Peter C. Wyer

How to Read a Systematic Review and Meta-analysis and Apply the Results to Patient Care: Users’ Guides to the Medical Literature

Clinical decisions should be based on the totality of the best evidence and not the results of individual studies. When clinicians apply the results of a systematic review or meta-analysis to patient care, they should start by evaluating the credibility of the methods of the systematic review, ie, the extent to which these methods have likely protected against misleading results. Credibility depends on whether the review addressed a sensible clinical question; included an exhaustive literature search; demonstrated reproducibility of the selection and assessment of studies; and presented results in a useful manner. For reviews that are sufficiently credible, clinicians must decide on the degree of confidence in the estimates that the evidence warrants (quality of evidence). Confidence depends on the risk of bias in the body of evidence; the precision and consistency of the results; whether the results directly apply to the patient of interest; and the likelihood of reporting bias. Shared decision making requires understanding of the estimates of magnitude of beneficial and harmful effects, and confidence in those estimates.

Where is the wisdom? I--a conceptual history of evidence-based medicine.

Rationale Evidence-based medicine (EBM) has been acclaimed as a major advance in medical science, but criticized as a proposed alternative model for the practice and teaching of medicine. Ambiguity regarding the proper role of the contributions of EBM within the fabric of medicine and health care has contributed to this discrepancy. Aims and objectives We undertook a critical review of the history of the EBM movement, beginning with its origins in the 1970s and continuing through this century. We drew upon the results of an independent project that rationalized the EBM domain from the perspective of educational evaluation and assessment. We considered the content of EBM in relationship to the propositions and promises embodied in advocacy publications. Results EBM emerged in the context of the explosion of biomedical information in the decade preceding public access to the Internet in the mid-1990s and drew upon the independently derived information literacy formula developed by information scientists during the 1980s. The critically important content and achievements of EBM are fully explained within the confines of the information literacy model. The thesis that EBM offers an alternative paradigm for individualized health care, asserted in the advocacy literature, is not supported by published models of evidence-based clinical practice. Conclusion A critical historical review of the origins, content and development of the EBM movement proposes that full integration of the fruits of the movement into routine clinical care remains a conceptual and practical challenge.

The Association of Emergency Department Crowding During Treatment for Acute Coronary Syndrome With Subsequent Posttraumatic Stress Disorder Symptoms

ed clinical data from medical charts. We assessed inhospital depression symptoms with the Beck Depression Inventory (BDI), and ACS-induced PTSD symptoms by telephone interview 1 month later using the Impact of Events Scale-Revised (IES-R)6 -specific for ACS. We tested for group differences across ED crowding tertiles using one-way analysis of variance for continuous variables and chi-square for categorical variables. We used multiple linear regression to assess the association of ED crowding to PTSD symptoms at 1 month.

The utility of B-type natriuretic peptide in the diagnosis of heart failure in the emergency department: a systematic review

BackgroundDyspnea is a common chief complaint in the emergency department (ED); differentiating heart failure (HF) from other causes can be challenging. Brain Natriuretic Peptide (BNP) is a new diagnostic test for HF for use in dyspneic patients in the ED. The purpose of this study is to systematically review the accuracy of BNP in the emergency diagnosis of HF.MethodsWe searched MEDLINE (1975–2005) supplemented by reference tracking. We included studies that reported the sensitivity and specificity of BNP for diagnosing HF in ED patients with acute dyspnea. Two reviewers independently assessed study quality. We pooled sensitivities and specificities within five ranges of BNP cutoffs.ResultsTen studies including 3,344 participants met inclusion criteria. Quality was variable; possible verification or selection bias was common. No studies eliminated patients with obvious medical causes of dyspnea. Most studies used the Triage BNP assay; all utilized a clinical reference standard. Pooled sensitivity and specificity at a BNP cutoff of 100–105 pg/ml were 90% and 74% with negative likelihood ratio (LR) of 0.14; pooled sensitivity was 81% with specificity of 90% at cutoffs between 300 and 400 pg/ml with positive LR of 7.6.ConclusionOur analysis suggests that BNP has moderate accuracy in detecting HF in the ED. Our results suggest utilizing a BNP of less than 100 pg/ml to rule out HF and a BNP of greater than 400 pg/ml to diagnose HF. Many studies were of marginal quality, and all included patients with varying degrees of diagnostic uncertainty. Further studies focusing on patients with diagnostic uncertainty will clarify the real-world utility of BNP in the emergency management of dyspnea.

Where is the wisdom? II – Evidence‐based medicine and the epistemological crisis in clinical medicine. Exposition and commentary on Djulbegovic, B., Guyatt, G. H. & Ashcroft, R. E. (2009) Cancer Control, 16, 158–168

Evidence-based medicine (EBM) burst on the scene in 1992 [1] as a challenging, innovative and ultimately enigmatic newcomer to the stage of clinical medicine. Its challenge to blind obeisance to authority and its systematic approach to the problems posed by the rapidly expanding terrain of medical knowledge ranked high on the list of EBM’s compelling features. A critical historical review, and companion piece to this exposition and commentary [2], concluded that EBM contributed tools and resources of unprecedented importance to the practice of clinical medicine in the Age of Information, but fell short of its initially bold claims to define a comprehensive and revolutionary practice model, despite several published attempts to elaborate it. Challenges to EBM on epistemological and philosophical grounds have constituted a prominent aspect of criticisms of EBM since the 1992 proclamation. However, with few exceptions [3], responses to criticisms from the EBM camp have been confined to methodological issues pertaining to clinical research designs and to general goals and objectives [4]. Djulbegovic et al.’s [5] recent contribution constitutes the first attempt from within EBM to respond systematically to the published epistemological and philosophical challenges and, for this reason alone, deserves attention. However, our commentary is motivated not only by the historical importance of their submission. Rather we perceive clinical medicine to be in the midst of an epistemological crisis and the issues to which Djulbegovic et al. appear to be responding to be centrally related to this crisis. The stated objective of EBM has been to close the gap between research and clinical practice [6]. However, such an endeavour begs the question of what constitutes the nature of that gap, that is, the proper role of research in determining or informing clinical action. As pointed out by Tonelli [6], this in turn constitutes an epistemological question insofar as it implies, following Djulbegovic, a ‘propose(d) specific relationship between theory, evidence, and knowledge’. It defines the need for a more rigorous delineation and understanding of the scientific foundations of clinical practice. As stated by Tonelli, EBM represents a school of medical epistemology [6]. Epistemology deals with the theory of knowledge and is concerned not just with the nature but also with the limitations of knowledge. Hence, to discuss EBM within an epistemological framework we must address not only its accomplishments but also its main limitations. Epistemology deals with questions such as ‘What is knowledge?’, ‘How do we know what we know?’, ‘How is knowledge acquired?’ and ‘How does knowledge lead to wise and just action?’Among these, the latter, corresponding to the realm of ‘practical wisdom’ or ‘phronesis’ in classical Aristotelian terms, appears most salient to the issue at hand. Thus, the need to address these matters in the framework of relevant concepts of science and scientific knowledge defines the need for a ‘clinical epistemology.’ [7] We find the paper by Djulbegovic to be a convenient and timely pretext for clarifying these issues in some depth.

Environmental factors and their association with emergency department hand hygiene compliance: an observational study

Objectives Hand hygiene is effective in preventing healthcare-associated infections. Environmental conditions in the emergency department (ED), including crowding and the use of non-traditional patient care areas (ie, hallways), may pose barriers to hand hygiene compliance. We examined the relationship between these environmental conditions and proper hand hygiene. Methods This was a single-site, observational study. From October 2013 to January 2014, trained observers recorded hand hygiene compliance among staff in the ED according to the World Health Organization ‘My 5 Moments for Hand Hygiene’. Multivariable logistic regression was used to analyse the relationship between environmental conditions and hand hygiene compliance, while controlling for important covariates (eg, hand hygiene indication, glove use, shift, etc). Results A total of 1673 hand hygiene opportunities were observed. In multivariable analyses, hand hygiene compliance was significantly lower when the ED was at its highest level of crowding than when the ED was not crowded and lower among hallway care areas than semiprivate care areas (OR=0.39, 95% CI 0.28 to 0.55; OR=0.73, 95% CI 0.55 to 0.97). Conclusions Unique environmental conditions pose barriers to hand hygiene compliance in the ED setting and should be considered by ED hand hygiene improvement efforts. Further study is needed to evaluate the impact of these environmental conditions on actual rates of infection transmission.

Validating the acute heart failure index for patients presenting to the emergency department with decompensated heart failure

Background The acute heart failure index (AHFI) is a previously derived prediction rule to identify patients presenting to emergency departments (ED) with decompensated heart failure (DHF) at low risk of early life-threatening events. Study objectives To validate the AHFI prospectively. Methods Using a prospective cohort study, adult patients presenting to an urban university hospital ED with DHF were included. Data on 21 variables were gathered to calculate the AHFI. Primary endpoints included inpatient death and non-fatal serious outcomes (myocardial infarction, ventricular fibrillation, cardiogenic shock, cardiac arrest, intubation, or cardiac reperfusion). Secondary endpoints included death from any cause or readmission for heart failure within 30u2005days. Primary and secondary endpoint rates were calculated with 95% CI for the low and higher-risk subgroups. Results 259 patients were enrolled. 245/259 (95%) were admitted. 60/259 (23%) met low-risk criteria, of whom 1/60 (1.7%, CI 0.04 to 8.9) was discharged after sustaining pulseless electrical activity arrest. The comparable primary outcome rate in the derivation study was 1.4% (CI 1.1 to 1.7). 17/199 (8.5%, CI 5.1 to 13.3) higher-risk patients experienced an endpoint, compared with 13.3% (CI 12.9 to 13.7) in the derivation cohort. One low-risk patient (1.7%, CI 0.04 to 8.9) died within 30u2005days, and five (8.3%, CI 2.8 to 18.4) were readmitted. Corresponding rates in the derivation study were 2% and 5%, respectively. Conclusion The results are consistent with those previously reported for the low-risk subgroup of the AHFI. Further research is needed to determine the impact, safety and full range of generalisability of the AHFI as an adjunct to decision making.

Relationship-centred care: antidote, guidepost or blind alley? The epistemology of 21st century health care.

Contemporary health care is increasing in complexity and lacks a unifying understanding of epistemology, methodology and goals. Lack of conceptual consistency in concepts such as patient-centred care (PCC) typifies system-wide discordance. We contrast the fragmented descriptions of PCC and related tools to its own origins in the writings of Balint and to a subsequent construct, relationship-centred care (RCC). We identify the explicit and elaborated connection between RCC and a defined epistemological foundation as a distinguishing feature of the construct and we demonstrate that this makes possible the recognition of alignments between RCC and independently developed constructs. Among these, we emphasize Schons reflective practice, Nonakas theory of organizational knowledge creation and the research methodology of realist synthesis. We highlight the relational principles common to these domains and to their common epistemologies and illustrate unsatisfying consequences of adherence to less adequate epistemological frameworks such as positivism. We offer RCC not as an antidote to the dilemmas identified at the outset but as an example that illuminates the value and importance of explicit identification of the premises and assumptions underlying approaches to improvement of the health care system. We stress the potential value of identifying epistemological affinities across otherwise disparate fields and disciplines.

Depression is associated with longer emergency department length of stay in acute coronary syndrome patients

BackgroundPatient demographic characteristics have been associated with longer emergency department (ED) treatment times, but the influence of psychosocial characteristics has not been assessed. We evaluated whether depression was associated with greater ED length of stay (LOS) in non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA) patients presenting to a large metropolitan academic medical center.MethodsWe calculated ED LOS for NSTEMI or UA patients enrolled an observational cohort study by taking the difference between ED triage time in the medical record and time of transfer to an inpatient bed from standardized transfer documentation forms. Depression status was defined as current, past, or never by clinical interview and also by self-report on the Beck Depression Inventory.ResultsParticipants were 120 NSTEMI/UA patients [mean age= 62, 36% women, 56% Hispanic, 26% Black/African American, 40% NSTEMI, mean global registry of acute cardiac events (GRACE) score= 93.9]. Mean ED LOS was 11.6 hours, SD= 8.3. A multiple linear regression model that included the above demographic and clinical variables, and time of presentation to ED, explained 11% of the variance in ED LOS, F (11, 108)= 2.35, p= .01, R2 adj.= .11. Currently depressed patients spent 5.4 more hours (95% CI= .40, 10.4 hours) in the ED on average than patients who had never been depressed.ConclusionsCurrently depressed NSTEMI/UA patients are in the ED for an average of 5 hours longer than those who have never been depressed. Further research is needed to identify the reasons for this difference.

Teaching Evidence Assimilation for Collaborative Health Care (TEACH) 2009-2014: Building Evidence-Based Capacity within Health Care Provider Organizations.

Background: Clinical guidelines, prediction tools, and computerized decision support (CDS) are underutilized outside of research contexts, and conventional teaching of evidence-based practice (EBP) skills fails to change practitioner behavior. Overcoming these challenges requires traversing practice, policy, and implementation domains. In this article, we describe a program’s conceptual design, the results of institutional participation, and the program’s evolution. Next steps include integration of instruction in principles of CDS. Conceptual Model: Teaching Evidence Assimilation for Collaborative Health Care (TEACH) is a multidisciplinary annual conference series involving on- and off-site trainings and facilitation within health care provider organizations (HPOs). Separate conference tracks address clinical policy and guideline development, implementation science, and foundational EBP skills. The implementation track uses a model encompassing problem delineation, identifying knowing-doing gaps, synthesizing evidence to address those gaps, adapting guidelines for local use, assessing implementation barriers, measuring outcomes, and sustaining evidence use. Training in CDS principles is an anticipated component within this track. Within participating organizations, the program engages senior administration, middle management, and frontline care providers. On-site care improvement projects serve as vehicles for developing ongoing, sustainable capabilities. TEACH facilitators conduct on-site workshops to enhance project development, integration of stakeholder engagement and decision support. Both on- and off-site components emphasize narrative skills and shared decision-making. Experience: Since 2009, 430 participants attended TEACH conferences. Delegations from five centers attended an initial series of three conferences. Improvement projects centered on stroke care, hospital readmissions, and infection control. Successful implementation efforts were characterized by strong support of senior administration, involvement of a broad multidisciplinary constituency within the organization, and on-site facilitation on the part of TEACH faculty. Involvement of nursing management at the senior faculty level led to increased presence of nursing and other disciplines at subsequent conferences. Conclusions: A multidisciplinary and multifaceted approach to on- and off-site training and facilitation may lead to enhanced use of research to improve the quality of care within HPOs. Such training may provide valuable contextual grounding for effective use of CDS within such organizations.