Snake oil for the 21st century

Evidence-based medicine is the use of the best current evidence in making decisions about the care of individual patients. Practicing EBM requires recognition that in most encounters with patients, questions arise that should be answered to provide the patient with the best available medical care. Asking well-built clinical questions that contain 4 elements--a patient or problem, an intervention, a comparison intervention (if necessary), and an outcome--is an important step in practicing EMB. Once appropriate questions have been formulated, the best source for finding most types of best evidence is by searching the MEDLINE database by computer. MEDLINE searches have inherent software and operator limitations that make their reliability quite variable. One should be aware of these limitations and improve one's skills in searching. The Cochrane Collaboration Controlled Clinical Trials Registry contains more than 190,000 controlled clinical trials and is the best source of evidence about treatment. The quality (strength) of evidence is based on a hierarchy of evidence: results of systematic reviews of well-designed clinical studies, results of 1 or more well-designed clinical studies, results of large case series, expert opinion, and personal experience. Once the best evidence has been found, the EBM approach involves critically appraising the quality of the evidence, determining its magnitude and precision, and applying it to the specific patient. Guidelines to critically appraise and apply evidence are available. The clinical question, best evidence, and its critical appraisal should be saved in a format that can be easily retrieved for future use.     

Practicing psychologists’ reflections on evidence-based practice in psychology.

An American Psychological Association (APA) policy definition of evidence-based practice in psychology (EBPP) states that practice based on evidence must consider the best available research, use clinical expertise, and consider client contextual variables (APA Presidential Task Force, 2006). The researchers qualitatively examined clinical and counseling psychologists’ attitudes toward EBPP using grounded theory. The study explored the extent to which the official view of EBPP reflects current psychological practice as well as whether EBPP is an idealistic definition to work toward. An examination of themes from this research yielded evidence that the framework for EBPP is in place, although many participants initially confused EBPP with research. Psychologists will benefit from an open-minded review of the official APA policy definition and from considering how the policy may affect their practice and interactions with managed care providers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preventing and managing pelvic inflammatory disease: key questions, practices, and evidence

Clinicians play a pivotal role in protecting women from pelvic inflammatory disease (PID), one of the most prevalent and serious diseases affecting women of reproductive age. This article examines PID prevention and management by critically addressing five questions: (1) What are the key risk factors for PID? (2) What are the principal microorganisms involved in PID? (3) What are the appropriate diagnostic criteria for PID? (4) What are the best treatment regimens for PID? and (5) What are the effective strategies for preventing PID? In addressing each of these questions, the quality of available evidence and recommended practice is discussed and gaps in the evidence are highlighted.     

The influence of mortality trials on the evolution of clinical practice

Clinical practice is complex and is influenced by a number of factors such as time since medical qualification, opportunities for further education and peer review, as well as trial results and marketing. Systematic audit and peer review are powerful tools that are being used increasingly. When aided by the intelligent, but not Draconian, use of financial carrots they are an effective means of changing practice. Positive trials, such as those of thrombolytic therapy, have rapidly resulted in the widespread use of such treatment. Negative trials, for example those involving anti-arrhythmic prophylaxis after myocardial infarction or the use of calcium antagonists in patients with impaired left ventricular function, have also correctly resulted in an appropriate change in practice. Advertising does not always reflect best clinical practice and could lead to under-promotion of older but more useful drugs. Peer review and audit are probably the best available methods for promoting good clinical practice.     

Differences between evidence based-medicine and best conventional medicine

The practical application of rational concepts will be possible in the health care system if two conditions will be met. The legal framework has to fit these goals and new strategies are to establish. The new strategies will be needed to identify from the huge amount of data "evidence" which will support the medical progress. Evidence-Based Medicine (EBM) offers these strategies. Modifications of our conventional procedures are necessary to establish EBM: the conditions of clinical actions, the definitions of goals of medical training, the rational of clinical decisions and the continued medical education.     

Preventive therapies: weighing the pros and cons

The author comments on three issues raised by Dr. Kenneth G. Marshall in his series on the benefits and harms of preventive therapies, which begins in this issue on page 1493. First, because the method by which the results of clinical trials are presented markedly affects the perception of those results some measure of absolute benefit and harm must be used when the results of clinical trials are presented. Second, there is increasing interest in decision aids as a means of helping patients to understand evidence and make therapeutic choices. It is important that these aids undergo rigorous testing before they are adopted for common use. Third, evidence-based clinical practice guidelines are a welcome resource for busy clinicians. However, physicians and patients should bear in mind that interpretations of the available evidence can vary, leading to different conclusions about the appropriateness of preventive therapies.     

Divorce mediation.

Mediation is a growing alternative to the adversarial settlement of divorce disputes that is part of a broader movement toward the private ordering of divorce. Problems with the indeterminant "best interests" standard and evidence from psychological research make mediation particularly appealing for settling child-custody disputes. Although some encouraging evidence is available on diversion of disputes from courts and consumer satisfaction with mediation, there is a considerable need for further research. Moreover, a number of practical, legal, and ethical questions about mediation remain unanswered. Psychologists can play a vital role in systematically evaluating divorce mediation and in shaping policy in regard to its practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The use of dental radiographs to estimate the probability of cavitation of carious interproximal lesions. Part II: Two patient scenarios

Diagnosis of a cavitated interproximal lesion is often not confirmed until the tooth is treated. Before treatment, clinicaians and patients are dealing with probabilities which can be estimated from clinical evidence, radiographic evidence, and information found in the dental literature. The probability of a diagnostic test result being correct is affected by the threshold of the test and the pretest probability of the disease in question, which varies with the prevalence of the disease. We illustrate how clinicians can inform themselves and their patients of the probability of a radiographic lesion being truly cavitated based on graphs that summarize the currently available evidence. Dentists who use these graphs can more accurately inform their patients who can then choose the course of care that best meets their individual needs.     

Use of evidence in the process of practice change in a clinical team: a study-forming part of the Autocontrol Project

The Autocontrol Project is concerned with the accessing, processing and communication of high quality information so that a clinical team can make and implement decisions for practice change, and then evaluate if improvement has been achieved. High quality information is used as evidence for change. In this study, we have evaluated how evidence is used by a clinical team to explain an identified problem of inappropriate use of blood gas tests. In an experimental study of the Surgical Intensive Care Unit, video recordings of team meetings of nurses and doctors were undertaken, structured according to a problem-based format. Evidence of current practice patterns derived from the hospital information system, as well as the results of a questionnaire to the unit's staff about knowledge and use of blood gas measurements, were supplied to the participants beforehand. At the second meeting, the output of the first meetings and a summarised analysis of pertinent literature were made available. This second meeting was required to finalise the list of causes of inappropriate blood gas use and propose pragmatic strategies for practice change. The video data of the meetings were coded to analyse the use of evidence, the categories of causes, issues and solutions proposed, and the quality of team interaction. The results indicate that in order to achieve consensus, the team used different types of evidence, including objective evidence of practice patterns, personal experience about direct and indirect organisational influences, and literature-based research evidence of best practice. Furthermore, group dynamics were favoured by the problem-based meeting structure, and a high level of cognitive critiquing between team members was observed. This research suggests that a combination of approaches involving identification of both operational factors (e.g. appropriate access to different types of evidence and meeting structure) and cognitive and behavioural approaches (e.g. ensuring expression of different viewpoints) is needed to support strategic decision-making for practice change in a clinical unit. This combined approach should favourably influence the provision of an effective and efficient evidence support environment for the clinical team.     

Evidence-based medicine. 2. Research of clinically relevant biomedical information. Gruppo Italiano per la Medicina Basata sulle Evidenze--GIMBE

Evidence-based Medicine is a product of the electronic information age and there are several databases useful for practice it--MEDLINE, EMBASE, specialized compendiums of evidence (Cochrane Library, Best Evidence), practice guidelines--most of them free available through Internet, that offers a growing number of health resources. Because searching best evidence is a basic step to practice Evidence-based Medicine, this second review (the first one has been published in the issue of March 1998) has the aim to provide physicians tools and skills for retrieving relevant biomedical information. Therefore, we discuss about strategies for managing information overload, analyze characteristics, usefulness and limits of medical databases and explain how to use MEDLINE in day-to-day clinical practice.     

Clinical methods for diagnostic confirmation of stroke subtypes

Clinicians faced with a patient having a sudden-onset, focal neurological deficit must answer three fundamental questions: is it a stroke?, is it ischemia or hemorrhage? and what kind of ischemic stroke is it? Clinical information (that is, history and examination) is immediately available to every physician, and its role in answering these questions is extremely important, even though a 100% certainty can only be obtained with instrumental diagnostic tools. In fact, when diagnosis is based on properly designed clinical criteria, the percentage of diagnostic mistakes is quite low. Clinical methods are still the best way of orientating topographic and etiologic diagnosis, as well as prognosis. In addition, time might be saved if randomization in clinical trials could be done using clinical methods before complex investigations are applied.     

Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology

Guidelines for clinical practice are intended to suggest preferable approaches to particular medical problems as established by the interpretation and collation of scientifically valid research, derived from an extensive review of published literature. When data are not available that will withstand objective scrutiny, a recommendation may be made based on a consensus of experts. Guidelines are intended to apply to the clinical situation for all physicians without regard to specialty. Guidelines are intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are inflexible and rarely violated. Given the wide range of choices in any health care problem, the physician should select the course best suited to the individual patient and the clinical situation presented. These guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee. These guidelines are also approved by the governing boards of the American Gastroenterology Association and the American Society of Gastrointestinal Endoscopy. Expert opinion is solicited from the outset for the document. Guidelines are reviewed in depth by the Committee, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time. The following guidelines are intended for adults and not for pediatric patients.     

Tertiary structural changes and iron release from human serum transferrin

Guidelines for clinical practice are intended to suggest preferable approaches to particular medical problems as established by interpretation and collation of scientifically valid research, derived from extensive review of published literature. When data are not available that will withstand objective scrutiny, a recommendation may be made based on a consensus of experts. Guidelines are intended to apply to the clinical situation for all physicians without regard to specialty. Guidelines are intended to be flexible, not necessarily indicating the only acceptable approach, and should be distinguished from standards of care that are inflexible and rarely violated. Given the wide range of choices in any health care problem, the physician should select the course best suited to the individual patient and the clinical situation presented. These guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee. These guidelines are also approved by the governing boards of American College of Gastroenterology and Practice Parameters Committee. Expert opinion is solicited from the outset for the document. Guidelines are reviewed in depth by the committee, with participation from experienced clinicians and others in related fields. The final recommendations are based on the data available at the time of the production of the document and may be updated with pertinent scientific developments at a later time. The following guidelines are intended for adults and not for pediatric patients.     

Crossing the Quality Chasm in Behavioral Health Care: The Role of Evidence-Based Practice.

The concept of evidence-based practice (EBP) is one receiving increasing attention from providers, managers, payers, and regulators of care, yet practical guidelines for professional psychologists who may be interested in incorporating EBPs into their own work settings are not available. The author explores the pragmatics of EBP adoption within the broad context of quality problems in American health care, particularly as described in a heralded 2001 publication by the Institute of Medicine. Concrete suggestions are offered to help practitioners locate EBP resources for specific clinical problems, use an evidence hierarchy to infer "best practices," address the science-to-service management challenge, and generate outcomes data and feedback loops to continuously improve clinical effectiveness. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How to use an article on therapy or prevention: pneumonia prevention using subglottic secretion drainage

Evidence based critical care medicine involves integrating clinical experience, expertise, and patient preferences with explicit, systematic, and judicious use of current best evidence in making medical decisions. Published evidence has many sources: research from the basic sciences of medicine, and from patient-centered clinical research on the accuracy of diagnostic tests, the power of prognostic markers, and the effectiveness and safety of preventive, therapeutic, rehabilitative, and palliative interventions. When critically appraising a clinical article for potential use in intensive care unit (ICU) practice, the first question we ask ourselves is: Is this study valid? If examination of the study methods reveals that the design is rigorous, we can turn to the two other key questions: What are the results? and, Will the results help me care for my patients? This approach may aid in the interpretation of an article on therapy or prevention; in it we discuss a strategy designed to prevent ventilator associated pneumonia in critically ill patients.     

In defense of clinical judgment, credentialed clinicians, and reflective practice.

Although clinical psychology is rightly characterized by its commitment to science, the author argues that clinical practice cannot rely entirely or primarily on scientific evidence and empirically supported treatments. Too many of the problems that clinicians encounter will invariably fall outside the purview of scientific evidence. Whether grounded in questions of value or the particularities of human experience, clinicians inevitably deal with uncertainty and cannot avoid clinical judgment. An overly narrow and hyperskeptical approach to clinical practice would impoverish clinical training and would both disenfranchise and impose excessive restrictions on conscientious clinicians. A more inclusive definition of evidence-based practice is necessary, one that values scientific and clinical evidence and reasoning equally. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The master therapist: Ideal character or clinical fiction? Comments and questions on Jennings and Skovholt's "The Cognitive, Emotional, and Relational Characteristics of Master Therapists."

L. Jennings and T. A Skovholt's (1999) study constitutes a useful step toward deepening scientific understanding of what therapists at their best are capable of offering to their clients. Both the study's strengths and limitations stimulate questions, which this commentary attempts to consider. These questions mainly concern the lack of a clear initial definition of "master therapist," the lack of meaningful comparison groups needed to infer the distinctive characteristics of master therapists, the incomplete communication of data-analytic procedures, and the formulation of results as a uniform ideal–typical pattern that precludes recognition of individual differences. Despite this, the clinical richness of the findings is well appreciated, and the questions stimulated by the study indicate its high heuristic value. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Beyond the guidelines of ethical/legal standards: Update.

Ethical issues in practice are viewed as dynamic questions that evolve from changes occurring both outside and within the profession. New questions have arisen from (1) changes in public attitudes, (2) changes in economic circumstances, (3) increased diversity in styles and standards of professional practice, and (4) psychologist functioning in new settings such as the public media. Enforcement and proactive ethical action strategies are discussed in the contexts of clinical training facilities, placement or internship agencies, peer review committees, licensing boards, and ethics committees. The dilemmas of the individual practitioner in confrontation with other practitioners or in public advocacy roles are discussed. The need for openness to collegial consultation is stressed, and expanded roles for ethics committees are offered to fill this void. (French abstract) (24 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Meta-analysis of clinical trials for chemotherapy in cancer

Meta-analysis has attracted great interest among clinical practitioners in recent years, leading to a steady output of related publications. Meta-analytic articles are easily found in the MEDLINE database using the publication-type option. This paper reviews how to use and understand meta-analysis with a special reference to chemotherapy applied to cancer patients. It is described in relationship to evidence-based medicine (EBM) and clinical practice guidelines. Cochrane collaboration is also referred to as an active voluntary organization conducting meta-analysis. In the technical sections, statistical issues and graphic representations are clearly illustrated using the example of hepatic arterial infusion for colorectal cancer patients. The difference between fixed and random effects models is briefly explained. Finally, an example from Cochrane Library, namely progestagen therapy for endometrial cancer, is illustrated to show the implications of meta-analysis for clinical practice.     

Improving clinical effectiveness through an evidence-based approach: meeting the challenge for nursing in the United Kingdom

Improving clinical effectiveness is a major challenge facing nurses working in the United Kingdom and requires a coordinated approach in order to ensure that the information about which interventions work is made available to those in a position to use it. This means that policy makers, administrators, and nurses need to base decision making on the best available evidence. In this article we explore the background to the drive for evidence-based practice and discuss how a group of nurse researchers have begun working with nurse administrators and practitioners in a large acute hospital to help change the rhetoric of evidence-based practice in nursing into reality.