 weeks. While 40 mg/m² has recently been used in clinical practice, evidence supporting this use remains lacking.

Methods

This phase III randomized, non-inferiority study compared progression-free survival (PFS) for patients with platinum-resistant ovarian carcinoma between an experimental arm (40 mg/m² PLD) and a standard arm (50 mg/m² PLD) until 10 courses, disease progression or unacceptable toxicity. Eligible patients had received ≤2 prior lines. Stratification was by performance status and PFS of prior chemotherapy (<3 months versus ≥3 months). The primary endpoint was PFS and secondary endpoints were overall survival (OS), toxicity profile, clinical response and tolerability. The total number of patients was 470.

Results

The trial was prematurely closed due to slow recruitment, with 272 patients randomized to the experimental arm (n=137) and standard arm (n=135). Final analysis was performed with 234 deaths and 269 events for PFS. In the experimental arm vs. standard arm, median PFS was 4.0 months vs. 4.0 months (hazard ratio [HR]=1.065; 95% confidence interval [CI]=0.830–1.366) and median OS was 14.0 months vs. 14.0 months (HR=1.078; 95% CI=0.831–1.397). Hematologic toxicity and oral cavity mucositis (≥grade 2) were more frequent in the standard arm than in the experimental arm, but no difference was seen in ≥grade 2 hand-foot skin reaction.

Conclusion

Non-inferiority of 2 PLD dosing schedule was not confirmed because the trial was closed prematurely. However, recommendation of dose reduction of PLD should be based both on efficacy and safety.

Trial Registration

UMIN Clinical Trials Registry Identifier: UMIN000003130

The Cultural Politics of 'Implementation Science'

Despite the growing profile of 'implementation science', its status as a field of study remains ambiguous. Implementation science originates in the evidence-based movement and attempts to broaden the scope of evidence-based medicine to improve 'clinical effectiveness' and close the 'implementation gap'. To achieve this agenda, implementation science draws on methodologies from the social sciences to emphasise coherence between qualitative and quantitative approaches. In so doing, we ask if this is at the expense of ignoring the dominating tendencies of the evidence-based movement and consider if some of the methodologies being drawn on should be considered irreconcilable with evidence-based methodologies.

ClinicNet: machine learning for personalized clinical order set recommendations

OBJECTIVE

This study assesses whether neural networks trained on electronic health record (EHR) data can anticipate what individual clinical orders and existing institutional order set templates clinicians will use more accurately than existing decision support tools.

MATERIALS AND METHODS

We process 57 624 patients worth of clinical event EHR data from 2008 to 2014. We train a feed-forward neural network (ClinicNet) and logistic regression applied to the traditional problem structure of predicting individual clinical items as well as our proposed workflow of predicting existing institutional order set template usage.

RESULTS

ClinicNet predicts individual clinical orders (precision = 0.32, recall = 0.47) better than existing institutional order sets (precision = 0.15, recall = 0.46). The ClinicNet model predicts clinician usage of existing institutional order sets (avg. precision = 0.31) with higher average precision than a baseline of order set usage frequencies (avg. precision = 0.20) or a logistic regression model (avg. precision = 0.12).

DISCUSSION

Machine learning methods can predict clinical decision-making patterns with greater accuracy and less manual effort than existing static order set templates. This can streamline existing clinical workflows, but may not fit if historical clinical ordering practices are incorrect. For this reason, manually authored content such as order set templates remain valuable for the purposeful design of care pathways. ClinicNet's capability of predicting such personalized order set templates illustrates the potential of combining both top-down and bottom-up approaches to delivering clinical decision support content.

CONCLUSION

ClinicNet illustrates the capability for machine learning methods applied to the EHR to anticipate both individual clinical orders and existing order set templates, which has the potential to improve upon current standards of practice in clinical order entry.

Characterizing physicians' information needs related to a gap in knowledge unmet by current evidence

OBJECTIVE

The study sought to explore information needs arising from a gap in clinicians' knowledge that is not met by current evidence and identify possible areas of use and target groups for a future clinical decision support system (CDSS), which will guide clinicians in cases where no evidence exists.

MATERIALS AND METHODS

We interviewed 30 physicians in a large academic medical center, analyzed transcripts using deductive thematic analysis, and developed a set of themes of information needs related to a gap in knowledge unmet by current evidence. We conducted additional statistical analyses to identify the correlation between clinical experience, clinical specialty, settings of clinical care, and the characteristics of the needs.

RESULTS

This study resulted in a set of themes and subthemes of information needs arising from a gap in current evidence. Experienced physicians and inpatient physicians had more questions and the number of questions did not decline with clinical experience. The main areas of information needs included patients with comorbidities, elderly and children, new drugs, and rare disorders. To address these questions, clinicians most often used a commercial tool, guidelines, and PubMed. While primary care physicians preferred the commercial tool, specialty physicians sought more in-depth knowledge.

DISCUSSION

The current medical evidence appeared to be inadequate in covering specific populations such as patients with multiple comorbidities and elderly, and was sometimes irrelevant to complex clinical scenarios. Our findings may suggest that experienced and inpatient physicians would benefit from a CDSS that generates evidence in real time at the point of care.

CONCLUSIONS

We found that physicians had information needs, which arose from the gaps in current medical evidence. This study provides insights on how the CDSS that aims at addressing these needs should be designed.

A relevance and quality-based ranking algorithm applied to evidence-based medicine

BACKGROUND

The amount of information available about millions of different subjects is growing every day. This has led to the birth of new search tools specialized in different domains, because classical information retrieval models have trouble dealing with the special characteristics of some of these domains. Evidence-based Medicine is a case of a complex domain where classical information retrieval models can help search engines retrieve documents by considering the presence or absence of terms, but these must be complemented with other specific strategies which allow retrieving and ranking documents including the best current evidence and methodological quality.

OBJECTIVE

The goal is to present a ranking algorithm able to select the best documents for clinicians considering aspects related to the relevance and the quality of said documents.

METHODS

In order to assess the effectiveness of this proposal, an experimental methodology has been followed by using Medline as a data set and the Cochrane Library as a gold standard.

RESULTS

Applying the evaluation methodology proposed, and after submitting 40 queries on the platform developed, the MAP (Mean Average Precision) obtained was 20.26%.

CONCLUSIONS

Successful results have been achieved with the experiments, improving on other studies, but under different and even more complex circumstances.

Implementing high value back pain care in private physiotherapy in Australia: A qualitative evaluation of physiotherapists who participated in an "implementation to innovation" system

Objectives: Many barriers exist to delivering high-value care for people with low back pain (LBP). We have developed a multistrategy implementation system to overcome these barriers. Here we describe a qualitative evaluation of the experiences of private-sector physiotherapists implementing the system.

Design: PRISM (Practice-based innovation and implementation system) is an iterative clinician-as-scientist implementation program, tailored here for acute and subacute LBP. PRISM integrates strategies from behavioral change, implementation, and educational science fields. Semistructured interviews, group discussion forums, and electronic questionnaires were used to collect data at multiple time points that were then analyzed using an interpretative descriptive approach.

Participants: Six physiotherapists (purposive sample) practicing in private practice physiotherapy clinics in the Adelaide region, South Australia, were enrolled in the study.

Interventions: Interventions included an educational pain science and care workshop incorporating self-regulated learning principles, a co-planned clinical pathway, an electronic decision support tool, development and support of a community of practice, case study simulations, audit and feedback, and collaborative problem solving and innovation for physiotherapists.

Results: Participants’ experiences and perceptions centered around five themes: (1) knowledge and skills training; (2) networking and mentoring; (3) a clear clinical pathway; (4) practical tools; and (5) data feedback. Participants appraised the implementation process positively but identified patient receptiveness as a challenge at times. Suggestions for improvement included streamlining/automating data collection forms and processes and providing more simulation opportunities.

Conclusions: PRISM appears to be a promising approach to overcoming several barriers that prevent people with back pain from receiving high-value care. It consolidates and increases pain science knowledge and increases physiotherapist confidence in delivering high-value care. It appears to legitimize some current practices, enhance clinical reasoning and communication skills, extend knowledge in line with contemporary pain science, and facilitate the application of a biopsychosocial management approach. The high-level acceptance by participants provides a foundation for further research to test outcomes and delivery in different settings.

Contribution of the article

A quality improvement intervention designed to improve delivery of high-value care was well received by private practice physiotherapists.

Physiotherapists particularly valued using experiential learning to improve fluency in communicating with, and educating patients about, contemporary pain science.

A structured clinical pathway and tools guided physiotherapists on the basic elements of necessary care and allowed them to concentrate on higher levels of decision making and communication with patients.

Outlining the keyword co-occurrence trends in Shuanghuanglian injection research: A bibliometric study using CiteSpace III

Objective

Methods

Results

Conclusion

Implementation of evidence-based practice for alcohol and substance use disorders: protocol for systematic review

BACKGROUND

Whilst effective treatments exist for substance use and alcohol use disorders, they are not commonly practised. Studies have shown that only a small percentage of services provide evidence-based treatments such as addiction medications or psychosocial therapies. Although there is a growing body of literature on evidence-based treatment, no synthesis of research on the implementation of evidence-based addiction treatment exists. This proposed systematic review will synthesise and evaluate the effectiveness of implementation programmes in the treatment of patients with drug and alcohol problems using the Consolidated Framework for Implementation Research (CFIR) framework.

METHODS

We will search (from inception onwards) PubMed/MEDLINE, Cochrane Library, PsycINFO, Web of Science and CINAHL. Eligible studies will be clinical trials (e.g. randomised controlled trials, non-randomised controlled trials) and observational studies (e.g. before-and-after studies, interrupted time series) evaluating strategies used to implement evidence-based psychosocial treatments for alcohol and substance use disorders. The primary outcomes will be related to the implementation, service system, or clinical practice (e.g. acceptability, implementation costs, feasibility). Two researchers will independently screen all citations, full-text articles and abstract data. Risk of bias of individual studies will be appraised using appropriate tools. A narrative synthesis will be provided.

DISCUSSION

This project aims to provide evidence to help guide the design of translational research programmes to improve implementation of evidence-based care in drug and alcohol settings. Findings from the study will specify effective strategies for domains of influence including (1) intervention characteristics (e.g. evidence strength and quality, adaptability), (2) outer setting (e.g. patient needs and resources, external policies and incentives), (3) inner setting (e.g. implementation climate, readiness for implementation), (4) individuals involved (e.g. self-efficacy, knowledge and beliefs about the intervention) and (5) the implementation process (e.g. engaging members of the organisation, executing the innovation). Identified gaps in knowledge will guide further study.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019123812.

Are We Conditioning EBM Researchers to be Innovative or Narrow?

This short essay considers preferential publication and impact factor as stimuli, instrumentally conditioning medical researchers. The author postulates that publication houses emphasising publication of the highest levels of evidence (ie, meta-analyses) at the detriment of other levels of evidence, is inadvertently guiding researchers to overlook necessary research for more individualised care. The author recommends preferential publication and impact factor should be openly discussed by medical educators to ensure we are training researchers to conduct meaningful, high quality, innovative research.

Self-reported attitudes, knowledge and skills of using evidence-based medicine in daily health care practice: A national survey among students of medicine and health sciences in Hungary

In order to map attitudes, knowledge and skills related to evidence-based medicine (EBM) in students of medical and health sciences faculties, we performed an online survey during the spring semester 2019 in all medical and health sciences faculties in Hungary. In total, 1080 students of medicine and 911 students of health sciences completed the online questionnaire. The attitude towards EBM was generally positive; however, only a small minority of students rated their EBM-related skills as advanced. There were large differences in the understanding of different EBM-related terms, with 'sample size' as the term with the highest (65%) and 'intention-to-treat analysis' with the lowest (7%) proportion of medical students being able to properly explain the meaning of the expression. Medical students who already participated in some EBM training rated their skills in searching and evaluating medical literature and their knowledge of EBM-related terms significantly better and had a more positive attitude towards using EBM in the practice than students without previous EBM training. EBM trained medical students were more likely to choose online journals (17.5% compared to 23.9%, p<0.05) and professional guidelines (15.4% compared to 6.1%, p<0.001) instead of printed books (33.6% compared to 52.6, p<0.001) as the main source of healthcare information retrieval and used Pubmed/Medline, Medscape and the Cochrane Library to a significant higher rate than students without any previous EBM training. Healthcare work experience (OR = 1.59; 95% CI = 1.01–2.52), conducting student research (OR = 2.02; 95% CI = 1.45–2.82) and upper year university students (OR = 1.65; 95% CI = 1.37–1.98) were other factors significantly influencing EBM-related knowledge. We conclude that the majority of students of medical and health sciences faculties are keen to acquire EBM-related knowledge and skills during their university studies. Significantly higher EBM-related knowledge and skills among EBM trained students underline the importance of targeted EBM education, while parallel increase of knowledge and skills with increasing number of education years highlight the importance of integrating EBM terminology and concepts also into the thematic of other courses.