The postmodernist war on evidence-based practice

In this paper, we examine the war of words between those who contend that health care practice, including nursing, should primarily be informed by research (the evidence-based practice movement), and those who argue that there should be no restrictions on the sources of knowledge used by practitioners (the postmodernists). We review the postmodernist interventions of Dave Holmes and his colleagues, observing that the postmodernist style to which they adhere, which includes the use of continental philosophy, metaphors, and acerbic delivery, tends to obscure their substantive arguments. The heated nature of some responses to them has tended to have the same effect. However, the substantive arguments are important. Five main postmodernist charges are identified and discussed. The first argument, that the notion of ‘best evidence’ implies a hierarchical and exclusivist approach to knowledge, is persuasive. However, the contention that this hierarchy is maintained by the combined pressures of capitalism and vested interests within academia and the health services, is less well founded. Nevertheless, postmodernist contentions that the hierarchy embraced by the evidence-based practice movement damages health care because it excludes other forms of evidence that are needed to understand the complexity of care, it marginalizes important aspects of clinical knowledge, and it fails to take account of individuals or their experience, are all seen to be of some merit. However, we do not share the postmodernist conclusion that this adds up to a fascist order. Instead, we characterize evidence-based practice as a necessary but not sufficient component of health care knowledge.     

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2020

In a time of rapidly shifting evidence-based medicine, it is challenging to stay informed of research that modifies clinical practice. To enhance knowledge of practice-changing literature, a group of 7 internists reviewed titles and abstracts in 7 internal medicine journals with the highest impact factors and relevance to outpatient general internal medicine. Coronavirus disease-19 research was purposely excluded to highlight practice changes beyond the pandemic. New England Journal of Medicine (NEJM), The Lancet, Annals of Internal Medicine, Journal of the American Medical Association (JAMA), JAMA Internal Medicine, British Medical Journal (BMJ), and Public Library of Science (PLoS) Medicine were reviewed. The following collections of article synopses and databases were also reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on relevance to outpatient internal medicine, impact on practice, and strength of evidence. Clusters of articles pertaining to the same topic were considered together. In total, 7 practice-changing articles were included.     

Effectiveness of multiple sclerosis treatment with current immunomodulatory drugs

Introduction: Multiple sclerosis (MS) is a chronic inflammatory disease of the CNS of a putative autoimmune origin characterized by neurologic dysfunction disseminated in space and time due to demyelination and axonal loss that results in progressive disability. Recent advances in understanding the immune pathogenesis of the disease resulted in the introduction of numerous effective immunomodulatoty drugs having diverse mechanisms of action, modes of administration and risk–benefit profiles. This results in more complex albeit more promising treatment selection and choices.

Areas covered: The epidemiology, clinical features, pathogenesis and diagnosis of the disease are discussed. The mode of action and main characteristics of current immunomodulatory drugs for MS and their place in the therapeutic algorithm of the disease based on evidence from clinical trials are described. Speculation on new paradigms, treatment goals and outcome measures aimed at improving the landscape of MS treatment is presented.

Expert opinion: Multiple disease, drug and patient-related factors should be taken into consideration when selecting the appropriate drug and treatment strategy to the appropriate patient, thus paving the road for personalized medicine in MS.     

Low‐density lipoprotein cholesterol lowering in real‐world patients treated with evolocumab

BackgroundLow‐density lipoprotein cholesterol (LDL‐C) is a risk factor for atherosclerotic cardiovascular disease (ASCVD). There are limited real‐world data on LDL‐C lowering with evolocumab in United States clinical practice.HypothesisWe assessed LDL‐C lowering during 1 year of evolocumab therapy.MethodsThis retrospective cohort study used linked laboratory (Prognos) and medical claims (IQVIA Dx/LRx and PharMetrics Plus^®) data. Patients with a first fill for evolocumab between 7/1/2015 and 10/31/2019 (index event) and LDL‐C ≥ 70 mg/dL were included (overall cohort; N = 5897). Additionally, a patient subgroup with a recent myocardial infarction (MI) within 12 months (median 130 days) before the first evolocumab fill was identified (N = 152). Reduction from baseline LDL‐C was calculated based on the lowest LDL‐C value recorded during a 12‐month follow‐up period.ResultsThe mean (SD) age was 65 (10) years; 61.9% of patients had ASCVD diagnoses and 70.7% of patients were in receipt of lipid‐lowering therapy. Following evolocumab treatment, changes in LDL‐C from baseline were −60% in the overall cohort (median [interquartile range (IQR)] 146 [115–180] mg/dL to 58 [36–84] mg/dL) and −65% in the recent MI subgroup (median [IQR] 137 [109–165] mg/dL to 48 [30–78] mg/dL). In the overall cohort and recent MI subgroup, 62.1% and 69.7% of patients achieved LDL‐C < 70 mg/dL, respectively.ConclusionsIn this real‐world analysis, evolocumab was associated with significant reductions in LDL‐C comparable to that seen in the FOURIER clinical trial, which were durable over 1 year of treatment.     

Evidence‐Based Practice in a Global Context

This commentary examines how the adoption of benchmarking can promote the internationalization of evidence‐based practice. Given the increasing evidence documenting the role of culture and context in the shaping of experiences and expressions of distress, as well as influencing attitudes and conceptions of mental health services, benchmarking may not represent the best approach to addressing global public health agendas. A brief overview of the sequential approach to developing, evaluating, and disseminating treatments in novel cultural contexts is presented, in which benchmarking can play an important, albeit secondary role. It is argued that in a global context, benchmarking's role may better function to promote dissemination within particular contexts, rather than between them.     

The scope and conventions of evidence‐based medicine need to be widened to deal with “too much medicine”

In order that evidence‐based medicine can prevent “too much medicine”, it has to provide evidence in support of “gold standard” findings for use as diagnostic criteria, on which the assessment of other diagnostic tests and the outcomes of randomized controlled trials depend. When the results of such gold standard tests are numerical, cut‐off points have to be positioned, also based on evidence, to identify those in whom offering a treatment can be justified. Such a diagnosis depends on eliminating conditions that mimic the one to be treated. The distributions of the candidate gold standard test results in those with and without the required outcome of treatment are then used with Bayes rule to create curves that show the probabilities of the outcome with and without treatment. It is these curves that are used to identify a cut‐off point for offering a treatment to a patient and also to inform the patient's decision to accept or reject the suggested treatment. This decision is arrived at by balancing the probabilities of beneficial outcomes against the probabilities of harmful outcomes and other costs. The approach is illustrated with data from a randomized controlled trial on treating diabetic albuminuria with an angiotensin receptor blocker to prevent the development of the surrogate end‐point of “biochemical nephropathy”. The same approach can be applied to nonsurrogate outcomes such as death, disability, quality of life, relief of symptoms, and their prevention. Those with treatment‐justifying diagnoses such as “diabetic albuminuria” usually form part of a broader group such as “type 2 diabetes mellitus”. Any of these can be made the subject of evidence‐based differential diagnostic strategies.     

Suffering without a medical diagnosis. A critical view on the biomedical attitudes towards persons suffering from burnout and the implications for medical care

The search for causal explanations in medically unexplained syndromes such as burnout has not been resolved by evidence‐based medicine. A biomedical model encourages a reductionist diagnostic practice and a dualist split between physical and psychological symptoms. Therefore, diagnosing and treating these syndromes remains a challenge. Depression is a common aspect in burnout and, as a result, clinicians often diagnose burnout patients as depressed. The Norwegian government expects medical efficiency to reduce sick leaves. Medically treating depression has a documented effect. This practice may pose threats to the increasing number of individuals experiencing burnout. The clinical guidelines in evidence‐based medicine mirror what counts as knowledge in medical inquiry, which in turn shapes attitudes towards individual patients. The aim of this article is 2‐fold: firstly, to assess how the values that accompany the biomedical paradigm affect clinical care, and secondly, to replace the biomedical model with a genuine person‐centred approach. In the study described, an existential phenomenological method was applied. Eight individuals, who experienced burnout, were included. They had been on long‐term sick leave (>1 year) due to symptoms of fatigue and pain and fulfilled the criteria for Exhaustion Disorder (ICD‐10, F43.8A). Their symptoms were not medically explained, and almost all the participants were labelled as depressed. Four themes emerged that described how they experienced living with burnout: “unhomelike being in the world,” “the limit of diagnosis,” “naked in the eyes of the public,” and “a path to hopelessness.” I identify 2 main problems; firstly, the mismatch between the patient's experience of his or her illness and the doctor's interpretation of the condition can lead to ineffective treatment. Secondly, the interviewees struggled to be recognized as ill. Thus, the inherent values in the biomedical paradigm might have serious implications for the medical care of patients with burnout.