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G'day!

I think there's always been a tension, and it's always been a debate. When I first became involved in this area I was a consumer advocate, and my interest was also to a large extent based on my concern.

Certainly, my concerns were one of the main reasons I got involved in establishing the Cochrane Collaboration a couple of decades ago: I had hopes of playing a role into reducing the harm to consumer choice arising from people losing access to services because of one (or a few) researchers' subjective judgments & interpretations of evidence. That's one of the consequences of those upstream applications of evidence. I wrote something about whether consumers and EBM were allies or enemies many years ago - came then to the position that it could go either way. It depended on how patient-centred the evidence is, to a large extent, I think. 

We don't really know whether the results of EBM are beneficial: we believe it and assume it's better than the alternative, but that itself has not been tested. There are plenty of visible adverse effects - sometimes practice wheeling about in this direction and that in response to evidence, ending up back where non-EBM practitioners always were, for example. But people usually concentrate on the anecdotes of harm from NOT being evidence-based, and quote anecodotal cases where EBM helped. On balance, we just believe it's logical to assume that there's a net benefit because science is meant to be self-correcting. But we don't know that, because systematic reviews themselves can at times end further scientific enquiry or channel it certain ways.

Whether EBM as a system was evidence-based was discussed a lot in conjunction with a special BMJ issue in 2004: at the time, I think the consensus was that we didn't have an evidence base for the system. I don't think that's changed, has it? Certain aspects are tested in RCTs (often without the hoped-for results), but not the whole. I'm not saying it needs to be, but its effect on either making medicine more or less patient-centered would certainly be one of the outcomes of great interest.

Hilda







On Wed, May 8, 2013 at 7:42 AM, Neal Maskrey <[log in to unmask]> wrote:

>> I would like to argue that person-centred care is at the centre of the EBM definition but EBM is not explicitly within definitions of person-centred care.

 

Good question!

 

Is this reasonable? Yes!

 

But I’ve always found patients and the public entirely receptive to incorporating evidence into person-centred decision making about their care. After all, what is the alternative?

What I might gently add is that it seems to me there are 4 settings to get from evidence / information to informed individual decision making.

 

The settings, sequentially  I’d name as research, national guidance, local policies, and individual decision makings (RNLI).

 

EBM/P has focussed huge efforts at the first translation from research to “national guidance”. Discussions on this group are dominated by this – and very helpful they are. However, there is relatively little effort expended on the second translation from that guidance into local policies. Then there’s a relatively small amount of effort going into supporting evidence-based, shared decision making at the individual consultation level, but this is miniscule compared with the guidelines and technology appraisal effort. As Kev says, the issue is recognised but we still are woefully short on the “how to do it”. Adoption of evidence is arguably limited by this skewed effort, and by the lack of recognition that it takes a lot more than the first translation.

 

I think that RNLI model is useful, at least to me, when thinking about the journey from evidence to individual care. Each of the settings have their own paradigm - and translations to help move through what is often a far from an orderly, logical and sequential progression each require (very) different approaches, skills, attitudes, tools etc.

 

Good luck with linking the EBM paradigm with the patient centred paradigm. Do let us know how you get on!

 

Best wishes

 

 

Neal

Professor Neal Maskrey

Consultant Clinical Adviser, Medicines and Prescribing Centre

National Institute for Health and Care Excellence
Ground Floor Building 2000 Vortex Court | Enterprise Way | Wavertree Technology Park | Liverpool L13 1FB | United Kingdom

Tel: +44 (151) 353 7729 | Fax: +44 (151) 220 4334

Honorary Professor of Evidence-informed Decision Making, Keele University, Staffordshire. ST5 5BG.


Web: http://nice.org.uk

 

 

 

 

 

From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of k.hopayian
Sent: 08 May 2013 08:13
To: [log in to unmask]
Subject: Re: EBM and Person-centred care - can you have one without the other?

 

Hi Phyll,

There is the Sicily Statement which includes an explicit statement that those receiving care should be the ones who make decisions with clinicians seen as a resource of information. That puts patients at the centre of care. We debated the use of the term patient-centred but dropped it in the end because we were informed that (back then) there was not an equivalent in some languages.

Evidence-Based Practice (EBP) requires that decisions

about health care are based on the best available, current,

valid and relevant evidence. These decisions should be

made by those receiving care, informed by the tacit and

explicit knowledge of those providing care, within the

context of available resources.

What the statement leaves out is HOW.

 

Dr Kev (Kevork) Hopayian, MD FRCGP
General Practitioner, Leiston, Suffolk
Hon Sen Lecturer, Norwich Medical School, University of East Anglia
Primary Care Tutor, East Suffolk

RCGP Clinical Skills Assessment examiner

 

On 7 May 2013, at 16:51, Phyll Buchanan <[log in to unmask]> wrote:



Dear all,

This list has helped me many times, thank you.  

I am about to do a presentation and would like some help in thinking this through - and I would really like some critical feedback before I do this for real.

At a previous research conference we challenged experienced researchers, working in the field of person-centred care, to be clear about their definitions, in order to help us understand the findings and perhaps incorporate them into our work.

My colleague and I are tutors with a voluntary organisation which provides breastfeeding support to new mothers, so already feeling a bit overawed when our challenge was accepted and  we were invited back to present our own thoughts on defining person-centred care. The deadline is getting close - about a month away.

Now I know more about evidence-based healthcare I realise they were not using reporting techniques familiar to this list. So, if we are to do a decent presentation, it means showing this distinguished, but perhaps sceptic, audience the relevance of evidence-based healthcare for their work as well as explain our understanding of person-centred care.

Taking this challenge further, and having looked at the definitions pasted below, I would like to argue that person-centred care is at the centre of the EBM definition but EBM is not explicitly within definitions of person-centred care.

Is this reasonable?

I would then like to explore methods of testing whether care given is perceived by the person at the receiving end as both evidence-based and person-centred.


I will follow-up the leads given by Hudon ( 2011) on appropriate measurement tools but would be very grateful if anyone knew of any existing work testing how patients experience EBM care?


Definitions

EBM definition (Straus, 2011:1)
Evidence-based medicine (EBM) requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances.
Values are defined as … unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient.

Person centred care
Duncan seems the closest with the inclusion of effective care.
“Responsive to individual personal preferences, needs and values and assuring that patients values guide all clinical decisions”
Scottish Government (2010) Healthcare Quality Strategy (cited by Duncan, 2011)

‘Health care services and staff: Have characteristics that equip them to deliver consistently good care; act in ways that show they are willing and competent to attend to my health and care needs, and respect me as a person as they do so; and enable me to be and do what I value being and doing within and beyond my health care encounters’. (Entwistle, 2012)

…the patient needs to perceive that his or her individual needs and circumstances are at the heart of the clinical care he or she receives… (Hudon, 2011)


Phyll

My background: I am completing my MSc in Evidence-based Healthcare which has transformed my thinking, I was a nurse many years ago, co-founded a voluntary organisation 17 years ago and am involved in training women to become peer supporters for new mothers.


Duncan, E. (2011) Person Centred Care : what is it and how can it be improved? : University of Stirling.

Entwistle, V., Firnigl, D., Ryan, M., Francis, J. & Kinghorn, P. (2012) Which experiences of health care delivery matter to service users and why? A critical interpretive synthesis and conceptual map. J Health Serv Res Policy. 17, 70-8.

Hudon, C., Fortin, M., Haggerty, J. L., Lambert, M. & Poitras, M. E. (2011) Measuring patients' perceptions of patient-centered care: a systematic review of tools for family medicine. Ann Fam Med. 9, 155-64.

Straus, S. E., Glasziou, P., Richardson, S. W. & Haynes, R. B. (2011) Evidence-based medicine: how to practice and teach it. London, Churchill Livingstone /Elsevier.



 


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