Hi Andrew,
your efforts from "white sheep" era have been nothing but spectacular -
I hope that adopting a "logical positivistic" "half a black sheep"
academic attitude does not result in splitting the hairs, which we have
all, for better or worse, adopted to some degree. In relation to this
discussion, this has also been reflected by the fact that: a) we do not
tend to follow the guidelines we develop, as Paul reminded us, and b) we
can't agree what we need to measure. I am copying my response related to
these two issues that I sent a couple of days ago, but due to some
e-mail problem the post did not go through. Hope this discussion is
still of some relevance.
Happy New Year!
Ben
a) Paul Glasziou wrote: it "reminds me an interesting example of folk
not following there own guideline: and only 4 of the 36 (11%) fractures
which met there own guideline criteria were remanipulated. To quote from
the paper: "An unexpected finding was the reluctance of the
participating surgeons to remanipulate fractures that met the criteria
for remanipulation-criteria that the same surgeons had participated in
setting ... This stark difference between "armchair guidelines" set a
priori and the reality of a busy fracture clinic has been reported
elsewhere..."
Bohm ER, et al. A Randomized Controlled Trial Above and Below-the-Elbow
Plaster Casts for Distal Forearm Fractures in Children. J Bone Joint
Surg Am. 2006"
Similar thing did happen to me some time ago- when I wanted to treat one
of my patients using Rx for which there was only anecdotal evidence, the
insurance company sent me a copy of my own chapter telling me that there
was no sufficient evidence to support my decision! So, I may have
understood that overall, the treatment in question was not to be
advocated for the entire population of similar patients, but when I
faced a reality in my own practice, I elected to disregard the "armchair
guidelines" that I helped developed!
b) Regarding the issue what % of decisions can be evidence-based, it, of
course, all depends on definition (i.e. how we operationalize our
measurements and definitions). So, if the denominator is "patient" (and
decisions in INDIVIDUAL patient) then Micheal is right- the number of
permutation is infinite. However, if the denominator is a research study
(with hopefully clear cut definitions along the PICO lines) then it is
possible to determine how much of evidence is generated in more or less
reliable manner (i.e. how much medicine is "evidence-based"- I started
hating this term!). Finally, in some field like oncology, it is possible
to identify types of decisions that practitioners and physicians need
and link them to underlying evidence (e.g. some time ago, we roughly
counted that there are ~ 1,000 key decisions in oncology). When one does
this kind of exercise, then he/she is faced with the fundamental problem
in the contemporary medicine, which is of some relevance to this
discussion- research agenda bias (researchers study one type of issues,
while patients and physician need completely a different type of
evidence). Hence, we cannot agree on what to measure! And, hence
importance of Iain Chalmer's DUET database.
Benjamin Djulbegovic, MD,PhD
Professor of Oncology and Medicine
H. Lee Moffitt Cancer Center & Research Institute at the University of
South Florida Department of Interdisciplinary Oncology, MRC, Floor 2,Rm#
2067H
12902 Magnolia Drive
Tampa, FL 33612
e-mail:[log in to unmask]
e-mail:[log in to unmask]
http://www.hsc.usf.edu/~bdjulbeg/
phone:(813)972-4673
fax:(813)745-6525
-----Original Message-----
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Andrew Booth
Sent: Tuesday, January 02, 2007 04:25
To: [log in to unmask]
Subject: Re: What percentage of health decisions can be evidence based?
Dear All
Just to let you know that our Web page on "What percentage of health
decisions are evidence based?"
http://www.shef.ac.uk/scharr/ir/percent.html
(i.e. Methodology not answer!) is in the process of being updated by
one of
my new information officers. To be honest I hadn't really thought there
was
still much demand for this until we received an enquiry here in
mid-December
at which point we identifed it as a good "update project". Its archival
function has perhaps been confirmed by recent discussions on this list.
Apologies for its current presence as an out-of-date source - a
throw-back
to when I was a "white sheep" information specialist and a useful member
of
this community before becoming "half a black sheep" academic!
Regards
Andrew
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