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Evaluating and Integrating Research into Clinical Practice
The impetus for evidence-based medicine (EBM), or its younger brother, evidence-based practice, has been that it takes too long for efficacious and effective treatments to be brought to bear in routine clinical practice. The usual time given is a 17-year delay between demonstration of efficacy and routine practice, although the evidence for this specific time frame is sparse. However, as a social value in medicine, most believe that it is better for patients to receive effective care than none, so regardless of the true time delay, researchers, healthcare administrators, policy makers, clinicians, and patients all now recognize as crucial the systemic issues that delay the integration of research into practice. Like medical care, addressing this issue requires diagnosis of the systemic issues that prevent the translation of research into practice (TRIP) and requires treatment based on those diagnoses.
Diagnosis
A number of different approaches have been used to diagnose the systemic barriers. One is the diffusion of innovation formalism. Rogers identified five components of diffusion: (1) relative advantage, (2) compatibility, (3) complexity, (4) trialability, and (5) observability. Berwick and Greenhalgh provide a general framework for applying these to medical care. Early studies documented the slow uptake of basic innovations and documented, for instance, from the physician's point of view, the need for observability—the need for a local champion. Later studies showed that apparently not much had changed; from the patient's perspective, only about 55% received recommendation-based care for preventive, acute, or chronic care. Cabana showed the application of a barrier-based framework to the (non)use of clinical practice guidelines (CPGs), touted as one solution to the TRIP problem. He discerned that barriers ranged from issues of physician self-efficacy to systemic difficulties in getting access to the guidelines as well as traditional concerns such as disagreement over applicability.
Treatment
There are two basic approaches to the incorporation of research-based evidence into practice: active and passive. Active means that the clinical practitioner must make the explicit effort of finding the evidence and evaluating it. Passive means that the environment has been architected to bring the evidence to bear automatically.
Active Approaches
The primary active approach has been to teach clinicians the process of EBM in the hope that they would use those methods at the bedside. Supporting this agenda has required several components. First, EBM resources have been needed. The primary one has been PubMed, which references several thousand journals and several million articles. Almost all EBM searches end up at PubMed (in English-speaking countries), because the latest, authoritative results are available there. Searches there depend on skillful use of the PubMed-controlled vocabulary—MeSH (Medical Subject Headings)—as well as free text and other specifics of the indexing system. The Cochrane Database of Systematic Reviews houses systematic reviews of studies (primarily randomized controlled trials) that, themselves, are often indexed on PubMed. However, these reviews are extensive, reproducible, and go beyond PubMed, to include unpublished articles or novel data provided by published authors. Perforce, these reviews are not as current as PubMed. CPGs go beyond Cochrane reviews in authority, because they include the definition of standard of practice, as defined by professional societies. Because of this added layer of vetting, CPGs are the least up-to-date but the most authoritative. Thus, a reasonable search strategy is to start with CPGs (as indexed or contained at the National Guideline Clearinghouse), then move on to Cochrane to see if there is anything newer, and then move on to PubMed to look for anything newer still.
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- Basis for Making the Decision
- Acceptability Curves and Confidence Ellipses
- Beneficence
- Bioethics
- Choice Theories
- Construction of Values
- Cost-Benefit Analysis
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- Diagnostic Process, Making a Diagnosis
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- Evaluating and Integrating Research Into Clinical Practice
- Evidence Synthesis
- Evidence-Based Medicine
- Expert Opinion
- Genetic Testing
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- Confirmation Bias
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- Intuition Versus Analysis
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- Judgment
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- Learning and Memory in Medical Training
- Lens Model
- Lottery
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- Memory Reconstruction
- Mental Accounting
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- Numeracy
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- Pain
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- Personality, Choices
- Preference Reversals
- Probability Errors
- Probability, Verbal Expressions of
- Problem Solving
- Procedural Invariance and Its Violations
- Prospect Theory
- Range-Frequency Theory
- Risk Attitude
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- Risk Perception
- Scaling
- Social Factors
- Social Judgment Theory
- Stigma Susceptibility
- Support Theory
- Uncertainty in Medical Decisions
- Unreliability of Memory
- Value Functions in Domains of Gains and Losses
- Worldviews
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