Concepts of Evidence-Based Practice: Analysis of Evidence-Based Practice and Its Debate

Evidence-based practice (EBP) is a model for clinical decision-making, representing an interdisciplinary approach to clinical practice that aims to optimize clinical decision-making by emphasizing the use of evidence from well-designed research. An evidence-based decision is made by the individual clinician on basis of the best evidence available, in accordance with the patient’s preferences and circumstances. Since 1992, EBP has been a central concept within a growing range of professional fields of health care. At the same time, EBP has been subject to incessant criticism. EBP proponents have responded to criticism, and their responses have then become the object of further criticism. The basic principles of the EBP-model, along with the claims by proponents and opponents for and against these principles, which compose the EBP debate, are the main subjects of this thesis. The thesis has four chapters. In Chapter 1, the principles of Clinical epidemiology are presented as the main scientific framework of EBP. It is through this framework that epidemiologic, outcome-based data is considered the most reliable source of evidence for clinical interventions. In Chapter 2, the constitutive elements of EBP are analyzed, with particular attention to what kind of scientific knowledge (i.e., “research evidence”) and non-scientific knowledge and beliefs (i.e., “clinical expertise” and “patient preferences”) that are inherent in the concept of EBP. In addition, I differentiate between three theoretical concepts of EBP – “narrow”, “moderate”, and “maximal” – which differ relative to the degree to which “clinical expertise” and “patient autonomy” are included in the concept or not. I claim that only “moderate” EBP” is representative for an adequate understanding of the EBP model. Chapter 3 presents an analysis of central claims in the international EBP debate while Chapter 4 attends to central claims in the Norwegian EBP debate. I argue that the most relevant criticism pertains to the confidence in and the application of epidemiologic evidence-sources. This kind of criticism must be distinguished from the claim that EBP represents a narrow scope of evidence. The latter claim is based on a misunderstanding about what “evidence” entails in EBP literature and is representative to a narrow concept of EBP. Yet another kind of criticism, claiming that the EBP model ignores clinical expertise and patient autonomy, is also based on misunderstandings, largely due to lack of clarity in the EBP literature. A general conclusion is that the tendency to imply a narrow interpretation of EBP in much of the criticism, as well as the tendency to conceptual unclarities in much EBP literature, contribute to a less constructive debate. The thesis concludes by suggesting recommendations to both proponents and opponents, which can contribute to a more constructive basis for future EBP debates

Examining the application of STAMP in the analysis of patient safety incidents

This thesis examines the application of Systems-Theoretic Accident Model and Processes (STAMP) in healthcare and the analysis of patient safety incidents. Healthcare organisations have a responsibility for the safety of the patients they are treating. This includes the avoidance of unintended or unexpected harm to people during the provision of care. Patient safety incidents, that is adverse events where patients are harmed, are investigated and analysed as accidents are in other safety-critical industries, to gain an understanding of failure and to generate recommendations to prevent similar incidents occurring in the future. However, there is some dissatisfaction with the current quality of incident analysis in healthcare. There is dissatisfaction with the recommendations that are generated from healthcare incident analysis which are felt to produce weak and ineffective remedial actions, often including retraining of individuals and small policy change. Issues with current practice have been linked to the use of Root Cause Analysis (RCA), an analysis method that often results in the understanding of an accident as being the result of a linear chain of events. This type of simple linear approach has been the target of criticism in safety science research and is not felt to be effective in the analysis of incidents in complex systems, such as healthcare. Research in accident analysis methods has developed from a focus on technical failure and individual human actions to consideration of the interactions between people, technology and the organisation. Accident analysis methods have been developed that guide investigations to consideration of the whole system and interactions between system components. These system approaches are judged to be superior to simple linear approaches by the research community, however, they are not currently used in healthcare incident investigation practice. The systems approach of STAMP is felt to be a promising method for the improvement of healthcare incident analysis. STAMP strongly embodies the concepts of systems theory and analyses human decision-making. The application of STAMP in healthcare was investigated through three case studies, which applied STAMP in: 1. The analysis of the large-scale organisational failure at Mid-Staffordshire NHS Trust between 2005-2009. 2. The analysis of a common small-scale hospital-based medication prescription error. 3. The analysis of patient suicide in the community-based services of a Mental Health Trust. The effectiveness of the STAMP applications was evaluated with feedback from healthcare stakeholders on the usability and utility of STAMP and discussion of the STAMP applications against criteria for accident analysis models and methods. Healthcare stakeholders were generally positive about the utility of STAMP, finding it to provide a system view and guide consideration of interactions between system components. They also felt it would help them generate recommendations and were positive about the future application of STAMP in healthcare. However, many felt it to be a complicated method that would need specialist expertise to apply. The STAMP applications demonstrated the ability of STAMP to consider the whole system and guide an analysis to the generation of recommendations for system measures to prevent future incidents. From the findings of the research, recommendations are made to improve STAMP and to assist future applications of STAMP in healthcare. The research also discusses the other factors that influence incident analysis beyond that of the analytical approach used and how these need to be considered to maximise the effectiveness of STAMP

Hierarchies of evidence in evidence-based medicine

Hierarchies of evidence are an important and influential tool for appraising evidence in medicine. In recent years, hierarchies have been formally adopted by organizations including the Cochrane Collaboration [1], NICE [2,3], the WHO [4], the US Preventive Services Task Force [5], and the Australian NHMRC [6,7]. The development of such hierarchies has been regarded as a central part of Evidence-Based Medicine (e.g. [8-10]), a movement within healthcare which prioritises the use of epidemiological evidence such as that provided by Randomised Controlled Trials (RCTs). Philosophical work on the methodology of medicine has so far mostly focused on claims about the superiority of RCTs, and hence has largely neglected the questions of what hierarchies are, what assumptions they require, and how they affect clinical practice. This thesis shows that there is great variation in the hierarchies defended and in the interpretations they are, and can be, given. The interpretative assumptions made in using hierarchies are crucial to the content and defensibility of the underlying philosophical commitments concerning evidence and medical practice. Once this variation is been identified, it becomes clear that the little philosophical work that has been done so far affects only some hierarchies, under some interpretations. Modest interpretations offered by La Caze [11], conditional hierarchies like GRADE [12-14], and heuristic approaches such as that defended by Howick et al. [15,16] all survive previous philosophical criticism. This thesis extends previous criticisms by arguing that modest interpretations are so weak as to be unhelpful for clinical practice; that GRADE and similar conditional models omit clinically relevant information, such as information about variation in treatments’ effects and the causes of different responses to therapy; and that heuristic approaches lack the necessary empirical support. The conclusion is that hierarchies in general embed untenable philosophical assumptions: principally that information about average treatment effects backed by high-quality evidence can justify strong recommendations, and that the impact of evidence from individual studies can and should be appraised in isolation. Hierarchies are a poor basis for the application of evidence in clinical practice. The Evidence-Based Medicine movement should move beyond them and explore alternative tools for appraising the overall evidence for therapeutic claims

Repairing Innovation: A Study of Integrating AI in Clinical Care

Over the past two years, a multi-disciplinary team of clinicians and technologists associated with Duke University and Duke Health system have developed and implemented Sepsis Watch, a sociotechnical system combining an artificial intelligence (AI) deep learning model with new hospital protocols to raise the quality of sepsis treatment. Sepsis is a widespread and deadly condition that can develop from any infection and is one of the most common causes of death in hospitals. And while sepsis is treatable, it is notoriously difficult to diagnose consistently. This makes sepsis a prime candidate for AI-based interventions, where new approaches to patient data might raise levels of detection, treatment, and, ultimately, patient outcomes in the form of fewer deaths.As an application of AI, the deep learning model tends to eclipse the other parts of the system; in practice, Sepsis Watch is constituted by a complex combination of human labor and expertise, as well as technical and institutional infrastructures. This report brings into focus the critical role of human labor and organizational context in developing an effective clinical intervention by framing Sepsis Watch as a complex sociotechnical system, not just a machine learning model

It’s a Process: A Qualitative Study About the Resistance and Resilience of Transgender Youth of Color Navigating Parent/guardian Support and Societal Oppressions

Transgender youth of color experience alarming rates of marginalization and victimization within society, including experiences of rejection from parents/ guardians, which has been associated with various adverse health outcomes. Health care providers are encouraged to facilitate parent/guardian support for transgender youth to improve long term health, however nurses report feeling underprepared to care for transgender populations and nursing transgender health research is lacking. Therefore, the purpose of this study was to describe how transgender youth of color experience and navigate parent/guardian support, considering the broader societal context. This study was informed by critical and intersectionality theory. A qualitative secondary approach was used to analyze previously collected semi-structured qualitative interviews from a nation-wide study with transgender youth (n=24). Data was analyzed using narrative inquiry to describe stories of transgender youth of color age 16-18 years and their experiences regarding parent/guardian support related to their overall health and well-being, while navigating intersecting marginalization. The overarching theme It’s a Process described the ways that transgender youth of color navigated various barriers and milestones in pursuit of living their lives with authenticity. Additional subthemes emerged, including We Need Your Help, I’m Lucky to Have Support, Self-Advocacy/Resistance, and Having Hope/Resilience. This study was the first to explore the pivotal experiences of transgender youth turning 18, a turning point when youth were finally able to consent for their own health care, but may face limited access if still on their parent/guardian’s insurance without parent/guardian support. Findings of this study have important implications for nursing education, practice, and research as well as health care policy. Increased understanding about the ways transgender youth of color navigate intersecting barriers can improve nursing education and clinical care. Future research can develop clinical tools that will facilitate resistance and resilience processes for transgender youth of color, as well as parent/guardian support, ensuring culturally and developmentally appropriate interventions. Future research can also explore the structural causes of health inequities found in this study to inform policy change

Uncovering the stories behind the numbers : a case study of maternal death surveillance and response in Goma, Democratic Republic of Congo.

Globally, 303 000 women die each year from preventable causes related to pregnancy, with the Democratic Republic of Congo (DRC) having the tenth highest maternal mortality rate. Maternal Death Surveillance and Response (MDSR) is a surveillance-action cycle that aims to eliminate preventable maternal mortality by linking actionable data on maternal deaths with multi-level actions. While countries are increasingly adopting MDSR, there are research gaps on its implementation, outcomes, and best practices in developing countries including the DRC. This study assessed MDSR implementation in Goma Health Zone (HZ), DRC, specifically its structure, process, quality, outcomes, and influencing factors. A qualitative case study design was utilized, comprising semi-structured interviews with 15 key informants from seven sites, a review of 52 MDSR documents, and an observation of a maternal death review. Data analysis was conducted in Dedoose using the constant comparative method. Findings suggest that MDSR integration into an existing Integrated Disease Surveillance and Response system in the DRC has facilitated its acceptability and institutionalization in integrated (i.e. government-affiliated) health facilities in Goma HZ, where it is sustained by existing organizational resources. However, the MDSR system had weak community and private health sector linkages. Additionally, this study revealed a systematic implementation of early MDSR phases (notification-review) but gaps in completing advanced MDSR functions such as response implementation. With respect to quality, the MDSR system’s major strengths were its simplicity, acceptability, and timeliness in integrated health facilities, while its major challenges were its acceptability, data quality, and timeliness in communities and non-integrated facilities. The political commitment to MDSR and strong support from the HZ and facility leadership were key enablers of MDSR implementation, while unregulated private facilities and the links between MDSR and disciplinary action were the most prominent barriers. While MDSR in Goma HZ has yielded some improvements in the quality of care at HZ and facility levels, its overall impact on maternal health outcomes remains reportedly weak due to limited response implementation at higher levels of the health system.To strengthen Goma’s MDSR, this study suggests the need for a non-threatening MDSR environment, multisectoral partnerships, and mechanisms to follow-up on recommendations

White Paper 5: Brain, Mind & Behaviour

© CSICThe study of the brain will tell us what makes us humans and how our social behavior generates. Increasing our understanding of how the brain functions and interacts with the ecosystem to interpret the world will not only help to find effective means to treat and/or cure neurological and psychiatric disorders but will also change our vision on questions pertaining to philosophy and humanities and transform other fields such as economy and law. Neurosciences research at the CSIC is already valuable and should be intensified mainly focused on the eight major challenges described in this volume

Challenge 2: From genes & circuits to behavior

Understanding the brain from genes and circuits to behavior is a major scientific challenge. The large repertoire of cell activities supporting behavior stems from an equally diverse range of specialized cell types, from neuron to glia. To untangle mechanisms underlying brain function, elementary processes should be dissected, from the complex machinery of signaling pathways at the level of single cells and synapses, to the intricate phenomena leading to orchestrated ensemble activity and the establishment of engrams driving memory-guided behaviors. In this chapter we identify the main key tasks required to address some of the open questions in the field, and discuss on the main issues and strategies