Goal Of Evidence-based Medicine Research Articles

A step towards dignity in life and death.

All too many patients with cancer will die in pain, fear, or confusion, or with goodbyes unsaid, having spent the last few months of their lives experiencing treatment-related adverse events. With most patients given the highest amount of chemotherapy treatment during their last months of life, it seems that we have forgotten that extension of life at any cost is a price not worth paying. If the goal of evidence-based medicine is the use of research for people to live their lives in the best possible health, surely we should also use research to establish how patients can also have the best possible death. When a patient is diagnosed with cancer, part of their provision of care must be to plan for amelioration of adverse events or the possibility of their treatment not working, and to have careful, structured dialogues with them and their loved ones about how they would like to proceed in such eventualities. It is the steps needed to make this goal a reality that Stein Kaasa and colleagues address in The Lancet Oncology's latest Commission. 1 Kaasa S Loge JH Aapro M et al. Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol. 2018; (published online Oct 18.)http://dx.doi.org/10.1016/S1470-2045(18)30415-7 Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar Integrating palliative care into health systems is essential to achieve Universal Health CoveragePalliative care and pain relief have been largely ignored in global health.1 The Lancet and The Lancet Oncology have taken up this gauntlet by releasing two Commission reports2,3 that provide roadmaps to close the growing abyss in access to palliative care and pain relief for large parts of the world.4,5 Full-Text PDF Oncology and palliative care: patients need a seamless serviceIn The Lancet Oncology Commission,1 Stein Kaasa and colleagues lay out their purpose clearly: “to show why and how palliative care can be integrated with oncology for adults with cancer, irrespective of treatment intention”. The first part of this manifesto is more clearly fulfilled than the second. To marshal the modest, but accumulating, evidence for better patient outcomes when oncology and palliative care work in synergy is straightforward,2–6 but to say how integration between the specialties should be achieved is much harder, given the variations between countries in health-care organisation and culture. Full-Text PDF Integration of oncology and palliative care: less-mentioned issues and a Japanese perspectiveWe welcome the comprehensive Lancet Oncology Commission1 by Stein Kaasa and colleagues, which clarifies a reliable pathway to achieve patient-centered care through the integration of oncology and palliative care.1 Full-Text PDF Integrating palliative and oncology care: paediatric considerationsCancers that affect adults inflict a worldwide burden of suffering. Stein Kaasa and colleagues' Lancet Oncology Commission1 on the integration of oncology and palliative care highlights important developments in our understanding of the pivotal contributions of palliative care to person-focused adult cancer care. For children with cancer, additional and expanded constructs should be considered. Although childhood cancers are far less prevalent than cancers that affect adults, the need for integrated paediatric palliative care and oncology care is no less pressing. Full-Text PDF Integration of oncology and palliative care: a Lancet Oncology CommissionFull integration of oncology and palliative care relies on the specific knowledge and skills of two modes of care: the tumour-directed approach, the main focus of which is on treating the disease; and the host-directed approach, which focuses on the patient with the disease. This Commission addresses how to combine these two paradigms to achieve the best outcome of patient care. Randomised clinical trials on integration of oncology and palliative care point to health gains: improved survival and symptom control, less anxiety and depression, reduced use of futile chemotherapy at the end of life, improved family satisfaction and quality of life, and improved use of health-care resources. Full-Text PDF

Integration of oncology and palliative care: less-mentioned issues and a Japanese perspective.

We welcome the comprehensive Lancet Oncology Commission 1 Kaasa S Loge JH Aapro M et al. Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol. 2018; (published online Oct 18.)http://dx.doi.org/10.1016/S1470-2045(18)30415-7 Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar by Stein Kaasa and colleagues, which clarifies a reliable pathway to achieve patient-centered care through the integration of oncology and palliative care. 1 Kaasa S Loge JH Aapro M et al. Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol. 2018; (published online Oct 18.)http://dx.doi.org/10.1016/S1470-2045(18)30415-7 Summary Full Text Full Text PDF PubMed Scopus (178) Google Scholar A step towards dignity in life and deathAll too many patients with cancer will die in pain, fear, or confusion, or with goodbyes unsaid, having spent the last few months of their lives experiencing treatment-related adverse events. With most patients given the highest amount of chemotherapy treatment during their last months of life, it seems that we have forgotten that extension of life at any cost is a price not worth paying. If the goal of evidence-based medicine is the use of research for people to live their lives in the best possible health, surely we should also use research to establish how patients can also have the best possible death. Full-Text PDF Integrating palliative care into health systems is essential to achieve Universal Health CoveragePalliative care and pain relief have been largely ignored in global health.1 The Lancet and The Lancet Oncology have taken up this gauntlet by releasing two Commission reports2,3 that provide roadmaps to close the growing abyss in access to palliative care and pain relief for large parts of the world.4,5 Full-Text PDF Oncology and palliative care: patients need a seamless serviceIn The Lancet Oncology Commission,1 Stein Kaasa and colleagues lay out their purpose clearly: “to show why and how palliative care can be integrated with oncology for adults with cancer, irrespective of treatment intention”. The first part of this manifesto is more clearly fulfilled than the second. To marshal the modest, but accumulating, evidence for better patient outcomes when oncology and palliative care work in synergy is straightforward,2–6 but to say how integration between the specialties should be achieved is much harder, given the variations between countries in health-care organisation and culture. Full-Text PDF Integrating palliative and oncology care: paediatric considerationsCancers that affect adults inflict a worldwide burden of suffering. Stein Kaasa and colleagues' Lancet Oncology Commission1 on the integration of oncology and palliative care highlights important developments in our understanding of the pivotal contributions of palliative care to person-focused adult cancer care. For children with cancer, additional and expanded constructs should be considered. Although childhood cancers are far less prevalent than cancers that affect adults, the need for integrated paediatric palliative care and oncology care is no less pressing. Full-Text PDF Integration of oncology and palliative care: a Lancet Oncology CommissionFull integration of oncology and palliative care relies on the specific knowledge and skills of two modes of care: the tumour-directed approach, the main focus of which is on treating the disease; and the host-directed approach, which focuses on the patient with the disease. This Commission addresses how to combine these two paradigms to achieve the best outcome of patient care. Randomised clinical trials on integration of oncology and palliative care point to health gains: improved survival and symptom control, less anxiety and depression, reduced use of futile chemotherapy at the end of life, improved family satisfaction and quality of life, and improved use of health-care resources. Full-Text PDF

Unpacking the process of interpretation in evidence-based decision making.

Evidence-based medicine (EBM) has promoted the conscientious and systematic use of the best available scientific evidence in clinical decision making [1]. From an EBM point of view, only experimental evidence, especially results from randomized controlled trials and meta-analyses of trial results, count as strong evidence. Experiential evidence based upon expert opinion is classified as weak and placed at the bottom of the evidence hierarchy. EBM is often contrasted with traditional clinical medicine which considered pathophysiological reasoning and expert knowledge as the principal sources of clinical decision making. In a recently published article in Journal of Evaluation in Clinical Practice, Jeannette Hofmeijer describes EBM as a revision of medical epistemology and points to the neglected role of expert opinion and the lack of focus on the principles of reasoning underpinning EMB [2]. More specifically, she shows how EBM involves important processes of interpretation. Hofmeijer is mainly concerned with the role of interpretation in the production of scientific knowledge within the EBM tradition, and she illustrates how the quest for evidence relies upon interpretation both in formulating a hypothesis and in accepting the accumulated evidence as sufficient. We will argue a related but still different perspective demonstrating the principles of reasoning involved in the integration of experimental and experiential knowledge in clinical decisions and the role of interpretation in this respect. The goal of EBM is, according to Sackett et al., the integration of (1) clinical experience and expertise; (2) scientific evidence; and (3) patient values and preferences to provide high-quality services [1]. However, a weakness of EBM is the lack of guidance on how to combine the main knowledge components of the model. The EBM literature says little about how to create a fruitful interaction between research, clinical expertise and patient preferences. Although the principal aim of EBM is to promote more conscientious and systematic clinical decision making, an important element of the model remains black boxed: the principles of reasoning according to which the different knowledge sources are combined. This paper aims to make explicit the often implicit interpretational work involved when scientific evidence, clinical expertise and patient preferences are combined. We believe that better awareness about this process of interpretation can promote better and more trustworthy decision making. Lack of individualization is a recurrent criticism against EBM [3,4]. Randomized clinical trials measure average effects and do not necessarily match the local and complex situation of the individual patient [5]. The need for a situated, practice-based reasoning has been argued, and concepts such as clinical intuition [6], tacit knowledge [7], wisdom [8] and collectively defined ‘mind lines’ [9] have been introduced to challenge a unilateral focus on implementing research evidence. More recently, the literature on patient-centred medicine and shared decision making has emphasized the importance of involving patients in medical decisions and suggested useful methods and approaches [10,11]. In spite of these attempts, the principles of reasoning according to which the knowledge sources are combined and applied are still poorly understood. There are few, if any, models and concepts available which make explicit the interpretational operations involved when combining and applying the knowledge components. We intend to throw light on this process by drawing on a four-step model of knowing developed by the Canadian philosopher Bernard Lonergan [12].

Evidence-based medicine in aesthetic medicine and surgery: reality or fantasy?

The goal of evidence-based medicine (EBM) is for health-care professionals to incorporate existing medical evidence into clinical practice to achieve the greatest possible outcomes. The theory of EBM has been employed since the 11th century and has evolved dramatically into the modern application used by practicing physicians today. There are five levels of evidence currently used to evaluate if certain techniques, methods, and surgical procedures are the "best" to be used in practice. Despite the outlined format of EBM, plastic surgeons have difficulty applying EBM in clinical practice because of the influence of expert opinion and the subjective nature of outcomes. This article explores the function of EBM in aesthetic plastic surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Factors That Influence Effective Evidence-Based Medicine Instruction

Evidence-based medicine (EBM) as a health care practice is being incorporated into education programs across the spectrum of medical education to develop lifelong learning skills and to enhance the practice of evidence-based health care. Since improving the quality of patient care is the ultimate goal of EBM, EBM learning must be integrated with clinical application, and resulted outcomes must be reflected in learning transfer (or EBM practice) within the context of solving patient problems. Different factors may constitute the context or environment in which EBM is learned, practiced, and sustained. However, these contextual factors are seldom considered and examined in the development, implementation, and evaluation of EBM instruction for learners at different levels. This article will introduce several contextual factors as tips and strategies that affect EBM learning and transfer. Also included in the article are recommended practices for designing effective EBM instruction that would contribute to a sustainable change in learner behavior.

Research Methodology: An Innovative Approach to a Venerable Course

This paper outlines a number of innovations that we have recently implemented in the Research Methodology Course at the University of Michigan's School of Public Health. Consistent with the goals of evidence-based medicine, evidence-based public health, intrinsic motivation, and phase 4 (T4) translational research, we have placed the emphasis on enhancing the students' desire to learn-and more specifically on their desire to learn rigorous methods for conducting useful research that delivers practical benefits in a straightforward manner. A dozen innovations, along with some preliminary outcomes, are outlined in detail.

Qualitative research and the take-up of evidence-based practice

In this paper it is argued that evidence-based medicine (EBM) is a social movement as well as a scientific enterprise, and that as such it requires qualitative investigation of its various activities to understand its impact and take-up. Randomised controlled trials (RCTs) are a blunt instrument of assessing whether interventions achieve intended or unintended outcomes, or whether they are acceptable to those they are aimed at. To understand the success or failure of evidence-based interventions, it is necessary to investigate practitioners’ acceptance of, or resistance to, EBM. This involves exploration of the perceived relationships between practical clinical knowledge derived from everyday practice and scientific knowledge. The implementation of best evidence also requires the acknowledgement of local contextual factors. The goals of EBM will not be achieved if patients do not accept the advice and prescriptions they are given by professionals. One of the reasons that some professionals find it difficult to use the results of RCTs in their clinical practice is because they are aware of patients’ differing priorities and life experiences. If we accept that EBM is a social movement, then the methods needed to investigate its activities are those of the social sciences, including qualitative methods.

Ethical and evidence-based practice in brain injury rehabilitation

The ultimate goal of evidence-based medicine (EBM) is to develop a scientific basis for choosing interventions that will benefit individuals with defined characteristics under specified conditions. By referencing practice recommendations to the strength of the scientific evidence gleaned from systematic reviews, EBM avoids the influence of professional biases. The randomised controlled trial (RCT) has come to be considered the gold standard for EBM methodology. Strengths as well as risks and weaknesses of RCT-focused EBM are reviewed. EBM is also linked to the medical model in which the target of the intervention is a disorder within the individual patient. Some interventions in brain injury rehabilitation may be more appropriately studied within a social model of disability in which the target of intervention is the individual's environment or social system. While the pursuit of a scientific basis for practice is clearly an ethical mandate, defining ethical practice in the absence of strong evidence and in the presence of competing methodologies is elusive. Balancing these considerations, the ethical practice of brain injury rehabilitation requires an awareness not only of the scientific evidence for an intervention but also of current best practices recommended by professional traditions and consensus, the practice situation, and the individual's current and evolving situation, needs and preferences.

Limitations of Evidence in the Practice of Evidence-Based Medicine

The goal of evidence-based medicine (EBM) is to support population-based policies and individual medical decisions that serve to improve health outcomes through the use of the most proven effective treatments. The essence of EBM is to use evidence (typically research data) related to the effectiveness of medical interventions to guide decisions about whether to use those interventions in clinical practice. The quality of evidence is the critical component in understanding and using EBM. This article discusses the kinds and limitations of the evidence used in the practice of EBM.

Critique of (im)pure reason: evidence-based medicine and common sense.

While the goal of evidence-based medicine (EBM) is certainly laudable, it is completely based on the proposition that 'truth' can be gleaned exclusively from statistical studies. In many instances, the complexity of human physiology and pathophysiology makes this a reasonable, if not necessary, assumption. However, there are two additional large classes of medical 'events' that are not well served by this paradigm: those that are based on physically required causality, and those that are so obvious (to the casual observer) that no self-respecting study will ever be undertaken (let alone published). Frequently, cause-and-effect relationships are so evident that they fall into both categories, and are best dealt with by the judicious use of common sense. Unfortunately, the use of common sense is not encouraged in the EBM literature, as it is felt to be diametrically opposed to the very notion of EBM. As is more fully discussed in the manuscript, this active disregard for common sense leaves us at a great disadvantage in the practical practice of medicine.

Evidence-based behavioral medicine: what is it and how do we achieve it?

The goal of evidence-based medicine is ultimately to improve patient outcomes and quality of care. Systematic reviews of the available published evidence are required to identify interventions that lead to improvements in behavior, health, and well-being. Authoritative literature reviews depend on the quality of published research and research reports. The Consolidated Standards for Reporting Trials (CONSORT) Statement (www.consort-statement.org) was developed to improve the design and reporting of interventions involving randomized clinical trials (RCTs) in medical journals. We describe the 22 CONSORT guidelines and explain their application to behavioral medicine research and to evidence-based practice. Additional behavioral medicine-specific guidelines (e.g., treatment adherence) are also presented. Use of these guidelines by clinicians, educators, policymakers, and researchers who design, report, and evaluate or review RCTs will strengthen the research itself and accelerate efforts to apply behavioral medicine research to improve the processes and outcomes of behavioral medicine practice.

Clinical research and the physician-patient relationship.

All practicing physicians should be prepared to respond to requests from patients for advice about participating in clinical trials research. Even physicians who choose not to conduct clinical trials but rather devote their practice to clinical care may have patients who consider volunteering for research. In advising patients about clinical research, physicians enhance the physician-patient relationship and contribute to the overall goals of evidence-based medicine. We discuss several ethical and practical challenges facing physicians who wish to help their patients make decisions about volunteering for clinical trials. In addition, we suggest how preparation for advising patients about clinical research participation can be incorporated into the medical education process.

Neurological aspects of patent foramen ovale: in search of the optimal treatment.

Although paradoxical embolism through a patent foramen ovale (PFO) has become an established cause of cerebral ischemia in younger patients without other obvious causes of stroke, the therapeutic options have not been investigated satisfactorily. There are still uncertainties about the natural history of PFO patients after suffering a stroke, and diagnostic criteria proving a causal and not incidental relation to the embolic event are not established. The stroke recurrence has been evaluated in several studies in a heterogeneous population and seems as low as 1.9% per year. Secondary prophylactic treatment has become a matter of discussion since efforts were made to close the PFO either surgically or by percutaneous transcatheter methods. Foramen closure seems to be effective in eliminating the mechanism of paradoxical embolism but its benefit-risk ratio has yet to be established. Following the goals of evidence-based medicine, none of the therapeutic options can be recommended. Fortunately, the issue has gone to trial and there are two studies underway to compare foramen closure to medical therapy.

Evidence-based migraine therapy: learning needs and knowledge assessment.

One of the primary goals of continuing medical education (CME) is to enhance the learners' performance, and a major goal of evidence-based medicine (EBM) is to improve knowledge of current best care. This paper overviews the use of a Learning Needs and Knowledge Assessment tool to highlight the potential learning needs and knowledge of neurologists and to focus the issues, interest and interactions of neurologists in a workshop on EBM migraine therapy. Virtually all neurologists felt they used evidence-based medicine in their daily practice. Surprisingly, 50% of neurologists agreed that they were uncertain which triptan to use. The great majority of neurologists felt that the triptans were not all equally efficacious. Our survey identified significant knowledge gaps among neurologists regarding how to appraise the validity of evidence from a randomized clinical trial, and with regard to what are the most clinically useful measures of benefit in clinical trials.

The Stroke Prevention Policy Model: linking evidence and clinical decisions.

Simulation models that support decision and cost-effectiveness analysis can further the goals of evidence-based medicine by facilitating the synthesis of information from several sources into a single comprehensive structure. The Stroke Prevention Policy Model (SPPM) performs this function for the clinical and policy questions that surround stroke prevention. This paper first describes the basic structure and functions of the SPPM, concentrating on the role of large databases (broadly defined as any database that contains many patients, regardless of study design) in providing the SPPM inputs. Next, recognizing that the use of modeling continues to be a source of some controversy in the medical community, it discusses the philosophical underpinnings of the SPPM. Finally, it discusses conclusions in the context of both stroke prevention and other complex medical decisions. We conclude that despite the difficulties in developing comprehensive models (for example, the length and complexity of model development and validation processes, the proprietary nature of data sources, and the necessity for developing new software), the benefits of such models exceed the costs of continuing to rely on more conventional methods. Although they should not replace the clinician in decision making, comprehensive models based on the best available evidence from large databases can support decision making in medicine.