Great discussion! Thanks for the references.


I believe that cognitive engineering may be useful as we think about
this set of issues. Vicente and Rasmussen (reference below) observe the
following about (not-just-computer) interface design, but it seems to me
equally relevant to how we conceive clinical guidelines and their
incorporation into care processes:
"Because the interface content is based on the means-end hierarchy
[their model, explicated most clearly in the second reference below),
the operator is free to choose whatever means are available to satisfy
any given function. This contrasts with the traditional human factors
approach to design which is typically based on behavior rather than
structure [of the domain in which the work is performed--the work
domain]. The classic approach would be to conduct a task analysis to
identify a single sequence of overt behaviors for performing each task
(e.g., Meister, 1985). Following this philosophy, the design would be
optimized for that particular way of performing the task, but it would
not necessarily support other control strategies. On the contrary, it
may even impede other strategies."  228


So perhaps the issue is not as much guidelines as it is the way we seek
to incorporate them into care processes.




Vicente, K. and J. Rasmussen (1990). "The Ecology of Human-Machine
Systems II:  Mediating "Direct perception" in Complex Work Domains."
Ecological Psychology 2(3): 207-249.


Vicente, K. (1999). Cognitive Work Analysis. Mahwah, NJ, Lawrence
Erlbaum.


"At one plant, operators would not always follow the written procedures
when they went to the simulator for recertification.  They deviated from
them for one of two reasons.  In some cases, operators achieved the same
goal using a different, but equally safe and efficient, set of actions. 
In other  cases, the operators would deviate from the procedures because
the desired goal would not be achieved if the procedures were followed. 
In either case, the operators' actions seem justifiable, particularly in
the latter set of circumstances.  The people who were evaluating the
operators in the simulator did not agree, however.  They criticized the
operators for "lack of procedural compliance."  Despite this
admonishment, the operators got their licenses renewed.


"This happened several times.  Eventually, the operators became
frustrated with the evaluators' repeated criticism because they felt it
was unwarranted.  The operators decided that, the next time they had to
go into the simulator for recertification, they would do exactly what
the procedure said--no matter what.  One team of operators followed this
"work-to-rule" approach in the simulator and became stuck in an infinite
loop.  At one point, an emergency procedure told operators to switch to
another procedure, but then that procedure eventually sent operators
back to the first one.  The operators dutifully followed the procedures,
and thus wound up in a cycle, repeating the same set of actions several
times.  The evaluators were not amused.  They eventually turned off the
simulator, ending that particular test.


"Later, the evaluators wrote a letter to the utility that employed this
group of operators.  In that letter, the evaluators criticized the
operators yet again, this time for "malicious procedural compliance."


Jim

James M. Walker, MD, FACP
Chief Medical Information Officer
Geisinger Health System

The best way to predict the future is to invent it.
                                               - Alan Kay
>>> "Dr. Carlos Cuello"  02/23/11 9:07 AM >>>
Thanks, Ben, Amy, and Dan. It´s always good to have information. It will
be
handy when discussing in our lectures. That´s why I eagerly read this
list
;)

It seems to me that the less we know (i.e., the less evidence on a CPG),
the
individualised clinical judgement will beat CPG and viceversa.

Another article I remember we discussed on this list two years ago, I
cited
an article by Pantell et al:

*Pediatric in treating febrile infants. In this study, relying on current clinical
guidelines would
not have improved care but would have resulted in more hospitalizations
and
laboratory
testing.

JAMA. 2004;291:1203-1212*
*
*
This results are based on an observational study too.

Althabe et al .,
performed an intervention which included EB guidelines and audits (which
is
and improvement on the CPG and part of the whole EB process...). A
randomised clinical trial that I always mention when someone ask me if
it is
worthy to implement CPG and the EB practice.

I do not know the evidence behind recommendations in the MRSA guidelines
for
adults, but in the paediatric field,
evidenceon
what antibiotic to choose for MRSA, is fair, sometimes even low; and
in
the case of infants and fever, evidence nowadays still is scarce and
based
on observational studies, and I think (my guess) we will today get the
same
results if we ask the same question (if fever CPGs are used vs
individualized clinical judgement).



Best wishes



On Tue, Feb 22, 2011 at 22:29, Dr. Amy Price  wrote:

> I would agree that I have seen evidence from both sides too, but how
would
> this gap be bridged particularly when reductions in funding mean
greater
> workloads and less qualified /experienced health professionals are 
making
> more decisions or having to wait past prime time for intervention for
an ok
> from a senior supervisor who is occupied with other things.
>
>
>
> Amy
>
>
>
> *From:* Evidence based health (EBH) [mailto:
> [log in to unmask]] *On Behalf Of *Djulbegovic,
Benjamin
> *Sent:* 22 February 2011 10:25 PM
>
> *To:* [log in to unmask]
> *Subject:* Re: more on clinical practice guidelines
>
>
>
>
>
> Unfortunately, the opposite example can also be found:
>
> Implementation of evidence-based guidelines led to INCREASE IN
MORTALITY
> (The Lancet Infectious Diseases, 20 January 2011
>
> doi:10.1016/S1473-3099(10)70314-5. Implementation of guidelines for
> management of possible multidrug-resistant pneumonia in intensive
care: an
> observational, multicentre cohort study).
>
> Both studies have methodological weakness, but appear to indicate that
> human judgements cannot be so easily replaced – for better, or worse-
by
> formulaic approach to complex decisions where uncertainty reigns and
errors
> are inevitable…
>
> Ben
>
> *From: *"Dr. Carlos Cuello" 
> *Reply-To: *"Dr. Carlos Cuello" 
> *Date: *Tue, 22 Feb 2011 20:53:11 -0500
> *To: *"[log in to unmask]" <
> [log in to unmask]>
> *Subject: *more on clinical practice guidelines
>
>
>
> We recently commented on the basis for practicing an EB process every
time
> we see a patient. Individualised versus institutionalised.
>
>
>
> Here is the article of Al-Khatib et al from Duke University
publishedin JAMA recently.
>
>
>
> Nice results based on the research question: In patients in which
> evidence-based recommendations are not followed vs those in which EB
> recommendations are followed, is there an increase in mortality,
morbidity
> or any other important clinical outcomes?
>
>
>
> The authors analysed the national cardiovascular registry to compare
those
> who received an implantable cardioverter-defibrillator (ICD) with no
EB
> indication versus the evidence-based ICD recipients.
>
>
>
> Of all the ICD implanted, 22.5% were not evidence-based (did not have
the
> indication), and these non-evidence-based ICD recipients were more
likely to
> die in-hospital, and more likely to have a complication from the
procedure.
>
>
>
> It is, nonetheless, an observational study with possible biases but I
think
> is worth to discuss in a journal club.
>
>
>
> Cheers
>
> --
> Carlos A. Cuello-García, MD
> Director, Centre for Evidence-Based Medicine
>
> Tecnologico de Monterrey School of Medicine
>
> Cochrane Collaboration Iberoamerican branch
>
> CITES piso 3. Morones Prieto 3000 pte. Col. Do> www.cmbe.net ⚫ Twitter  ⚫ Linkedin
>
>
>
>
> The content of this data transmission must not be considered an offer,
> proposal, understanding or agreement unless it is confirmed in a
document
> signed by a legal representative of ITESM. The content of this data
> transmission is confidential and is intended to be delivered only to
the
> addressees. Therefore, it shall not be distributed and/or disclosed
through
> any means without the authorization of the original sender. If you are
not
> the addressee, you are forbidden from using it, either totally or
partially,
> for any purpose
>
>
>



-- 
Carlos A. Cuello-García, MD
Director, Centre for Evidence-Based Medicine
Tecnologico de Monterrey School of Medicine
Cochrane Collaboration Iberoamerican branch
CITES piso 3. Morones Prieto 3000 pte. Col. Doctores 64710
Monterrey, NL. Mexico.
☎ +52.81.8888.2223 & 2154. Fax: +52.81.8888.2052 Skype: dr.carlos.cuello
www.cmbe.net ⚫ Twitter  ⚫
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