Evidence-based Practice Decisions Research Articles

Applying a democratic evidence-based decision-making model: a case illustration of policy development at an Arab University

ABSTRACT This case study explores the potential for democratic governance in state-regulated Arab higher education systems focusing on institutional committee members’ adoption of deliberative, empowered and participatory evidence-based decision-making practices while engaged in university policy development. Amidst a landscape characterised by the forces of globalisation and internationalisation, coupled with an intensifying focus on quality assurance and accreditation that increasingly shape governance structures, this research examines decision-making at the practical micro-level within an Arab State institution. This university, mirroring others in the Gulf Cooperation Council region, functions within a largely centralised political system where government bodies exert substantial influence. By presenting an illustrative case of grassroots democratic evidence-based decision-making during committee members’ formulation of a new institution-wide policy, this study aims to partially bridge the conceptual and applied research void. It delves into the opportunities and challenges of practicing shared, evidence-based decision-making in multiplex universities operating within characteristically state-regulated, management-centric political contexts.

Who Benefits More From IBMS or Qigong? Clinical Data-Mining RCT Data

Purpose: A recent three-arm randomized controlled trial (RCT) with depressed Hong Kong adults demonstrated the comparable effectiveness of integrative Body-Mind-Spirt (IBMS) and Qigong interventions in relieving sleep disturbance and depression, but not which is best for whom? Guided by concept and theory-based hypotheses, clinical data-mining (CDM), the RCT data answers the more clinically relevant question: who responds best to which intervention? Method: Paired-sample t-tests and Wilcoxon signed-ranked tests were adopted to compare the within-subgroup differences; linear mixed models for normally distributed outcomes and generalized linear mixed models for non-normally distributed outcomes were used to compare the between-subgroup differences. Results: Results indicate that IBMS is more efficacious for older, more educated females, suffering from physical pain and illness; whereas younger, less educated males, not in full-time employment benefit more from Qigong. Discussion: This productive joining together of RCT and CDM recommends itself to both past and future RCTs, further informing evidence-based practice decision making.

Single-Case Experimental Design in Rehabilitation: Basic Concepts, Advantages, and Challenges.

Single-case experimental design is a family of experimental methods that can be used to examine the efficacy of interventions by testing a small number of patients or cases. This article provides an overview of single-case experimental design research for use in rehabilitation as another option along with traditional group-based research when studying rare cases and rehabilitation interventions of unknown efficacy. Basic concepts related to single-case experimental design and the characteristics of common subtypes ( N-of-1 randomized controlled trial, withdrawal design, multiple-baseline design, multiple-treatment design, changing criterion/intensity design, and alternating treatment design) are introduced. The advantages and disadvantages of each subtype are discussed along with challenges in data analysis and interpretation. Criteria and caveats for interpreting single-case experimental design results and their use in evidence-based practice decisions are discussed. Recommendations are provided for appraising single-case experimental design articles as well as using single-case experimental design principles to improve real-world clinical evaluation.

Pandemic Preparedness among Big Energy Companies: Call to Research and Action.

The COVID-19 pandemic, as a global phenomenon, has affected all the working realities, worldwide, with the same issues. The aim of the present work is to assess the experiences of management and their preparedness during the pandemic among big companies, in particular, in the energy sector. Based on an overview of scientific evidence and grey literature, we found that big companies followed evidence-based decision-making practices and offered preparedness and information plans. Specifically, these plans contained recommendations and best practices to be followed to avoid the risk of infection in the workplaces, as well as in the field of epidemiological surveillance and vaccination. Nevertheless, many research efforts are required, and it is important that a large number of big companies and corporations address these challenges worldwide, adopting a new sustainable approach that includes both the productivity and health of the workers. A Call to Action was then issued in order to achieve evidence-based leadership to address current and future public health emergency scenarios.

Prioritized research recommendations and potential solutions: addressing gaps surrounding dietary supplement ingredients for boosting brain health and optimizing cognitive performance

In the market of dietary supplements, a low level of certainty exists in the state of the science, coupled with not always knowing what is in the product. Together these issues make weighing benefits/risks difficult and hinder the ability to guide evidence-based practice decisions. The authors sought to identify priorities and develop potential solutions to address research gaps so that information disseminated, can ultimately, be relied upon, when trying to make appropriate and safe decisions. Using a modified-Delphi process, 8 panelists reviewed evidence, provided from systematic review, on dietary supplement ingredients for brain health, and prioritized gaps identified and offered potential solutions. Research gaps specific to dietary supplements research included the need for quality testing of products, the question of bioavailability and absorption of ingredients, and optimal composition and standardization of supplements under investigation. Other gaps related to populations studied; a general sense of bias towards focusing research on diseased rather than maintaining or optimizing performance in healthy populations. Additionally, the lack of uniform cognitive performance measures and metrics used across research is a gap, as well as whether the metrics are accurate representations of or even generalizable to “real-life” participants wishing to optimize their performance. Methodological quality and ethical concerns in the conduct and reporting of science encompass all issues. If resources map to potential solutions outlined in this paper, then these proposed next steps offered will help facilitate meaningful research, move evidence into practice recommendations, and ultimately develop better decision-making tools for consumers to trust and rely upon for making safe supplement decisions.

Medical Simulation in High-Risk AML Improves Clinical Decision Making of Hematologists/Oncologists

Background: Our understanding of the biology of acute myeloid leukemia (AML) has increased dramatically with the use of next-generation sequencing. The identification of recurrently mutated genes in AML has allowed for better risk stratification and provided novel therapeutic targets. The European Leukemia Network (ELN) 2017 prognostic system divides patients into favorable, intermediate, and adverse groups based on genetic abnormalities.[Döhner 2017] Patients with features including MDS related changes, complex karyotype and adverse molecular features including mutations in FLT3 are at high risk (HR AML) for treatment failure and relapse.Aim: This study was conducted to determine if an online, simulation-based continuing medical education (CME)-certified intervention could improve clinical decision making of hematologists/oncologists (hem/oncs) regarding treatment selection for patients with HR AML.Description of Intervention: A CME-certified virtual patient simulation (VPS) was made available via a website dedicated to continuous professional development. The VPS consisted of 2 cases of HR AML presented in a platform that allows hem/oncs to assess the patients and make clinical decisions supported by an extensive database of diagnostic and treatment possibilities, matching the scope and depth of actual practice.*CASE 1* 63-year-old male with AML-MRC, mutations detected: RUNX1, TET2, SRSF2; no mutations detected in NPM1, CEBPA, IDH1, IDH2, KIT, KRAS, NRAS, ASXL1, ASXL2, BCR-ABL1, WT1.*CASE 2* 57-year-old female with FLT3-ITD mutated AML who is a candidate for intensive induction therapy.Methods: Clinical decisions were analyzed using a sophisticated decision engine, and tailored clinical guidance (CG) employing up-to-date evidence-base and faculty recommendations was provided after each decision. Decisions were collected post-CG and compared with each user's baseline (pre-CG) decisions using McNemar's test to determine p-values (P < .05 indicates significance). Data were collected between October 8, 2020 and July 22, 2021.Results: At the time of assessment, 186 hem/oncs who made clinical decisions were included in the analysis (112 case 1, 74 case 2). From pre- to post-CG in the VPS, hem/oncs were significantly more likely to make evidence-based practice decisions across all learning objectives, see the Table.*CASE 1* For the case of AML-MRC, the VPS led to a higher percentage of community-based hem/oncs ordering necessary diagnostic tests and ordering an appropriate treatment. After clinical guidance, slightly more academic-based hem/oncs identified the correct diagnosis for the patient.*CASE 2* For the patient with FLT3-ITD mutated AML, the VPS led to a higher percentage of community-based hem/oncs ordering and correctly interpreting diagnostic tests in order to make an accurate diagnosis. After clinical guidance, a higher percentage of academic-based hem/oncs ordered an appropriate treatment for the patient based on the FLT3-ITD mutation and their fitness assessment. Treatment rationales were collected and can be presented.Conclusions: This study demonstrates that VPS that immerses and engages hem/oncs in an authentic learning experience improved evidence-based clinical decisions related to the management of HR AML. Clinical guidance in the VPS improved hem/oncs clinical decision making for all learning objectives and the improvements were statistically significant. For almost all learning objectives, the activity had a significant and larger impact on improving clinical decision making of community-based hem/oncs compared to hem/oncs from other practice settings. This study indicates that unique educational methodologies and platforms, which are available on-demand, can be effective tools for promoting guideline-based therapy selection and clinical decision making. Additional education is recommended about the role for FLT3 inhibitors and the optimal treatment for AML-MRC.Acknowledgement: This CME activity was supported by an independent educational grant from Jazz Pharmaceuticals.

P31 Management of Disordered Eating Behavior Risk in Clients Varies Among Outpatient Dietitians: A Qualitative Thematic Analysis

BackgroundSixty-two percent of dietitians recommend nutrition apps to patients, with calorie-tracking apps the most popular. While previous research has indicated common characteristics of nutrition app users, little is understood about how client characteristics impact dietitians’ decisions about recommending apps. Addressing this relationship would provide guidance for dietitians to make evidence-based practice decisions regarding which clients would benefit.ObjectiveTo explore the role of client characteristics in outpatient dietitians’ decisions to recommend apps.Study Design, Setting, ParticipantsTwenty- to 60-minute semi-structured interviews conducted by phone, videoconferencing, or in-person from November 2019 to July 2020 with U.S. outpatient dietitians (n = 20).Measurable Outcome/AnalysisInterviews investigated dietitian experiences surrounding their app decision-making process, including the client-, app-, and practice-related factors involved. Two coders conducted a qualitative thematic analysis of the client-related factors.ResultsDietitians years in practice ranged from 2 to 42 year and they identified weight management and diabetes as top counseling topics. We identified 3 client-related themes: motivation, tech/health literacy, and disordered eating behaviors. While clients’ motivation and literacy level may impact the dietitian's decision, the presence of disordered eating behaviors more consistently impacted these decisions, leading dietitians to avoid or carefully select apps for clients, especially calorie-tracking apps. Many participants perceived that apps would benefit or harm clients based on a nuanced set of characteristics, such as being numbers-oriented vs obsessive. Several participants reported they avoided the use of calorie-tracking apps for all clients, including those without concerning characteristics or behaviors, due to worries that their use would increase risk of developing disordered eating behaviors.ConclusionWhile several client features influenced dietitians’ app decisions, disordered eating behaviors appeared to be the most consistent characteristic leading to avoidance or adjusted use. Despite this consistency, dietitians differed regarding whether apps promote these behaviors in all clients. Further research to understand this relationship is needed to guide dietitians and app design. Sixty-two percent of dietitians recommend nutrition apps to patients, with calorie-tracking apps the most popular. While previous research has indicated common characteristics of nutrition app users, little is understood about how client characteristics impact dietitians’ decisions about recommending apps. Addressing this relationship would provide guidance for dietitians to make evidence-based practice decisions regarding which clients would benefit. To explore the role of client characteristics in outpatient dietitians’ decisions to recommend apps. Twenty- to 60-minute semi-structured interviews conducted by phone, videoconferencing, or in-person from November 2019 to July 2020 with U.S. outpatient dietitians (n = 20). Interviews investigated dietitian experiences surrounding their app decision-making process, including the client-, app-, and practice-related factors involved. Two coders conducted a qualitative thematic analysis of the client-related factors. Dietitians years in practice ranged from 2 to 42 year and they identified weight management and diabetes as top counseling topics. We identified 3 client-related themes: motivation, tech/health literacy, and disordered eating behaviors. While clients’ motivation and literacy level may impact the dietitian's decision, the presence of disordered eating behaviors more consistently impacted these decisions, leading dietitians to avoid or carefully select apps for clients, especially calorie-tracking apps. Many participants perceived that apps would benefit or harm clients based on a nuanced set of characteristics, such as being numbers-oriented vs obsessive. Several participants reported they avoided the use of calorie-tracking apps for all clients, including those without concerning characteristics or behaviors, due to worries that their use would increase risk of developing disordered eating behaviors. While several client features influenced dietitians’ app decisions, disordered eating behaviors appeared to be the most consistent characteristic leading to avoidance or adjusted use. Despite this consistency, dietitians differed regarding whether apps promote these behaviors in all clients. Further research to understand this relationship is needed to guide dietitians and app design.

Probing into Pre-Service Science Teachers’ Practices of Scientific Evaluation and Decision-Making on Socio-scientific Issues

ABSTRACT A common practice amongst scientists is to evaluate the connections between evidence and claims about natural and human-induced phenomena. Teacher education coursework may improve understanding of this important activity and facilitate teachers to implement evidential thinking approaches into their future science teaching. Instructional scaffolds that actively engage students in scientific evaluation can be introduced in teacher education programs to increase pre-service teachers’ understanding of critical evaluation as a scientific practice. The purpose of this qualitative exploratory study was to investigate pre-service science teachers’ critical evaluation and decision-making practices using scientific evidence to consider competing, alternative explanations about controversial phenomena (genetically modified organisms and climate change). In this context, we analyzed pre-service science teachers’ evaluations about the connections between scientific evidence and alternative explanations, as well as their decision-making practices by examining their certainty and plausibility judgments. Our findings indicated that participants’ associations between evidence and explanatory models, their evaluative reasoning practices, and the correctness and complexity of their evaluations revealed variations in both topics. The participants’ evaluation and decision-making practices also showed disputes with their plausibility judgments about alternative explanations, as well as the certainty of their evaluations. The findings were discussed in the light of the literature and suggested that critical evaluation is a scientific practice that should be explicitly taught in teacher education programs to increase pre-service science teachers’ engagement and understanding of evidence-based decision-making practices.

Show Me the Evidence: COVID-19 and School Nursing in the 21st Century.

The emergence of COVID-19 and how to control its spread has highlighted the importance of understanding and applying evidence-based decisions into school nursing practice. This is the fifth and final article in NASN’s series on how the Framework for 21st Century School Nursing PracticeTM is a mind-set that can be applied to everyday school nursing practice and will focus on the principle of Standards of Practice, and particularly how evidence-based practice decisions are made during COVID-19.

A Proposed Regulatory Review Model to Support the South African Health Products Regulatory Authority to Become a More Efficient and Effective Agency.

Background: National regulatory agencies of various sizes and maturity levels, including the South African Health Products Regulatory Authority (SAHPRA), have had to revise systems and re-engineer processes in order to adapt to the new regulatory environment and increase the effectiveness of regulatory operations. This study aimed to develop a new regulatory review model for improved regulatory performance, underpinned by the parameters of the World Health Organization Global Benchmarking Tool (WHO GBT) that support strengthening of regulatory systems. Methods: A new enhanced model for regulatory review, was developed based on the key recommendations from 6 studies, previously conducted by the authors, that were identified as fundamental elements in enhancing regulatory performance. The elements selected to define the new regulatory review model were endorsed through the integration of the parameters of the WHO GBT that, when embedded within regulatory systems, support enhanced regulatory performance. Results: Opportunities for improvement in regulatory performance were identified and include quality measures; monitoring and evaluating review times; a risk-based evaluation; transparency and communication; and training and education. An improved model for the South African regulatory review and benefit-risk (BR) assessment supported by quality decision-making was proposed as well as recommendations for the application of risk-stratification strategies, strengthening of reliance networks, reinforcing good regulatory practices (GRPs) and enhancing transparency. Conclusion: If implemented the proposed improved regulatory model may pave the way towards more efficient and transparent, streamlined review processes, coupled with increased consistency, evidence-based decision-making practices, reduced timelines and improved patients’ access to new medicines in South Africa.

Mental health professionals' perceptions, judgements and decision-making practices regarding the use of electronic cigarettes as a tobacco harm reduction intervention in mental healthcare: A qualitative focus group study

BackgroundSmoking prevalence remains significantly higher among individuals with mental health conditions compared with the general population. Tobacco harm reduction (THR) in the form of replacing cigarettes for electronic cigarettes (ECs) is an alternative approach which may prove useful for these smokers who find it difficult to quit. Exploring how mental health professionals' (MHPs) perceive ECs, and how these influence decision making regarding their use in clinical settings is essential to determine the feasibility of incorporating ECs into the treatment pathway. MethodsWe conducted six focus groups between March and August 2017. A total of 39 MHPs were recruited from mental healthcare services in England. Discussions were guided by a semi-structured guide, and responses were recorded, transcribed and coded using thematic framework analysis. ResultsMHPs generally adopt a risk-averse approach when judging the safety and suitability of ECs. Risk-aversion was influenced by perceived obscurity surrounding ECs and THR, as well as high exposure to adverse and unreliable information regarding ECs, and perceived analogies between ECs and conventional cigarettes. Some MHPs adopt a pragmatic approach when making decisions based on THR and EC use in daily practice by considering the context of treatment and patient circumstances. However, this is often accompanied by a high degree of caution and misconceptions which limits the potential benefit this intervention could have in mental healthcare settings. ConclusionImproved dissemination of national guidance and scientific literature regarding THR and ECs is essential in mental healthcare to eliminate misconceptions and better inform MHPs evidence-based decision-making practices.

2015 Evidence Analysis Library Evidence-Based Nutrition Practice Guideline for the Management of Hypertension in Adults

Hypertension (HTN) or high blood pressure (BP) is among the most prevalent forms of cardiovascular disease and occurs in approximately one of every three adults in the United States. The purpose of this Evidence Analysis Library (EAL) guideline is to provide an evidence-based summary of nutrition therapy for the management of HTN in adults aged 18 years or older. Implementation of this guideline aims to promote evidence-based practice decisions by registered dietitian nutritionists (RDNs), and other collaborating health professionals to decrease or manage HTN in adults while enhancing patient quality of life and taking into account individual preferences. The systematic review and guideline development methodology of the Academy of Nutrition and Dietetics were applied. A total of 70 research studies were included, analyzed, and rated for quality by trained evidence analysts (literature review dates ranged between 2004 and 2015). Evaluation and synthesis of related evidence resulted in the development of nine recommendations. To reduce BP in adults with HTN, there is strong evidence to recommend provision of medical nutrition therapy by an RDN, adoption of the Dietary Approaches to Stop Hypertension dietary pattern, calcium supplementation, physical activity as a component of a healthy lifestyle, reduction in dietary sodium intake, and reduction of alcohol consumption in heavy drinkers. Increased intake of dietary potassium and calcium as well as supplementation with potassium and magnesium for lowering BP are also recommended (fair evidence). Finally, recommendations related to lowering BP were formulated on vitamin D, magnesium, and the putative role of alcohol consumption in moderate drinkers (weak evidence). In conclusion, the present evidence-based nutrition practice guideline describes the most current recommendations on the dietary management of HTN in adults intended to support the practice of RDNs and other health professionals.

Evaluating a Teaching Module on Ethically Responsible Evidence-Based Practice Decision Making in an Advanced Micro Practice Course

ABSTRACTThis article adds to the growing body of literature on the use of evidence-based practice (EBP) in social work. Specifically, it examines a 9-hour EBP educational model designed to prepare MSW students for appropriate decision-making strategies in working with multicultural client populations. The model places emphasis on identification and application of critical thinking skills for micro- and mezzo-level practice in urban social work systems. It moves beyond traditional research approaches and emphasizes community-based and emic approaches for generating evidence appropriate for ethnic minority populations. Students’ written assignments (N = 80) demonstrated the model’s pedagogical value as a learning strategy for applying EBP. Students’ evaluations demonstrated the model’s value in sensitizing students to the importance of becoming ethically responsible research consumers.

Effects of an Evidence-Based Practice (EBP) Education Program on EBP Practice Readiness and EBP Decision Making in Clinical Nurses

Effects of an Evidence-Based Practice (EBP) Education Program on EBP Practice Readiness and EBP Decision Making in Clinical Nurses

Decision-making experiences of public library CEOs

Purpose – The purpose of this paper is to explore and describe the decision-making practices of public library managers in the context of interpersonal influence and evidence-based information sources, and to investigate the relationship between models of evidence-based practice and interpersonal influence in the decision-making process of public library managers. Design/methodology/approach – Data were collected through short audio blog posts participants made about their everyday decisions and coded considering the facets of three existing evidence-based library and information practice (EBLIP) models as well as the facets of interpersonal influence. Findings – The findings show that public library CEOs decision-making behaviours reflect the use of a variety of practices from analytical to intuitive as is expected of managers in any sector; however, a stronger reliance on gathering objective information may be present than in other sectors. Seeking multiple sources of information and a tendency towards rationalism may indicate a more sophisticated approach to decision making, but be less indicative of the practices employed more broadly. A possible outcome of these tendencies may result in discordance with external partners and collaborators. Practical implications – The findings from this study may inform the work of associations, library and information science (LIS) educators, and library managers in developing strategic directions and instructional strategies within their organisations. It is also the first study to jointly examine models of interpersonal influence and evidence-based decision-making practices in any field. Originality/value – While the study of the decision-making practices of various groups is growing, little previous research has been conducted with public library managers, and none has been undertaken in Canada.

Accelerated tooth movement: Do we need a new systematic review?

Current systematic reviews are important for health care providers in supporting their evidence-based practice decisions. Equally important is the ability to determine when a new systematic review is needed in view of the rapid publication output. The current best evidence from a 2013 systematic review suggests that certain treatments may accelerate orthodontic tooth movement. Our aim was to determine if an updated systematic review is needed on this topic by applying the modified Ottawa method. A systematic search of Pubmed, Embase, CENTRAL, and Web of Science databases, identical to the previous systematic review, was executed. Two authors performed screening for inclusion/exclusion of studies and selected full-text articles were reviewed. Qualitative and quantitative criteria were applied to assess studies describing the following types of interventions to accelerate tooth movement: electrical, photobiomodulation, micro-osteoperforations, vibration, corticotomy, and low-level laser therapy. The Ottawa method showed that studies produced since 2011 have (1) potentially invalidating evidence and description of new methods and (2) combined new data that would enhance the precision of the existing evidence on low-level laser therapy. These collectively indicate the need for a new systematic review on adjunct procedures to accelerate orthodontic tooth movement, which may offer new evidence and techniques not previously mentioned.

Laying the groundwork for evidence-based public health: why some local health departments use more evidence-based decision-making practices than others.

We examined variation in the use of evidence-based decision-making (EBDM) practices across local health departments (LHDs) in the United States and the extent to which this variation was predicted by resources, personnel, and governance. We analyzed data from the National Association of County and City Health Officials Profile of Local Health Departments, the Association of State and Territorial Health Officials State Health Departments Profile, and the US Census using 2-level multilevel regression models. We found more workforce predictors than resource predictors. Thus, although resources are related to LHDs' use of EBDM practices, the way resources are used (e.g., the types and qualifications of personnel hired) may be more important.

Strategies for searching and managing evidence-based practice resources.

Evidence-based nursing practice requires the use of effective search strategies to locate relevant resources to guide practice change. Continuing education and staff development professionals can assist nurses to conduct effective literature searches. This article provides suggestions for strategies to aid in identifying search terms. Strategies also are recommended for refining searches by using controlled vocabulary, truncation, Boolean operators, PICOT (Population/Patient Problem, Intervention, Comparison, Outcome, Time) searching, and search limits. Suggestions for methods of managing resources also are identified. Using these approaches will assist in more effective literature searches and may help evidence-based practice decisions.

Evidence-Based Practice Behaviours: A Comparison amongst Occupational Therapy Students and Clinicians

Occupational therapy graduates are expected to demonstrate entry-level competencies in evidence-based practice. To support students during the course of professional education in developing the knowledge, skills, and attitudes for integrating scientific findings into clinical practice, educators must identify the process by which these competencies are developed. To identify the differences in evidence-based practice decisions amongst occupational therapy students and experienced clinicians. Using a vignette depicting an older client with a history of falls, participants' evidence-based practice decisions were compared to a reference model. In the initial steps of the process, knowledge of evidence-based practice concepts appeared to be dependent upon formal instruction, whereas expert-like behaviours in the integration of evidence for decision-making seemed to be a function of clinical experience. Academic and clinical educators can use identified gaps in knowledge and synthesis of concepts to update the evidence-based practice content in occupational therapy curricula and fieldwork.

Summary of AHRQ's Comparative Effectiveness Review of Disease-Modifying Antirheumatic Drugs for Children with Juvenile Idiopathic Arthritis.

A systematic review on the comparative effectiveness of disease-modifying antirheumatic drugs (DMARDs) used to treat children with juvenile idiopathic arthritis (JIA) was published by the Agency for Health Care Research and Quality (AHRQ) in September 2011. Studies from 198 articles included in the review addressed the benefits and harms of DMARDs compared with conventional treatments and other DMARDs used to treat JIA. The review also incorporated studies comparing various clinical tools used for diagnosing JIA and measuring disease activity. Clinical outcome measures were analyzed to determine the most effective methods to measure disease state. The lack of current research for the treatment of JIA motivated AHRQ to contract with researchers to synthesize the available information with the intent of enabling health professionals to make evidence-based practice decisions for their patients. The review alsohighlights gaps in the research and areas that need to be addressed in the future. To (a) educate health care practitioners on the findings from AHRQ's 2011 comparative effectiveness review on DMARDs used to treat children with JIA, (b) apply review findings to make diagnosis and treatment decisions in clinical practice, and (c) recognize limitations and gaps n the current research relating to the comparative benefits and harms of DMARDs for treatment of JIA. JIA is a chronic inflammatory disease affecting approximately 300,000 children and adolescents in the United States.1 Initially manifesting with inflammation, swelling, pain, and stiffness of the joints, the disease as no apparent or known cause. JIA is a clinical diagnosis based on several actors including the number of affected joints and the involvement of other tissues (e.g., the skin and lymphoid tissues), and JIA has 7 categories: systemic-onset arthritis, oligoarthritis, rheumatoid-factor positive polyarthritis, rheumatoid-factor negative polyarthritis, enthesitis-related arthritis, psoriatic arthritis, and undifferentiated arthritis.2 Complete remission and resolution of disease activity are the ultimate treatment goals; however, there is no present cure. Inhibition of inflammation, prevention of joint damage, and promotion of a high level of functioning are the immediate goals of treatment. Even with treatment, patients with JIA continue to experience disease activity, joint destruction, suboptimal function, and impaired quality of life, all of which extend into adulthood.3 JIA can be severely debilitating and places a heavy physical and psychological burden on children and families affected by the disease. Methotrexate is a nonbiologic DMARD with an unknown mechanism of action. Methotrexate has been used for so long in the treatment of JIA that it is frequently considered a part of conventional treatment; the evidence shows that methotrexate is superior to conventional treatment with NSAIDsand/or intra-articular corticosteroids. The introduction of newer biologic DMARDs has spawned optimism that treatment will increasingly lead to improved outcomes for JIA, but the evidence is insufficient to support superiority over methotrexate. There is moderate evidence to support the claim that continued treatment from 4 months to 2 years with a biologic DMARD in children who have responded to a biologic DMARD decreases the risk of a flare. However, the safety of biologic DMARDs for long-term use has not been determined and may be associated with the developmentof cancer. The association between tumor necrosis factor (TNF) alpha inhibitors and potential increased risk of lymphoma caused the U.S. Food and Drug Administration (FDA) to place boxed warning labels on biologic DMARDs including etancercept, infliximab, and adalimumab. The effectiveness of the DMARDs appears to vary among categories of JIA and the treatment history of individual patients. Except for methotrexate, there is insufficient evidence to support selection of a specific drug or drug class over another in the treatment of JIA. The AHRQ review examines the scientific literature on DMARDs used in children with JIA in an effort to synthesize what is known about the subject, and the comprehensive review identifies important research gaps in the literature that need to be addressed. Only 8 studies (in 9 publications) were rated "good quality" by the AHRQ investigators.