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Thanks, Anjana. What you're describing sounds to me more like the evidence-based systematic reviews (EBSRs) that we are definitely doing, an overview of the evidence in an as-objective-as-possible, or at least transparent, way. I think the particulars of the U.S. health care system, though, make the distinction between EBSRs and guidelines a particularly important one for us.
 
Health insurors have latched on to the whole idea of evidence-based medicine here, sometimes for the good, sometimes not. In the latter case, insurors have issued there own (purportedly evidence-based) practice guidelines which often are simply tools to deny coverage. So, they will give their overview of the evidence and what they consider that to mean in terms of best practice. On the patient care side, if we "stop" at the overview of the evidence without taking the next step to say what we think that means in terms of best practice, then we run the very real risk of leaving theirs as the only voice to be heard describing best practice.
 
So, as a researcher, I'm more than a little uncomfortable with this excursion into the political sphere, but if I want my work to have any impact...
 
 
-Rob
 

 

 

 

Rob Mullen

Director

National Center for Evidence-Based Practice in Communication Disorders

American Speech-Language-Hearing Association

10801 Rockville Pike

Rockville, MD 20852, United States

voice: 301-897-5700  ext. 4265

fax: 301-468-9742

e-mail: [log in to unmask]

 

 

 

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From: Evidence based health (EBH) on behalf of Anjana N Patel
Sent: Sat 2/17/2007 7:25 AM
To: [log in to unmask]
Subject: Re: What is "enough" evidence to support a practice guideline?

Rob,
 
Perhaps you could look at this in a different way. A pragmatic approach would be to aim to provide guidelines that are clearly transparent about the 'state of the evidence' rather than determination of a standard 'threshold' for sufficient evidence. Trying to determine a standard 'threshold' is difficult because the level of evidence varies for different possible outcomes for the same intervention. A further complication is that acceptability of risk also varies according to the possible outcomes i.e 'life or death' at one end of the spectrum and 'quality of life' at the other end of the spectrum. There are people who would prefer to die rather than live with a poor quality of life and other people who would choose to live at any cost.
 
Another factor to bear in mind is the sole purpose of 'guidelines'. I view guidelines as resources to help health professionals make difficult decisions (although some would argue that guidelines 'tell people what to do' and 'Guidance' would be a more appropriate term to use). Guidelines are misused for many reasons, but you cannot control how people use the guidelines produced by your professional society.
 
In the world of pharmacy in the UK, guidelines are generally considered to be useful if they are clear about:
 
1. the 'state of the evidence' from which a recommendation was derived
2. when there is a situation where we just 'don't know', in which case it is helpful to know what your colleagues would do when faced with a similar situation (i.e. a consensus statement). Whether or not you choose to do the same is entirely a personal decision but is necessary to be able to justify it.
3. the 'life-span' of the guideline i.e. the date it was first published and when it will be re-visited and updated if necessary. This indicates a clear acknowledgement of the ever-changing nature of 'the evidence' and clinical practice.
 
I hope that this helps.
 
Best wishes
 
Anjana
 
 
Anjana Patel BPharm, Msc, PhD MRPharmS
Independent Pharmaceutical Scientist and Writer
UK
 
   
----- Original Message -----
From: [log in to unmask] href="mailto:[log in to unmask]">Rob Mullen
To: [log in to unmask] href="mailto:[log in to unmask]">[log in to unmask]
Sent: Thursday, February 15, 2007 6:32 PM
Subject: What is "enough" evidence to support a practice guideline?

Our professional society is in the process of moving from consensus-based clinical practice guidelines to guidelines that are evidence-based. One aspect of this transition is that the new guidelines (or updates of existing guidelines) will be preceded by and directly linked to evidence-based systematic reviews.

 

One of the issues with which I’m struggling is the determination of a “threshold” for sufficient evidence on which to base a guideline. At one end of the spectrum is the position we could take of issuing a guideline only when the evidence of what a clinician should or should not do in a specific circumstance is so strong that to act differently would be approaching malpractice. My concern here is that we would issue very, very few guidelines, as we typically do not have that clarity of evidence.

 

At the other end of the spectrum is the position that we could issue a practice guideline any time there is a preponderance of evidence in one direction or another, and qualify the recommendations with caveats about the relative strength or weakness of the supporting evidence, and the importance of incorporating clinical expertise and patient values into the decision-making process. My concern is that the caveats might often be ignored, and all of the guidance coming from my organization would be considered on essentially equal footing.

 

I’d appreciate any thoughts about how to resolve this dilemma. Thank you!

 

-Rob

 

 

 

Rob Mullen

Director

National Center for Evidence-Based Practice in Communication Disorders

American Speech-Language-Hearing Association

10801 Rockville Pike

Rockville, MD 20852, United states

voice: 301-897-5700  ext. 4265

fax: 301-468-9742

e-mail: [log in to unmask]

 

 

 

Be an Ambassador!  Promote the professions with these ASHA resources: 

Reward Yourself with a Career as a College Professor in CSD

Reward Yourself with a Career in Health Care

Reward Yourself with a Career as a School-Based Speech-Language Pathologist