What counts as evidence in evidence‐based practice?

BACKGROUND: Considerable financial and philosophical effort has been expended on the evidence-based practice agenda. Whilst few would disagree with the notion of delivering care based on information about what works, there remain significant challenges about what evidence is, and thus how practitioners use it in decision-making in the reality of clinical practice. AIM: This paper continues the debate about the nature of evidence and argues for the use of a broader evidence base in the implementation of patient-centred care. DISCUSSION: Against a background of financial constraints, risk reduction, increased managerialism research evidence, and more specifically research about effectiveness, have assumed pre-eminence. However, the practice of effective nursing, which is mediated through the contact and relationship between individual practitioner and patient, can only be achieved by using several sources of evidence. This paper outlines the potential contribution of four types of evidence in the delivery of care, namely research, clinical experience, patient experience and information from the local context. Fundamentally, drawing on these four sources of evidence will require the bringing together of two approaches to care: the external, scientific and the internal, intuitive. CONCLUSION: Having described the characteristics of a broader evidence base for practice, the challenge remains to ensure that each is as robust as possible, and that they are melded coherently and sensibly in the real time of practice. Some of the ideas presented in this paper challenge more traditional approaches to evidence-based practice. The delivery of effective, evidence-based patient-centred care will only be realized when a broader definition of what counts as evidence is embraced.     

Human osteoarthritic chondrons outnumber patient‐ and joint‐matched chondrocytes in hydrogel culture—Future application in autologous cell‐based OA cartilage repair?

Autologous chondrocyte implantation (ACI) is used in 34–60% for osteoarthritic (OA) cartilage defects, although ACI is neither recommended nor designed for OA. Envisioning a hydrogel‐based ACI for OA that uses chondrons instead of classically used chondrocytes, we hypothesized that human OA chondrons may outperform OA chondrocytes. We compared patient‐ and joint surface‐matched human OA chondrons with OA chondrocytes cultured for the first time in a hydrogel, using a self‐assembling peptide system. We determined yield, viability, cell numbers, mRNA expression, GAPDH mRNA enzyme activity, Collagen II synthesis (CPII) and degradation (C2C), and sulfated glycosaminoglycan. Ex vivo, mRNA expression was comparable. Over time, significant differences in survival led to 3.4‐fold higher OA chondron numbers in hydrogels after 2 weeks (p = .002). Significantly, more enzymatically active GAPDH protein indicated higher metabolic activity. The number of cultures that expressed mRNA for Collagen Types I and VI, COMP, aggrecan, VEGF, TGF‐β1, and FGF‐2 (but not Collagen Types II and X) was different, resulting in a 3.5‐fold higher number of expression‐positive OA chondron cultures (p < .05). Measuring CPII and C2C per hydrogel, OA chondron hydrogels synthesized more than they degraded Collagen Type II, the opposite was true for OA chondrocytes. Per cell, OA chondrons but not OA chondrocytes displayed more synthesis than degradation. Thus, OA chondrons displayed superior biosynthesis and mRNA expression of tissue engineering and phenotype‐relevant genes. Moreover, human OA chondrons displayed a significant survival advantage in hydrogel culture, whose presence, drastic extent, and timescale was novel and is clinically significant. Collectively, these data highlight the high potential of human OA chondrons for OA ACI, as they would outnumber and, thus, surpass OA chondrocytes.     

Symptom‐based diagnosis of urinary tract infection in women: are we over‐prescribing antibiotics?

Background: Current clinical guidelines for the management of symptoms suggesting urinary tract infection recommend empiric antibiotic therapy. Objective: To determine the diagnostic accuracy of urinary tract symptoms for early identification of urinary tract infection (UTI) in sexually active women when culture results are not available. Method: This was a cross‐sectional observational study conducted in a tertiary care hospital between July 2009 and May 2011. Subjects comprised 312 women ≥ 18 year of age who reported to the physician with symptoms suggestive of UTI. A predesigned questionnaire was filled and urine was analysed by microscopic examination and culture. Diagnostic values were calculated against gold standard urine culture results (> 10² CFU/ml) and 95% CIs and likelihood ratios are reported. Results: A total of 312 women were enrolled, as culture was contaminated in 36 only 276 women were included in final analysis. Prevalence of UTI was 46.01% amongst symptomatic women. Urgency (p = 0.001), burning sensation during micturition (p = 0.035), dysuria (p = 0.004), frequency of sexual intercourse > 5 per month (p = 0.010) and pyuria (p = 0.000) were significantly associated with culture positivity. Absence of pyuria emerged as best predictor for ruling out UTI even if the woman had symptoms (sensitivity 93.70%, NPV 91.84%, AUC 77.07%, LR? 0.1). The combination of urgency, burning during micturition and pyuria was the best predictor of UTI in our study (sensitivity 85.83%, PPV 71.71%, AUC 78.48%, LR+ 2.97) Conclusion: Symptoms alone have low accuracy when assessed against the reference standard for diagnosing UTI. Empiric treatment of UTI based on symptoms may expose large number of patients to unnecessary antibiotics. Wet mount microscopy for presence of pyuria as a ‘near patient test’ before starting antibiotics seems a rational approach for management of UTI in symptomatic women.     

Mechanisms: what are they evidence for in evidence‐based medicine?

Even though the evidence‐based medicine (EBM) movement labels mechanisms a low quality form of evidence, consideration of the mechanisms on which medicine relies, and the distinct roles that mechanisms might play in clinical practice, offers a number of insights into EBM itself. In this paper, I examine the connections between EBM and mechanisms from several angles. I diagnose what went wrong in two examples where mechanistic reasoning failed to generate accurate predictions for how a dysfunctional mechanism would respond to intervention. I then use these examples to explain why we should expect this kind of mechanistic reasoning to fail in systematic ways, by situating these failures in terms of evolved complexity of the causal system(s) in question. I argue that there is still a different role in which mechanisms continue to figure as evidence in EBM: namely, in guiding the application of population‐level recommendations to individual patients. Thus, even though the evidence‐based movement rejects one role in which mechanistic reasoning serves as evidence, there are other evidentiary roles for mechanistic reasoning. This renders plausible the claims of some critics of EBM who point to the ineliminable role of clinical experience. Clearly specifying the ways in which mechanisms and mechanistic reasoning can be involved in clinical practice frames the discussion about EBM and clinical experience in more fruitful terms.     

Volumetric or time‐based capnography for excluding pulmonary embolism in outpatients?

Summary. Background: Volumetric capnography is technically more demanding but theoretically better than the time‐based alveolar deadspace fraction (P_aco ₂ – Etco ₂)/P_aco ₂ as a bedside diagnostic tool for excluding pulmonary embolism (PE) in outpatients. Objective: We compared both diagnostic accuracy in patients with a suspected PE and positive D‐dimer enzyme‐linked immunosorbent assay results. Patients and methods: In this clinical multicenter trial with prospective inclusion and 3‐month follow‐up, alveolar deadspace fraction was compared by receiver operating characteristic (ROC) analysis with other parameters derived from volumetric capnography. Results: Capnography was performed in 239 patients, and 205 tests (86%) were conclusive. The incidence of PE was 33%. The alveolar deadspace fraction accuracy expressed with ROC curve analysis was 0.73 ± 0.04. The diagnostic performances of parameters from volumetric capnography were not significantly better. Sixteen per cent [95% confidence interval (CI) 12–21%] of patients presented a (P_aco ₂ – Etco ₂)/P_aco ₂ ratio under the cut‐off value of 0.15, with a low clinical probability. This combination excluded PE, with a sensitivity of 96% (95% CI 89–99%) and a negative likelihood ratio of 0.17 (95% CI 0.09–0.33%). Conclusion: Volumetric capnography failed to show superiority to alveolar deadspace fraction measurements [(P_aco ₂ – Etco ₂)/P_aco ₂] for exclusion of PE in outpatients with positive D‐dimer test results. Future studies should clarify the safety of excluding PE in patients combining low clinical probability with positive D‐dimer results and (P_aco ₂ – Etco ₂)/P_aco ₂ ratios below the cut‐off value of 0.15.     

Drugs and blood transfusions: dogma‐ or evidence‐based practice?

summary .  There is a lack of consensus on the safety of the coadministration of drugs and red blood cells (RBCs). A systematic review was undertaken to establish the evidence base for this question and assess how the evidence may be translated into present clinical day practice. Comprehensive searches of MEDLINE, EMBASE, CINAHL, the Cochrane Library and hand searching of transfusion journals, guidelines and websites identified 12 relevant papers: 11 in-vitro experiments and 1 case report. Data on incidences of haemolysis and agglutination following coadministration were extracted and analysed. Overall findings suggest that iron chelators (two papers), antimicrobials (three papers) and lower doses of opioids (three papers) are safe to coadminister with RBCs. Haemolysis was observed with higher doses of opioids (three papers). Transposition of these findings to clinical practice is limited because of the lack of clinical applicability of in-vitro experiments and diversity in how, and what, clinical outcome measures were used. Further evidence from true clinical settings would be required to inform clinical practice on the efficacy and safety of the coadministration of drugs and RBCs.     

Lost in transformation? Reviving ethics of care in hospital cultures of evidence‐based healthcare

Drawing on previous empirical research, we provide an exemplary narrative to illustrate how patients have experienced hospital care organized according to evidence‐based fast‐track programmes. The aim of this paper was to analyse and discuss if and how it is possible to include patients’ individual perspectives in an evidence‐based practice as seen from the point of view of nursing theory. The paper highlights two conflicting courses of development. One is a course of standardization founded on evidence‐based recommendations, which specify a set of rules that the patient must follow rigorously. The other is a course of democratization based on patients’ involvement in care. Referring to the analysis of the narrative, we argue that, in the current implementation of evidence‐based practice, the proposed involvement of patients resembles empty rhetoric. We argue that the principles and values from evidence‐based medicine are being lost in the transformation into the current evidence‐based hospital culture which potentially leads to a McDonaldization of nursing practice reflected as ‘one best way’. We argue for reviving ethics of care perspectives in today's evidence practice as the fundamental values of nursing may potentially bridge conflicts between evidence‐based practice and the ideals of patient participation thus preventing a practice of ‘McNursing’.     

Meta‐analysis: the glass eye of evidence‐based practice?

Meta-analysis was developed as a technique for combining the results of many different quantitative studies: it is often used to produce quantitative estimates of causal relations and/or association between variables. Meta-analysis is sometimes regarded as a central component of evidence-based practice. We draw attention to an incompatibility in the epistemology and methods of reasoning in quantitative meta-analysis and the epistemology and reasoning implicit in expert practice. We argue that this may be because the common perception of meta-analysis appeals to truth as correspondence; we suggest that rejecting the naive realism that underpins truth as correspondence allows meta-analysis to be understood in terms of truth as coherence. We can then develop an account of meta-analysis that does not depend upon reduction to a mathematical procedure but is an attempt to maximise coherence in beliefs about what works that is consistent with clinical reasoning in expert practice.     

Evidence‐based postoperative pain management in nursing: is a randomized‐controlled trial the most appropriate design?

There is an increasing drive to make nursing care evidence-based. High quality evidence from systematic reviews relevant to postoperative pain relief exists, yet pain after surgery remains poorly controlled for many patients. This study aimed to assess whether implementing evidence-based pain management improved postoperative pain outcomes. Pain on a 0-10 scale was the primary outcome and analgesic consumption a secondary outcome. A baseline audit was undertaken on four surgical wards to establish whether there was a need for the study. A randomized-controlled trial was then designed to assess the effects of implementing an evidence-based approach to postoperative pain management. The four wards were randomized to receive the intervention or act as a control. Outcomes were assessed 3 months after the intervention on both intervention and control wards. The intervention (implementation of an oral analgesic algorithm derived from systematic reviews) was then implemented on the control wards and outcomes reassessed after 3 months on the control wards. The intervention was designed using an evidence-based approach to effective implementation. Four interactive sessions covered: (1) detailed feedback of baseline data and discussion (utilizing audit and feedback), (2) why systematic reviews, analgesic league tables and choice of drugs to develop an analgesic algorithm (see Figure 1), (3) principles of evidence based health care (EBHC), including critical appraisal and (4) facilitation and change workshop. The findings revealed no significant differences in pain level or drug use between the intervention and control wards. However, the control wards also changed during the control period. Possible explanations for this are discussed. When looking at changes compared with baseline, both intervention and control wards increased their use of algorithm drugs and reduced use of non-algorithm drugs during the study. No effects were found on pain in the intervention wards. Pain ratings at rest since surgery, on movement since surgery and worst pain on movement were significantly reduced compared with baseline in the control wards. Although there are many pressures to utilize a randomized-controlled trial study design in the culture of evidence-based health care, there will be times, especially when implementing complex changes in practice that other types of design should be considered.     

Congruence or conflict? Challenges in implementing problem‐based learning across nursing cultures

Using the "real-life" situation of delivering an Australian nursing curriculum in the Maldives, this paper argues that successful offshore delivery requires far more than simply implementing an existing programme on a different site. In health education, cultural and contextual circumstances necessitate a critical appraisal of the needs of the community and the corresponding attributes of those who provide health-care services. This means designing programmes that are process oriented and easily adapted to different circumstances, and a commitment to maintaining effective communication systems. Although it would seem that problem-based learning (PBL) provides the framework for a process-oriented, learner-centred curriculum, the paper raises questions about how universally relevant the processes embedded in PBL are and describes concerns about the intent and purpose of nominating PBL as the preferred instructional strategy for cross-cultural projects.     

Is there an underestimation of intima‐media thickness based on M‐mode ultrasound technique in the abdominal aorta?

Measuring intima-media thickness (IMT) in the common carotid artery (CCA) is a valuable resource for the evaluation of subclinical atherosclerosis. The main objective of this study was to explore whether a B-mode ultrasound technique, Philips ATL, and an M-mode ultrasound technique, Wall Track System (WTS), show interchangeable results when measured in CCA and the abdominal aorta (AA). A total of 24 healthy, young subjects were examined. IMT and lumen diameter (LD) of the AA and the CCA were measured twice by two skilled ultrasonographers with two different ultrasound equipment B-mode: (Philips, ATL and M-mode: WTS).The intra-observer variability of IMT in CCA and AA using B-mode showed a coefficient of variation 8% and 9%, and with M-mode 11% and 15%, respectively. Interobserver variability of IMT in CCA and AA using B-mode was 6% and 12%, and with M-mode 11% and 18%, respectively. CCA IMT was 0·53 ± 0·07 and 0·53 ± 0·09 mm using B-mode and M-mode, respectively. However, in AA, IMT was 0·61 ± 0·05 and 0·54 ± 0·10 mm using B-mode and M-mode, respectively. Thus, AA IMT was 11·5% thicker using B-mode (P < 0·01). We received adequate IMT readings from the carotid artery as well as the AA using two commonly used B-mode and M-mode techniques. B-mode technique seems to show less variability, especially in the AA. More importantly, the two techniques measured different IMT thickness in the aorta, emphasizing the importance of using similar technique when comparing the impact of absolute values of IMT on cardiovascular disease.     

Brain‐based treatment—A new approach or a well‐forgotten old one?

For a relatively long period of time, mental functioning was mainly associated with personal profile while brain functioning went by the wayside. After the 90s of the 20th century, or the so called “Decade of the Brain”, today, contemporary specialists work on the boundary between fundamental science and medicine. This brings neuroscience, neuropsychology, psychiatry, and psychotherapy closer to each other. Today, we definitely know that brain structures are being built and altered thanks to experience. Psychotherapy can be more effective when based on a neuropsychological approach—this implies identification of the neural foundations of various disorders and will lead to specific psychotherapeutic conclusions. The knowledge about the brain is continually enriched, which leads to periodic rethinking and updating of the therapeutic approaches to various diseases of the nervous system and brain dysfunctions. The aim of translational studies is to match and combine scientific areas, resources, experience and techniques to improve prevention, diagnosis and therapies, and “transformation” of scientific discoveries into potential treatments of various diseases done in laboratory conditions. Neuropsychological studies prove that cognition is a key element that links together brain functioning and behaviour. According to Dr. Kandel, all experimental events, including psychotherapeutic interventions, affect the structure and function of neuronal synapses. The story of why psychotherapy works is a story of understanding the brain mechanisms of psychic processes, a story of how the brain has been evolving to ensure learning, forgetting, and the mechanisms of permanent psychological change. The new evidence on brain functioning necessitates the integration of neuropsychological achievements in the psychotherapeutic process. An integrative approach is needed to take into account the dynamic interaction between brain functioning, psyche, soul, spirit, and social interaction, ie, development of a model of psychotherapeutic work based on cerebral plasticity! Brain‐based psychotherapy aims at changing brain functioning not directly, but through experiences. This is neuro‐psychologically informed psychotherapy.     

What is protocol‐based care? A concept analysis

AIM: To define protocol-based care to make this way of delivering health care amenable to theoretical and empirical studies. BACKGROUND: Although protocol-based care is associated with the evidence-based practice and standardization movements, it is an ill-defined and understood concept. METHOD: A multiphase concept analysis, inspired by an evolutionary view was used to clarify 'what is protocol-based care'. The inductive, five-phase process drew upon content analysis of policy documents and the literature, plus interviews with a purposive sample of 35 opinion leaders. RESULTS: The term was used interchangeably with protocols, pathways and guidelines in policy and guidance documents. A search of seven databases produced only 57 references to protocol-based care. The concept analysis revealed a continuum of scope and specificity and also distinguished specialist and generic applications of protocol-based care. CONCLUSIONS: Managers need to take cognizance of the significance and complexity of protocol-based care when introducing this way of working.     

Does self‐care agency change between hospital admission and discharge? An Orem‐based investigation

AIMS: To assess whether nursing care improved patients' self-care agency between admission to hospital care and discharge. METHODS: A pre-test-post-test comparative research design with random subject selection was used. One hundred and sixty patients and 52 nurses rated identical self-care agency assessment forms, based on Orem's framework, both at admission and discharge. Patient satisfaction with nursing care and nurse satisfaction with working conditions were also assessed. Repeated measures ancova as well as paired and independent t-tests were used to test differences at both time points. Level of significance was set at 0.05 in this study. RESULTS: Patients in general reported high self-care agency pre- and post-test. Compared with a reference group of elderly residents, the study sample showed significantly lower levels of self-care agency. We found no difference between patient and nurse assessments of self-care agency on admission and discharge. Better patient-nurse relationships were associated with greater self-care agency reported by patients. CONCLUSIONS: Authors found no change in patient self-care agency between hospital admission and discharge. Outcomes may have been due to the inappropriate choice of the conceptual framework applied for acute care settings or to the insufficient length of the study. A longitudinal approach to observe long-term improvement of self-care capabilities is recommended.