G'day! Yes, and if you add in what about the evidence about communicating with patients, and ensuring that their values are involved, then it gets even murkier.
I think the question is awfully hard. It depends what standards you are applying at so many levels.
But in some ways, the hardest thing here for me is the notion that there is one "right" health care choice in each circumstance. This is part of the difficulty of deciding at a guideline level, at a hospital level or whatever, what is the "right" health care choice. It depends what you mean by EBM. If it is the classic Sackett definition - evidence and patient values have been considered in making a decision - then the measure is, was there evidence and was that part of the decisionmaking process. What the choice is, well, that is something else entirely.
Otherwise, all we have done is say healthcare practice must conform to decisions made by someone else about what "should" be done. As such, EBM then becomes a tool for conformism. And I hope it is obvious by my choice of words that I don't think that is ideal! :) :)
I was also extremely sceptical when I saw that O&G paper - I sent it around for sake of updating Andrew Booth's list which Paul had sent around. And because there were more such articles in the references.
My background originally was as a maternity consumer advocate. And I would still go to the barricades to defend a woman's right to choose or reject a form of care in childbirth according to her values, and say there is no alternative but to leave it to women/mothers to make these decisions: informed, but not pushed or forced to conform. Evidence is information: it is not a prescription for what is best for each individual, and indeed, that is impossible. The decisions need to be made, as far as society can support (and I realise how great that limitation is), at the individual level.
One of the interesting things in "Effective Care in Pregnancy and Childbirth" though was the list of treatments that were just plain harmful, and which almost anyone could agree should be discontinued, because informed, almost no one would choose them. Perhaps it is the elimination of the absolute worst practices, is one goal worth trying to track. As I recall, one of the items on that list went something like this: "Failing to involve women in decisions about their care." What is right for an individual cannot so easily be handed down from far above and far away.
Hilda
= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =
Hilda Bastian
Ressortleiterin Gesundheitsinformation
Chefredakteurin: www.gesundheitsinformation.de
www.informedhealthonline.org
Head of Health Information Department
Editor in Chief:
www.informedhealthonline.org
www.gesundheitsinformation.de
Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen
Institute for Quality and Efficiency in Health Care
Dillenburger Str. 27
D-51105 Köln, Germany
tel: + 49-221 / 35685-401
fax: + 49-221 / 35685-1
email: [log in to unmask]
http://www.iqwig.de
-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Michael Power
Sent: Freitag, 29. Dezember 2006 09:47
To: [log in to unmask]
Subject: Re: What percentage of health decisions can be evidence based?
Hilda
I enjoyed your remark about "antibodies against EBM" and I read with
interest the paper that you recommended: "Is general inpatient obstetrics
and gynaecology evidence-based? A survey of practice with critical review
of methodological issues."
The paper, inadvertently, illustrates that the percentage you get when
measuring the proportion of care that is evidence-based depends on (i) the
granularity of the questions asked, and (ii) the viewpoint of the
questioner.
Granularity.
The authors seem (the article does not provide enough detail to make a
definite assessment) to have taken the highest (lumpiest) level of
granularity; for example caesarian section as an atom of intervention. I
doubt if they considered the evidence base for the type of incision,
choice of sutures, type of anaesthetic, supportive fluids, monitoring
equipment in the operating theatre, etc, etc
Point of view
The authors seem to have taken the viewpoint of an obstetrician-
gynaecologist. Other viewpoints might have looked for evidence for
different aspects of the care provided; for example: What is the evidence
for the infection control procedures used? Is there evidence that similar
results for mother and baby could not be obtained by specialist
nurses/midwives trained to provide the most commonly required services? Is
there evidence to support the length of time that the mothers and their
babies were kept in hospital? etc etc.
This shows that you could choose methods to measure the proportion of care
that is evidence-based in such a way that you could get the answer that
you wanted (and, as an added bonus, seem to be evidence-based while doing
it).
Skeptically yours,
Michael
On Thu, 28 Dec 2006 18:28:11 +0100, Bastian, Hilda
<[log in to unmask]> wrote:
>G'day!
>
>
>
>Yes, that list is really out of date. There was a new one on O&G
published this year, too:
>
>
>
>http://www.biomedcentral.com/1472-6874/6/5
>
>
>
>And its references 2 to 6 are similar, recent attempts to measure this.
>
>
>
>The problem is, it also depends then in which health service you mean it.
Some hospitals are no doubt better than others, for example. It differs
from country to country - and some payment systems or regulatory systems
make particular forms of evidence-based practice impossible. I live in a
country for example where the consultation times are so short, the
evidence about the best ways to communicate with patients must be applied
only a small proportion of the time, because the structure of the service
does not allow for it.
>
>
>
>One thing I think is pretty certain though: the 90% claim is one of those
types of statements that probably caused a lot of antibodies against EBM.
Life's just not that simple.
>
>
>
>Ruth's question is a really interesting one though: how do we know if we
are making progress?
>
>
>
>Hilda
>
>
>
>= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =
>
>
>
>Hilda Bastian
>
>
>
>Ressortleiterin Gesundheitsinformation
>
>Chefredakteurin: www.gesundheitsinformation.de
<http://www.gesundheitsinformation.de>
>
>www.informedhealthonline.org <http://www.informedhealthonline.org>
>
>
>
>Head of Health Information Department
>
>Editor in Chief:
>
>www.informedhealthonline.org <http://www.informedhealthonline.org/>
>
>www.gesundheitsinformation.de <http://www.gesundheitsinformation.de>
>
>
>
>Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen
>
>
>
>Institute for Quality and Efficiency in Health Care
>
>
>
>Dillenburger Str. 27
>
>D-51105 Köln, Germany
>
>
>
> tel: + 49-221 / 35685-401
>
> fax: + 49-221 / 35685-1
>
> email: [log in to unmask]
>
>
>
>http://www.iqwig.de
>
>
>
|