Evidence-based medicine and problem based learning a critical re-evaluation.

Evidence-based medicine (EBM) has been the subject of controversy since it was introduced in 1992. However, it has yet to be critically examined as an alternative paradigm for medical education, which is how it was proposed. This commentary examines EBM on the terms on which it was originally advanced and within the context that gave rise to it, the problem-based learning (PBL) environment at McMaster University in the 1970s and 80s. The EBM educational prescription is revealed to be aligned with the information processing psychology (IPP) model of learning through acquisition of general problem solving skills that characterized the early McMaster version of PBL. The IPP model has been identified in the literature as discordant with an alternative, constructivist, model that emerged at Maastricht University in the Netherlands over the subsequent period. Strengths and weaknesses of EBM are identified from the standpoint of the underlying cognitive theories. Principles are proposed with which to guide an educationally viable approach to learning and teaching the valuable skills included within the original EBM formula.

Revelation of mindlines in the setting of crisis.

During the devastating early months of the unfolding COVID-19 pandemic in New York, healthcare systems and clinicians dynamically adapted to drastically changing everyday practice despite having little guidance from formal research evidence in the face of a novel virus. Through new, silo-breaking networks of communication, clinical teams transformed and synthesized provisional recommendations, rudimentary published research findings and numerous other sources of knowledge to address the immediate patient care needs they faced during the pandemic surge. These experiences illustrated underlying social processes that are always at play as clinicians integrate information from various sources, including research and published guidelines, with their own tacit knowledge to develop shared yet personal approaches to practice. In this article, we provide a narrative account of personal experience during the COVID-19 surge. We draw on the concept of mindlines as developed by Gabbay and Le May as a conceptual framework for interpreting that experience from the standpoint of how early information from research and guidelines was drawn on and transformed in the course of day-to-day struggle with the crisis in New York City emergency rooms. Finally, briefly referencing the challenges to conventional models of healthcare knowledge creation and translation through research and guideline production posed by COVID-19 crisis, we offer a provisional perspective on current and future developments.

Eating a larger number of high-salt foods is not associated with short-term risk of acute decompensation in patients with chronic heart failure.

BACKGROUND: Risk factors for exacerbation of congestive heart failure have not been consistently validated. OBJECTIVE: Our objective was to examine the role of short-term dietary sodium intake in acute decompensated heart failure. METHODS: Patients with chronic congestive heart failure presenting to the Emergency Department for either acute decompensated heart failure (cases) or for other reasons (controls) were included in a case-control study. Cases and controls were compared with respect to age, smoking, recent sodium intake, medication nonadherence, coronary artery disease, and hypertension. A food frequency questionnaire was utilized to estimate recent sodium intake, defined as the number of food types consumed in the previous 3 days from the 12 highest-sodium food categories. RESULTS: There were 182 patients enrolled. One patient was excluded due to uncertainty about the primary diagnosis. When adjusted for age, smoking, medication nonadherence, coronary artery disease, and hypertension, acute decompensated heart failure was not associated with short-term dietary sodium intake. The odds ratio for acute decompensated heart failure for each increase in the number of high-sodium food types consumed was 1.1 (95% confidence interval 0.9-1.3; p = 0.3). Acute decompensated heart failure was associated with medication nonadherence, with an odds ratio for decompensation of 2.5 (95% confidence interval 1.2-5.1; p = 0.01). CONCLUSIONS: Patients with chronic congestive heart failure who presented to the Emergency Department with acute decompensated heart failure were no more likely to report consuming a greater number of high-sodium foods in the 3 days before than were patients with chronic congestive heart failure who presented with unrelated symptoms. On the other hand, those who presented with acute decompensated heart failure were significantly more likely to report nonadherence with medications.

On crowns, caravans and windmills: Commentary on an essay by Turcotte P., et al.

Patient-oriented research (POR) is a trend that has emerged over several decades and is particularly prominent in Canada, the United States and the United Kingdom. It involves patient and other stakeholder participation in the planning, conduct and dissemination of biomedical and health services research and it can be seen as a form of public participation and engagement in activities that affect the lives and well-being of communities. Criticisms of POR revolve around its susceptibility to tokenistic treatment of patient participants and paternalistic dominance of the research agenda by professional researchers, academics and clinicians. This commentary addresses one such critique by situating the POR agenda within the challenges and dilemmas faced by the health-related research enterprise over the past 30 years. It will explore the interface between POR, community activism and community-based participatory research. The contextual importance of the COVID-19 pandemic experience is stressed. The commentary will particularly focus on the US-based Patient Centred Outcomes Research Institute, its origins within a movement to enhance emphasis on publicly funded comparative effectiveness research, and its more recent evolution in the direction of community empowerment in POR.

Tips for teachers of evidence-based medicine: making sense of decision analysis using a decision tree.

Decision analysis is a tool that clinicians can use to choose an option that maximizes the overall net benefit to a patient. It is an explicit, quantitative, and systematic approach to decision making under conditions of uncertainty. In this article, we present two teaching tips aimed at helping clinical learners understand the use and relevance of decision analysis. The first tip demonstrates the structure of a decision tree. With this tree, a clinician may identify the optimal choice among complicated options by calculating probabilities of events and incorporating patient valuations of possible outcomes. The second tip demonstrates how to address uncertainty regarding the estimates used in a decision tree. We field tested the tips twice with interns and senior residents. Teacher preparatory time was approximately 90 minutes. The field test utilized a board and a calculator. Two handouts were prepared. Learners identified the importance of incorporating values into the decision-making process as well as the role of uncertainty. The educational objectives appeared to be reached. These teaching tips introduce clinical learners to decision analysis in a fashion aimed to illustrate principles of clinical reasoning and how patient values can be actively incorporated into complex decision making.

Do workshops in evidence-based practice equip participants to identify and answer questions requiring consideration of clinical research? A diagnostic skill assessment.

Evidence-based practice (EBP) requires practitioners to identify and formulate questions in response to patient encounters, and to seek, select, and appraise applicable clinical research. A standardized workshop format serves as the model for training of medical educators in these skills. We developed an evaluation exercise to assess the ability to identify and solve a problem requiring the use of targeted skills and administered it to 47 North American junior faculty and residents in various specialties at the close of two short workshops in EBP. Prior to the workshop, subjects reported prior training in EBP and completed a previously validated knowledge test. Our post-workshop exercise differed from the baseline measures and required participants to spontaneously identify a suitable question in response to a simulated clinical encounter, followed by a description of a stepwise approach to answering it. They then responded to successively more explicitly prompted queries relevant to their question. We analyzed responses to identify areas of skill deficiency and potential reasons for these deficiencies. Twelve respondents (26%) initially failed to identify a suitable question in response to the clinical scenario. Ability to choose a suitable question correlated with the ability to connect an original question to an appropriate study design. Prior EBP training correlated with the pretest score but not with performance on our exercise. Overall performance correlated with ability to correctly classify their questions as pertaining to therapy, diagnosis, prognosis, or harm. We conclude that faculty and residents completing standard workshops in EBP may still lack the ability to initiate and investigate original clinical inquiries using EBP skills.

Tips for teachers of evidence-based medicine: clinical prediction rules (CPRs) and estimating pretest probability.

BACKGROUND: Clinical prediction rules (CPR) are tools that clinicians can use to predict the most likely diagnosis, prognosis, or response to treatment in a patient based on individual characteristics. CPRs attempt to standardize, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments. The teaching tips series is designed to give teachers advice and materials they can use to attain specific educational objectives. EDUCATIONAL OBJECTIVES: In this article, we present 3 teaching tips aimed at helping clinical learners use clinical prediction rules and to more accurately assess pretest probability in every day practice. The first tip is designed to demonstrate variability in physician estimation of pretest probability. The second tip demonstrates how the estimate of pretest probability influences the interpretation of diagnostic tests and patient management. The third tip exposes learners to various examples and different types of Clinical Prediction Rules (CPR) and how to apply them in practice. PILOT TESTING: We field tested all 3 tips with 16 learners, a mix of interns and senior residents. Teacher preparatory time was approximately 2 hours. The field test utilized a board and a data projector; 3 handouts were prepared. The tips were felt to be clear and the educational objectives reached. Potential teaching pitfalls were identified. CONCLUSION: Teaching with these tips will help physicians appreciate the importance of applying evidence to their every day decisions. In 2 or 3 short teaching sessions, clinicians can also become familiar with the use of CPRs in applying evidence consistently in everyday practice.

Evidence-based emergency medicine/critically appraised topic. Evidence behind the 4-hour rule for initiation of antibiotic therapy in community-acquired pneumonia.

STUDY OBJECTIVE: US regulatory authorities mandate delivery of antibiotics within 4 hours of arrival for patients being admitted to the hospital with community-acquired pneumonia. This evidence-based emergency medicine review examines the scientific evidence pertaining to this requirement. METHODS: We searched MEDLINE, EMBASE, the Cochrane Library, other databases, and bibliographies. We selected articles allowing comparison of inpatient or 30-day mortality among patients receiving early versus delayed antibiotics. We prospectively categorized studies according to whether they were retrospective or prospective and whether they adjusted for severity with the Pneumonia Severity Index. We evaluated the precision with which the interval to initiation of antibiotic therapy was defined and the compliance of retrospective studies with standard reporting criteria for chart reviews. RESULTS: We identified 13 observational studies reporting comparative outcomes in patients receiving early versus delayed antibiotic initiation, of which 10 allowed calculation of our primary outcome. Of the 4 prospective studies, 1 allowed severity adjustment using the Pneumonia Severity Index score. Among the retrospective studies, definition of time to antibiotic therapy was frequently imprecisely defined, and compliance with standard reporting criteria for chart review was scanty in the subgroup lacking severity adjustment. Odds ratios (ORs) for mortality varied widely. One methodologically weak study reported a large benefit of early antibiotics (OR for mortality antibiotics <4 hours versus >4 hours 0.24; 95% confidence interval [CI] 0.08 to 0.71). The one study that used prospective enrollment and severity adjustment using the Pneumonia Severity Index observed a contrary result (adjusted OR for mortality, antibiotics <4 hours versus >4 hours 1.99; 95% CI 1.22 to 13.45). Results from studies reporting an 8-hour cutoff also varied in magnitude and direction of effect. CONCLUSION: Evidence from observational studies fails to confirm decreased mortality with early administration of antibiotics in stable patients with community-acquired pneumonia. Although timely administration of antibiotics to patients with confirmed community-acquired pneumonia should be encouraged, an inflated sense of priority of the 4-hour time frame is not justified by the evidence.

From MARS to MAGIC: The remarkable journey through time and space of the Grading of Recommendations Assessment, Development and Evaluation initiative.

For over 30 years, "evidence-based" clinical guidelines remained entrenched in an oversimplified, design-based, framework for rating the strength of evidence supporting clinical recommendations. The approach frequently equated the rating of evidence with that of the recommendations themselves. "Grading Recommendations Assessment, Development and Evaluation (GRADE)" has emerged as a proposed antidote to obsolete guideline methodology. GRADE sponsors and collaborators are in the process of attempting to amplify and extend the framework to encompass implementation and adaptation of guidelines, above and beyond the evaluation and rating of clinical research. Alternative schemes and models for such extensions are beginning to appear. This commentary reviews the strengths and weaknesses of GRADE with reference to other recent critiques. It considers the GRADE Working Group's "evidence-to-decision" extension of the evidence rating framework, together with proposed alternatives. It identifies pitfalls of the GRADE system's cooptation of relational processes necessary to the interpretation and uptake of recommendations that properly belong to end-users. It also identifies dangers inherent in blurring important boundaries between clinical and policy applications of guidelines. Finally, it addresses criticisms regarding the lack of a theoretical framework supporting the different facets of the GRADE approach and proposes a social constructivist orientation to clinical guideline development and use. Recommendations are offered to potential guideline developers and users regarding how to draw upon the strengths of the GRADE framework without succumbing to its pitfalls.

Stakeholder-Driven Quality Improvement: A Compelling Force for Clinical Practice Guidelines.

Clinical practice guideline development should be driven by rigorous methodology, but what is less clear is where quality improvement enters the process: should it be a priority-guiding force, or should it enter only after recommendations are formulated? We argue for a stakeholder-driven approach to guideline development, with an overriding goal of quality improvement based on stakeholder perceptions of needs, uncertainties, and knowledge gaps. In contrast, the widely used topic-driven approach, which often makes recommendations based only on randomized controlled trials, is driven by epidemiologic purity and evidence rigor, with quality improvement a downstream consideration. The advantages of a stakeholder-driven versus a topic-driven approach are highlighted by comparisons of guidelines for otitis media with effusion, thyroid nodules, sepsis, and acute bacterial rhinosinusitis. These comparisons show that stakeholder-driven guidelines are more likely to address the quality improvement needs and pressing concerns of clinicians and patients, including understudied populations and patients with multiple chronic conditions. Conversely, a topic-driven approach often addresses "typical" patients, based on research that may not reflect the needs of high-risk groups excluded from studies because of ethical issues or a desire for purity of research design.

Knowledge translation: closing the evidence-to-practice gap.

Knowledge translation describes any activity or process that facilitates the transfer of high-quality evidence from research into effective changes in health policy, clinical practice, or products. This increasingly important discipline attempts to conceptually combine elements of research, education, quality improvement, and electronic systems development to create a seamless linkage between interventions that improve patient care and their routine implementation in daily clinical practice. We outline the gap between research and practice and present a case study of an emergency medicine example of validated evidence that has failed to achieve widespread implementation. The authors describe a model of organization of evidence and its relationship with the process that links research from the scientific endeavor to changes in practice that affect patient outcomes. Obstacles to evidence uptake are explored, as well as the limitations of current educational strategies. Innovative strategies in realms such as computerized decision support systems designed to enhance evidence uptake are also described. The potential interface between knowledge translation and continuous quality improvement, as well as the role for bedside tools, is also presented. Research in knowledge translation includes studies that attempt to quantify and understand the discrepancies between what is known and what is done, as well as those that examine the impact and acceptability of interventions designed to narrow or close these gaps. Sentinel examples in this line of research conducted in the emergency department setting are described.

Vasopressin or epinephrine for out-of-hospital cardiac arrest.

STUDY OBJECTIVE: The use of vasopressin in patients with cardiac arrest presenting with specific rhythms is controversial. We performed an evidence-based emergency medicine review of evidence comparing vasopressin to epinephrine in structured cardiac arrest protocols. METHODS: We searched MEDLINE, EMBASE, the Cochrane Library, and other databases for randomized trials or systematic reviews comparing vasopressin to epinephrine for adults with cardiac arrest and measuring survival to hospital discharge and neurologic function in survivors. We used standard criteria to appraise the quality of published trials and systematic reviews. We used the random effects model in supplementary analyses to summarize results and to test for significant differences across subgroups of patients presenting with different arrest rhythms. RESULTS: We found 3 high-quality well-reported randomized trials and 1 rigorous meta-analysis. The evidence does not confirm a consistent benefit of vasopressin over epinephrine in increasing survival or improving neurologic outcome in survivors. Subgroup analysis reveals a large difference in effect of vasopressin over epinephrine in cardiac arrest patients with asystole, compared to other arrest rhythms, coming from within-trial comparisons. The difference is not consistent across otherwise similar trials, is not statistically significant, may reflect the application of multiple unplanned subgroup analyses, and is not supported by a plausible biological hypothesis. CONCLUSION: Evidence from randomized trials does not establish a benefit of vasopressin over epinephrine in increasing survival to discharge or improving neurologic outcomes in adult patients with nontraumatic cardiac arrest.

A survey to determine the prevalence and characteristics of training in Evidence-Based Medicine in emergency medicine residency programs.

We conducted a survey to determine the prevalence, training methods, and allotment of time for teaching evidence-based medicine (EBM) skills within accredited Emergency Medicine (EM) residency programs in the United States. A survey was mailed to program directors of all 122 accredited Emergency Medicine residency programs. The survey was also sent to program directors using an e-mail listserv. Responses were obtained from 53% of programs; 80% (95% CI: 68-89) of EM programs reported teaching some EBM. Although respondents believed a median of 10 hours were required to adequately cover this topic, only 22% provided more than 5 hours per year. Sixtey-three percent (95% CI: 50-75) of respondents reported using the JAMA Users' Guides series in journal club and 83% reported efforts to link journal clubs to patient care. Perceived barriers to integrating EBM into teaching and patient care included lack of trained faculty, lack of time, lack of familiarity with EBM resources, insufficient funding, and lack of interested faculty. In summary, academic EM programs are attempting to train residents in EBM, but perceive a lack of trained faculty, time, and funding as barriers. Desired resources include a defined curriculum, on-line training for faculty, and defined strategies for integration of EBM into training and patient care.

Teaching Evidence Assimilation for Collaborative Health Care (TEACH) 2009-2014: Building Evidence-Based Capacity within Health Care Provider Organizations.

BACKGROUND: Clinical guidelines, prediction tools, and computerized decision support (CDS) are underutilized outside of research contexts, and conventional teaching of evidence-based practice (EBP) skills fails to change practitioner behavior. Overcoming these challenges requires traversing practice, policy, and implementation domains. In this article, we describe a program's conceptual design, the results of institutional participation, and the program's evolution. Next steps include integration of instruction in principles of CDS. CONCEPTUAL MODEL: Teaching Evidence Assimilation for Collaborative Health Care (TEACH) is a multidisciplinary annual conference series involving on- and off-site trainings and facilitation within health care provider organizations (HPOs). Separate conference tracks address clinical policy and guideline development, implementation science, and foundational EBP skills. The implementation track uses a model encompassing problem delineation, identifying knowing-doing gaps, synthesizing evidence to address those gaps, adapting guidelines for local use, assessing implementation barriers, measuring outcomes, and sustaining evidence use. Training in CDS principles is an anticipated component within this track. Within participating organizations, the program engages senior administration, middle management, and frontline care providers. On-site care improvement projects serve as vehicles for developing ongoing, sustainable capabilities. TEACH facilitators conduct on-site workshops to enhance project development, integration of stakeholder engagement and decision support. Both on- and off-site components emphasize narrative skills and shared decision-making. EXPERIENCE: Since 2009, 430 participants attended TEACH conferences. Delegations from five centers attended an initial series of three conferences. Improvement projects centered on stroke care, hospital readmissions, and infection control. Successful implementation efforts were characterized by strong support of senior administration, involvement of a broad multidisciplinary constituency within the organization, and on-site facilitation on the part of TEACH faculty. Involvement of nursing management at the senior faculty level led to increased presence of nursing and other disciplines at subsequent conferences. CONCLUSIONS: A multidisciplinary and multifaceted approach to on- and off-site training and facilitation may lead to enhanced use of research to improve the quality of care within HPOs. Such training may provide valuable contextual grounding for effective use of CDS within such organizations.

The clinician and the medical literature: When can we take a shortcut?

[Wyer PC, Rowe BH, Guyatt GH, Cordell WH. The clinician and the medical literature: when can we take a shortcut? Ann Emerg Med. August 2000;36:149-155.].