-
Desafos y futuro de la medicina basda en la evidencia.Rafael
Bravo Toledorea 10 de atencin primariaAvances en Aspectos
Conceptuales y Metodolgicos de la Investigacin Clnica y la Medicina
Basada en la Evidencia
-
hablar del futurodos problemas:equivocarsepensando en el
presente y/o en el pasado
Telling the future by looking at the past assumes that
conditions remain constant. This is like driving a car by looking
in the rearview mirror. Herb Brodydesafos de la MBE
-
desafos de la mbesu propia influencia y desarrollo
la lucha contra el reverso tenebroso de la fuerza
desaparecer
-
su influencia
Jan 1, 2006
Hard Facts, Dangerous Half-Truths, and Total Nonsense: Profiting
from Evidence-based Management
-
su influencia
-
su influencia
The Campbell Collaboration was founded on the principle that
systematic reviews on the effects of interventions will inform and
help improve policy and services. Through its reviews and annual
Colloquiums, the Collaboration strives to make the best social
science research available and accessible. Campbell reviews provide
high quality evidence of "what works" to meet the needs of service
providers, policy makers, educators and their students,
professional researchers, and the general public. Campbell's
systematic reviews are published electronically so that they can be
updated promptly as relevant additional evidence emerges, and
amended in the light of criticisms and advances in methodology. In
addition to producing reviews, C2 provides three additional methods
of support through evidence-based practice:
Campbell's proven peer-review system C2's Register of
Interventions and Policy Evaluations (C2-RIPE), a unique database
of evidence-based reviews in social sciences A strategic network of
renown scholars and practitioners worldwide, culminating each year
with the Campbell Colloquium.
The Campbell Legacy The Campbell Collaboration is named in honor
of Dr. Donald T. Campbell. A member of the National Academy of
Sciences in the US, Campbell was an intellectual leader for the
idea that governmental reforms can be construed as societal
experiments to which scientific rules of evidence could be applied.
He was an advocate of the idea that better scientific evidence
could be generated to estimate the effects of governmental reforms
so as to inform policy and practice and to improve people's well
being. The idea of developing an international network of social
scientists that would produce, maintain and disseminate systematic
reviews of research evidence on the effectiveness of social
interventions was initially discussed at a meeting in London,
England in July 1999. The positive support for this idea from a
large number of social and behavioural scientists, and some social
practitioners, led tothe creation of the Campbell Collaboration
(C2). With partnerships developing in a number of countries,
Campbell began its exceptional tradition of annual Colloquia in
Philadelphia, PA (USA) in February of 2000.The Campbell
Collaboration works closely with its sibling organization in
healthcare, the Cochrane Collaboration, keeping C2's methods group
at the forefront in the development of research synthesis
models.Joint Cochrane-Campbell Methods Groups are being established
with the intent to stimulate empirical research and methodological
innovation necessary to improve the validity, relevance and
precision of systematic reviews and the primary studies upon which
reviews are based. A Nordic Campbell Centre was added to the
Collaboration in 2001, supported by the Danish Government and the
Nordic Council of Ministers. The Campbell Collaboration
collaborates with a number of other international organizations,
including the Norwegian and Danish governments and the American
Institutes for Research (AIR).
The Campbell Collaboration Bases its Work on Nine Key
Principles:
Collaboration, by internally and externally fostering good
communications, open decision-making and teamwork. Building on the
enthusiasm of individuals, by involving and supporting people of
different skills and backgrounds. Avoiding unnecessary duplication,
by good management and co-ordination to ensure economy of the
effort. Minimizing bias, through a variety of approaches such as
abiding by high standards of scientific evidence, ensuring broad
participation, and avoiding conflicts of interest. Keeping up to
date, by a commitment to ensure that Campbell Reviews are
maintained through identification and incorporation of new
evidence. Striving for relevance, by promoting the assessment of
policies and practices using outcomes that matter to people.
Promoting access, by wide dissemination of the outputs of the
Collaboration, taking advantage of strategic alliances, and by
promoting appropriate prices, content and media to meet the needs
of users worldwide. Ensuring quality, by being open and responsive
to criticism, applying advances in methodology, and developing
systems for quality improvement. Continuity, by ensuring that
responsibility for reviews, editorial processes and key functions
is maintained and renewed.
-
Pierre Louis (1787-1872)Inventor of the numeric method and the
method of observationEncontr que en promedio los pacientes que
recibieron sangra murieron ms que la que no la recibieron.
http://www.jameslindlibrary.org/trial_records/19th_Century/louis/louis_commentary.html
http://www.jameslindlibrary.org/trial_records/19th_Century/louis/louis_commentary.html
http://www.historiadelamedicina.org/louis.html
-
desarrollo:un poco de historiaLa bsqueda de la certeza La
cuantificacin en medicina J. Rosser Matthews Triacastela
ROSSER MATTHEWS, J.La bsqueda de la certeza. La cuantificacin en
medicinaIntroduccin a la edicin espaola de Jos Luis PuertaMadrid:
Triacastela, 2007. 303 pp. (Coleccin Humanidades Mdicas, 20)Con una
excelente traduccin a cargo de Assumpta Mauri Mas y Jos Luis Puerta
Lpez-Czar, autor tambin de laintroduccin, TRIACASTELA edita ahora
el volumen publicado en 1995 por la Universidad de Pricenton sobre
el ensayo clnicocontrolado y la eficacia de la metodologa
estadstica. Se trata pues de un clsico que mereci, en su momento,
los mejoresparabienes para su autor. A partir de 1946 la aspiracin
de la ciencia mdica a la certeza se encuadra en los
estudiosestadsticos y biomtricos. Tras ese inicio histrico, el
ensayo clnico controlado y aleatorizado es hoy imperante en el
sistema sanitario. No obstante su tardo desarrollo, el proceso
arranca del final del siglo XVIII, en concreto de 1794, con el
inicio en Francia de la etapa termidoriana, como muy bienresalta
Jos Luis Puerta en su introduccin.Supone la medicina cientfica
cuantitativa un riesgo para el enfermo concreto, que se convierte
en una pura cifra estadstica?Es muy claro que procesos como la
introduccin en la prctica clnica de nuevos medicamentos no seran
posibles sin estosplanteamientos de anlisis numrico. La certeza
mdica se consagra desde 1946 a partir de los ensayos clnicos que
asumen un papelcientfico y social determinantes. A travs de ocho
captulos el volumen realiza un recorrido histrico exhaustivoque da
comienzo con Conocimiento probable en la comunidad cientfica y
mdica parisin durante la Revolucin francesa, para continuarse en el
siguiente siglo: El mtodo numrico de Pierre Louis en la medicina
parisiense del siglo XIX. La retricade la cuantificacin, seguir con
las Crticas en el siglo XIX a las ideas de Jules Gavarret sobre el
clculo de probabilidadesen el mbito de la medicina, y analizar El
legado de Pierre Louis y la pujanza de la fisiologa. Dos puntos de
vista opuestossobre la objetividad mdica, en el que describe el
impacto breve pero importante que supuso la creacin de la Socit
MdicaledObservation en 1832, y finaliza el anlisis de los procesos
decimonnicos con La escuela biomtrica inglesa y la bacteriologa:La
creacin de Major Greenwood como especialista en estadstica mdica La
figura de Major Greenwood sigue siendouno de los contenidos del
penltimo captulo: El nacimiento del moderno ensayo clnico. El papel
fundamental delMedicinal Research Council. Da fin al desarrollo
capitular el apartado dedicado a Austin Bradford Hill y la
pujanzadel ensayo clnico. Da cierre al libro un captulo de
Conclusin, una exhaustiva Bibliografa y los ndices Analtico
yOnomstico. Nos parece que esta obra es imprescindible para
entender el proceso de bsquedade la certeza dentro de la ciencia y
de la prctica mdicas.Por Alberto Snchez lvarez-Insa(Instituto de
Filosofa, CSIC)ARBOR CLXXXIV 730 marzo-abril [2008] 367-372 ISSN:
0210-1963N 730370 RESEAS
-
desafos en el desarrollo de la mbeuso consciente, explcito y
juicioso de la mejor evidencia disponible para tomar decisiones
clnicas en el cuidado de los pacientes.
-
desafos en el desarrollo de la mbe1. convertir el problema
clnico en una pregunta.2. buscar la evidencia en la literatura3.
valoracin critica 4. aplicar los resultados a la practica
clnica
-
desafos en el desarrollo de la mbe1. convertir el problema
clnico en una pregunta.paso eminentemente practico pero que hace
pensar a los mdicos como un investigador, de forma sistemtica. Nos
hace reflexionar para que hacemos las cosas
-
desafos en el desarrollo de la mbe1. convertir el problema
clnico en una pregunta.como se parece a una hoja de bibliotecase
han simplificado y aclaradopero se siguen sin utilizara lo mejor se
tendra que cambiar o hacer muy patentes sus ventajas
-
bsqueda de la evidenciadesarrollo de fuentes
predigeridasminiaturizacinnuevas herram. de infor.(concepto) es
Internet estupido! y aqu entra la:
.sin olvidar las fuentes
-
Una pgina de una revista de resmenesTitularResultados
principales ( nuevos clculos)Resumen estructuradoComentario del
expertoReferencia artculo original
-
revistas de resmenes con valoracin crtica
-
http://perlascochrane.wordpress.com/
-
bsqueda de la evidenciadesarrollo de fuentes
predigeridasminiaturizacin
-
Canopy computing: using the Web in clinical practice.
McDonald CJ, et al.JAMA. 1998 Oct 21;280(15):1325-9.
Seguramente e l mejor ejemplo par explicar al estructura de
estas herramientas de informacin, sea la analoga que McDonald
exponen en su articulo Canopy Computing......... Siguiendo este
ejemplo la estructura de la historia clnica-herramienta de
informacin seria similar a la estructura de la bosques hmedos
tropicalesSi observamos la selva hmeda tropical desde lo alto, la
selva aparece como una tupida cubierta o Canopy (las copas de los
arboles junto a otra vegetacin. crean una que es un sistema
entretejido que proporciona un rico habitat para pjaros, insectos y
otros animales, que no necesitan rebuscar en el suelo las frutas
necesarias par sus sustento. ( como bromelias, orquideas, que
crecen directamente en la canopy o lianas )Sin embargo desde el
suelo el bosque aparece como una coleccin de arboles aislados, y en
que se puede dividir en varios estratos o capas.
-
infobuttons
nfobuttons are context-sensitive links embedded within a
Clinical Information System (CIS), which allow easy retrieval of
relevant information. During patient care, clinicians frequently
have need for information related to their clinical care
activities. These questions often go unanswered due to lack of time
or readily available resources. Estimates of information needs are
as high as four questions per patient encounter(1). Failure to
answer these questions may result in patient error and adverse
outcomes. The Infobutton makes it easier for providers to access
the information they need at the point of care. The Infobutton
functions by generating and sending queries to electronic health
information resources using data extracted from the patient record.
The CIS displays a button next to information such as diagnoses or
medications. When clicked, the Infobutton formulates a query based
on the context of the interaction, including patient demographics,
activity being performed, as well as the user role.(2) Thus, a
nurse preparing to administer a medication to a 70 year old woman
will generate a different query than a physician reviewing the
medication list of a 10 year old boy. The results of the query will
then be displayed by the CIS itself, or by an Infobutton Manager, a
concept proposed by James J. Cimino(3). An Infobutton Manager is
software that supports the implementation of Infobuttons in an
institution and application independent manner.(3) The CIS passes
parameters to the Infobutton Manager which generates an HTML
document with a set of natural language questions which are
hyperlinks to clinical information resources. Infobutton systems
have been created at Columbia University, Partners Healthcare
System, and Intermountain Healthcare System. In addition a number
of commercial Infobutton products are being developed or offered
from companies such as Epic, Thompson Micromedex, and MDConsult.
Since CIS systems may include products from multiple vendors, it is
important to have a standard for passing information from the CIS
to the Infobutton Manager and from the Infobutton Manager to the
electronic resources. For this reason, there is a proposed HL-7
standard for the Infobutton API which is currently being
reviewed.(2)
-
bsqueda de la evidenciadesarrollo de fuentes predigeridasnuevas
herram. de infor.(concepto) es Internet estupido ! y aqu entra
la:
-
la Web 2.0 es una actitud y no precisamente una tecnologa. Web
2.0 no es algo concreto, sino un conjunto de tecnologas, mtodos,
estilos... aplicaciones web enfocadas al usuario finalpromueve que
la creacin, organizacin y el flujo de informacin dependan del
comportamiento de las personas que acceden a ella Internet est
cambiando desde la web tradicional a
-
El universo Google
Buscadores 2.0de escritorioespecializadospersonalizados
La web como plataforma
de aplicaciones
Blogs
WikisSoftware social:Compartir documentos y crear redes
-
desafos en el desarrollo de la mbevaloracin crtica de la
literatura mdicaautocriticaotra forma y sitio de ensearlos lo que
debe saber un mdicosumarios para torpesen el futuro no debera ser
ningn problema
-
A systematic review of the content of critical appraisal
tools
http://www.biomedcentral.com/1471-2288/4/22
A systematic review of the content of critical appraisal tools
http://www.biomedcentral.com/1471-2288/4/22ackgroundConsumers of
research (researchers, administrators, educators and clinicians)
frequently use standard critical appraisal tools to evaluate the
quality of published research reports. However, there is no
consensus regarding the most appropriate critical appraisal tool
for allied health research. We summarized the content, intent,
construction and psychometric properties of published, currently
available critical appraisal tools to identify common elements and
their relevance to allied health research.MethodsA systematic
review was undertaken of 121 published critical appraisal tools
sourced from 108 papers located on electronic databases and the
Internet. The tools were classified according to the study design
for which they were intended. Their items were then classified into
one of 12 criteria based on their intent. Commonly occurring items
were identified. The empirical basis for construction of the tool,
the method by which overall quality of the study was established,
the psychometric properties of the critical appraisal tools and
whether guidelines were provided for their use were also
recorded.ResultsEighty-seven percent of critical appraisal tools
were specific to a research design, with most tools having been
developed for experimental studies. There was considerable
variability in items contained in the critical appraisal tools.
Twelve percent of available tools were developed using specified
empirical research. Forty-nine percent of the critical appraisal
tools summarized the quality appraisal into a numeric summary
score. Few critical appraisal tools had documented evidence of
validity of their items, or reliability of use. Guidelines
regarding administration of the tools were provided in 43% of
cases.ConclusionsThere was considerable variability in intent,
components, construction and psychometric properties of published
critical appraisal tools for research reports. There is no "gold
standard' critical appraisal tool for any study design, nor is
there any widely accepted generic tool that can be applied equally
well across study types. No tool was specific to allied health
research requirements. Thus interpretation of critical appraisal of
research reports currently needs to be considered in light of the
properties and intent of the critical appraisal tool chosen for the
task.
-
desafos en el desarrollo de la mbeaplicar los resultados a la
practica clnica decia Sackett que en el futuro no se hablara MBE
por que toda la medicina ser basada en la evidencia
-
(el reverso tenebroso de la fuerza)
las caras del pasadola jeta del arte de la medicinala mascara
del humanismoPseudoevidence based medicinesus discpulosbusiness is
business
MBE versus ERTF
-
el humanismo, la afectividad Es curioso cmo muchos profesionales
enfrentados con la racionalidad cientfica de su profesin e
incapaces de reconocer su anumerismo reaccionan con tpicos como el
arte de la medicina, el humanismo, la mejor tecnologa es la silla y
otros tan solemnes como vacuos. Se intenta hacer una enfrentada e
interesada dicotoma, como si intentar practicar una medicina
cientfica nos alejara de los sentimientos y como si simpatizar con
los nmeros nos recubriera de una mscara que nos impidiera conectar
con el paciente.
. A detailed and exact knowledge of the outcomes of different
treatments, derived from the research, can often save lives. For
example, consider the problem of whether to perform an
endarterectomy on a newly symptomatic patient with severe stenosis.
The benefit of surgery in reducing the risk of a major stroke or
fatality is summed up in the following table (L. Goldstein et al,
1995): % Patients with Major Stroke or Fatality SurgeryGroup
NoSurgery Number Needed to Treat
10%
19%
11 This means that you need only treat 11 patients, on average,
to prevent a major stroke or fatality - a clear and very
substantial benefit. However, when asked whether they would
recommend surgery in such a case, physicians answered as follows:
Would you recommend carotid endarterectomy fornewly symptomatic
patients with severe stenosis? . Seldom/Never Sometimes
Usually/Always All physicians
17%
28%
55% Primary carephysicians andinternists
47%
31%
20% This seems to imply that it is at least possible that some
patients are suffering a severe stroke or fatality that can at
least partly be attributed to physicians' lack of familiarity with
the medical literature.
-
Pseudoevidence based medicine
PBM can be defined as the practice of medicine based on
falsehoods that are disseminated as truth. Falsehoods may result
from corrupted evidence--evidence that has been suppressed,
contrived from purposely biased science, or that has been
manipulated and/or falsified, then published. Or falsehoods may
result from corrupted dissemination of otherwise valid evidence.
These falsehoods, when consumed as truth by unwitting and
well-intentioned practitioners of EBM, then disseminated and
adopted as routine practice, may well result not only in
inappropriate quality standards and processes of care, but also in
harms to patients.
Hard Facts, Dangerous Half-Truths, and Total Nonsense: Profiting
from Evidence-based Management The Campbell Collaboration was
founded on the principle that systematic reviews on the effects of
interventions will inform and help improve policy and services.
Through its reviews and annual Colloquiums, the Collaboration
strives to make the best social science research available and
accessible. Campbell reviews provide high quality evidence of "what
works" to meet the needs of service providers, policy makers,
educators and their students, professional researchers, and the
general public. Campbell's systematic reviews are published
electronically so that they can be updated promptly as relevant
additional evidence emerges, and amended in the light of criticisms
and advances in methodology. In addition to producing reviews, C2
provides three additional methods of support through evidence-based
practice:
Campbell's proven peer-review system C2's Register of
Interventions and Policy Evaluations (C2-RIPE), a unique database
of evidence-based reviews in social sciences A strategic network of
renown scholars and practitioners worldwide, culminating each year
with the Campbell Colloquium.
The Campbell Legacy The Campbell Collaboration is named in honor
of Dr. Donald T. Campbell. A member of the National Academy of
Sciences in the US, Campbell was an intellectual leader for the
idea that governmental reforms can be construed as societal
experiments to which scientific rules of evidence could be applied.
He was an advocate of the idea that better scientific evidence
could be generated to estimate the effects of governmental reforms
so as to inform policy and practice and to improve people's well
being. The idea of developing an international network of social
scientists that would produce, maintain and disseminate systematic
reviews of research evidence on the effectiveness of social
interventions was initially discussed at a meeting in London,
England in July 1999. The positive support for this idea from a
large number of social and behavioural scientists, and some social
practitioners, led tothe creation of the Campbell Collaboration
(C2). With partnerships developing in a number of countries,
Campbell began its exceptional tradition of annual Colloquia in
Philadelphia, PA (USA) in February of 2000.The Campbell
Collaboration works closely with its sibling organization in
healthcare, the Cochrane Collaboration, keeping C2's methods group
at the forefront in the development of research synthesis
models.Joint Cochrane-Campbell Methods Groups are being established
with the intent to stimulate empirical research and methodological
innovation necessary to improve the validity, relevance and
precision of systematic reviews and the primary studies upon which
reviews are based. A Nordic Campbell Centre was added to the
Collaboration in 2001, supported by the Danish Government and the
Nordic Council of Ministers. The Campbell Collaboration
collaborates with a number of other international organizations,
including the Norwegian and Danish governments and the American
Institutes for Research (AIR).
The Campbell Collaboration Bases its Work on Nine Key
Principles:
Collaboration, by internally and externally fostering good
communications, open decision-making and teamwork. Building on the
enthusiasm of individuals, by involving and supporting people of
different skills and backgrounds. Avoiding unnecessary duplication,
by good management and co-ordination to ensure economy of the
effort. Minimizing bias, through a variety of approaches such as
abiding by high standards of scientific evidence, ensuring broad
participation, and avoiding conflicts of interest. Keeping up to
date, by a commitment to ensure that Campbell Reviews are
maintained through identification and incorporation of new
evidence. Striving for relevance, by promoting the assessment of
policies and practices using outcomes that matter to people.
Promoting access, by wide dissemination of the outputs of the
Collaboration, taking advantage of strategic alliances, and by
promoting appropriate prices, content and media to meet the needs
of users worldwide. Ensuring quality, by being open and responsive
to criticism, applying advances in methodology, and developing
systems for quality improvement. Continuity, by ensuring that
responsibility for reviews, editorial processes and key functions
is maintained and renewed.
http://www.jameslindlibrary.org/trial_records/19th_Century/louis/louis_commentary.html
http://www.historiadelamedicina.org/louis.htmlROSSER MATTHEWS,
J.La bsqueda de la certeza. La cuantificacin en medicinaIntroduccin
a la edicin espaola de Jos Luis PuertaMadrid: Triacastela, 2007.
303 pp. (Coleccin Humanidades Mdicas, 20)Con una excelente
traduccin a cargo de Assumpta Mauri Mas y Jos Luis Puerta
Lpez-Czar, autor tambin de laintroduccin, TRIACASTELA edita ahora
el volumen publicado en 1995 por la Universidad de Pricenton sobre
el ensayo clnicocontrolado y la eficacia de la metodologa
estadstica. Se trata pues de un clsico que mereci, en su momento,
los mejoresparabienes para su autor. A partir de 1946 la aspiracin
de la ciencia mdica a la certeza se encuadra en los
estudiosestadsticos y biomtricos. Tras ese inicio histrico, el
ensayo clnico controlado y aleatorizado es hoy imperante en el
sistema sanitario. No obstante su tardo desarrollo, el proceso
arranca del final del siglo XVIII, en concreto de 1794, con el
inicio en Francia de la etapa termidoriana, como muy bienresalta
Jos Luis Puerta en su introduccin.Supone la medicina cientfica
cuantitativa un riesgo para el enfermo concreto, que se convierte
en una pura cifra estadstica?Es muy claro que procesos como la
introduccin en la prctica clnica de nuevos medicamentos no seran
posibles sin estosplanteamientos de anlisis numrico. La certeza
mdica se consagra desde 1946 a partir de los ensayos clnicos que
asumen un papelcientfico y social determinantes. A travs de ocho
captulos el volumen realiza un recorrido histrico exhaustivoque da
comienzo con Conocimiento probable en la comunidad cientfica y
mdica parisin durante la Revolucin francesa, para continuarse en el
siguiente siglo: El mtodo numrico de Pierre Louis en la medicina
parisiense del siglo XIX. La retricade la cuantificacin, seguir con
las Crticas en el siglo XIX a las ideas de Jules Gavarret sobre el
clculo de probabilidadesen el mbito de la medicina, y analizar El
legado de Pierre Louis y la pujanza de la fisiologa. Dos puntos de
vista opuestossobre la objetividad mdica, en el que describe el
impacto breve pero importante que supuso la creacin de la Socit
MdicaledObservation en 1832, y finaliza el anlisis de los procesos
decimonnicos con La escuela biomtrica inglesa y la bacteriologa:La
creacin de Major Greenwood como especialista en estadstica mdica La
figura de Major Greenwood sigue siendouno de los contenidos del
penltimo captulo: El nacimiento del moderno ensayo clnico. El papel
fundamental delMedicinal Research Council. Da fin al desarrollo
capitular el apartado dedicado a Austin Bradford Hill y la
pujanzadel ensayo clnico. Da cierre al libro un captulo de
Conclusin, una exhaustiva Bibliografa y los ndices Analtico
yOnomstico. Nos parece que esta obra es imprescindible para
entender el proceso de bsquedade la certeza dentro de la ciencia y
de la prctica mdicas.Por Alberto Snchez lvarez-Insa(Instituto de
Filosofa, CSIC)ARBOR CLXXXIV 730 marzo-abril [2008] 367-372 ISSN:
0210-1963N 730370 RESEAS
Seguramente e l mejor ejemplo par explicar al estructura de
estas herramientas de informacin, sea la analoga que McDonald
exponen en su articulo Canopy Computing......... Siguiendo este
ejemplo la estructura de la historia clnica-herramienta de
informacin seria similar a la estructura de la bosques hmedos
tropicalesSi observamos la selva hmeda tropical desde lo alto, la
selva aparece como una tupida cubierta o Canopy (las copas de los
arboles junto a otra vegetacin. crean una que es un sistema
entretejido que proporciona un rico habitat para pjaros, insectos y
otros animales, que no necesitan rebuscar en el suelo las frutas
necesarias par sus sustento. ( como bromelias, orquideas, que
crecen directamente en la canopy o lianas )Sin embargo desde el
suelo el bosque aparece como una coleccin de arboles aislados, y en
que se puede dividir en varios estratos o capas.nfobuttons are
context-sensitive links embedded within a Clinical Information
System (CIS), which allow easy retrieval of relevant information.
During patient care, clinicians frequently have need for
information related to their clinical care activities. These
questions often go unanswered due to lack of time or readily
available resources. Estimates of information needs are as high as
four questions per patient encounter(1). Failure to answer these
questions may result in patient error and adverse outcomes. The
Infobutton makes it easier for providers to access the information
they need at the point of care. The Infobutton functions by
generating and sending queries to electronic health information
resources using data extracted from the patient record. The CIS
displays a button next to information such as diagnoses or
medications. When clicked, the Infobutton formulates a query based
on the context of the interaction, including patient demographics,
activity being performed, as well as the user role.(2) Thus, a
nurse preparing to administer a medication to a 70 year old woman
will generate a different query than a physician reviewing the
medication list of a 10 year old boy. The results of the query will
then be displayed by the CIS itself, or by an Infobutton Manager, a
concept proposed by James J. Cimino(3). An Infobutton Manager is
software that supports the implementation of Infobuttons in an
institution and application independent manner.(3) The CIS passes
parameters to the Infobutton Manager which generates an HTML
document with a set of natural language questions which are
hyperlinks to clinical information resources. Infobutton systems
have been created at Columbia University, Partners Healthcare
System, and Intermountain Healthcare System. In addition a number
of commercial Infobutton products are being developed or offered
from companies such as Epic, Thompson Micromedex, and MDConsult.
Since CIS systems may include products from multiple vendors, it is
important to have a standard for passing information from the CIS
to the Infobutton Manager and from the Infobutton Manager to the
electronic resources. For this reason, there is a proposed HL-7
standard for the Infobutton API which is currently being
reviewed.(2)
A systematic review of the content of critical appraisal tools
http://www.biomedcentral.com/1471-2288/4/22ackgroundConsumers of
research (researchers, administrators, educators and clinicians)
frequently use standard critical appraisal tools to evaluate the
quality of published research reports. However, there is no
consensus regarding the most appropriate critical appraisal tool
for allied health research. We summarized the content, intent,
construction and psychometric properties of published, currently
available critical appraisal tools to identify common elements and
their relevance to allied health research.MethodsA systematic
review was undertaken of 121 published critical appraisal tools
sourced from 108 papers located on electronic databases and the
Internet. The tools were classified according to the study design
for which they were intended. Their items were then classified into
one of 12 criteria based on their intent. Commonly occurring items
were identified. The empirical basis for construction of the tool,
the method by which overall quality of the study was established,
the psychometric properties of the critical appraisal tools and
whether guidelines were provided for their use were also
recorded.ResultsEighty-seven percent of critical appraisal tools
were specific to a research design, with most tools having been
developed for experimental studies. There was considerable
variability in items contained in the critical appraisal tools.
Twelve percent of available tools were developed using specified
empirical research. Forty-nine percent of the critical appraisal
tools summarized the quality appraisal into a numeric summary
score. Few critical appraisal tools had documented evidence of
validity of their items, or reliability of use. Guidelines
regarding administration of the tools were provided in 43% of
cases.ConclusionsThere was considerable variability in intent,
components, construction and psychometric properties of published
critical appraisal tools for research reports. There is no "gold
standard' critical appraisal tool for any study design, nor is
there any widely accepted generic tool that can be applied equally
well across study types. No tool was specific to allied health
research requirements. Thus interpretation of critical appraisal of
research reports currently needs to be considered in light of the
properties and intent of the critical appraisal tool chosen for the
task.. A detailed and exact knowledge of the outcomes of different
treatments, derived from the research, can often save lives. For
example, consider the problem of whether to perform an
endarterectomy on a newly symptomatic patient with severe stenosis.
The benefit of surgery in reducing the risk of a major stroke or
fatality is summed up in the following table (L. Goldstein et al,
1995): % Patients with Major Stroke or Fatality SurgeryGroup
NoSurgery Number Needed to Treat
10%
19%
11 This means that you need only treat 11 patients, on average,
to prevent a major stroke or fatality - a clear and very
substantial benefit. However, when asked whether they would
recommend surgery in such a case, physicians answered as follows:
Would you recommend carotid endarterectomy fornewly symptomatic
patients with severe stenosis? . Seldom/Never Sometimes
Usually/Always All physicians
17%
28%
55% Primary carephysicians andinternists
47%
31%
20% This seems to imply that it is at least possible that some
patients are suffering a severe stroke or fatality that can at
least partly be attributed to physicians' lack of familiarity with
the medical literature. PBM can be defined as the practice of
medicine based on falsehoods that are disseminated as truth.
Falsehoods may result from corrupted evidence--evidence that has
been suppressed, contrived from purposely biased science, or that
has been manipulated and/or falsified, then published. Or
falsehoods may result from corrupted dissemination of otherwise
valid evidence. These falsehoods, when consumed as truth by
unwitting and well-intentioned practitioners of EBM, then
disseminated and adopted as routine practice, may well result not
only in inappropriate quality standards and processes of care, but
also in harms to patients.
