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Chiropractic Journal of Australia : CJA June 2013
Chiropractic Journal of Australia Volume 43 Number 2 June 2013 61 INTRODUCTION "...evidence is only one of many factors that play a role in clinical decision-making." -- Rubenfeld.-1 Before the question of how best to employ EBP can be even discussed, clarifcation should be made concerning more fundamental aspects of this paradigm concerning quality control in the health sciences. A recent paper in the BMJ expressed this by stating that “guidelines should refect all knowledge, not just clinical trials."2 Such reservations raise questions as to: • How reliable is the evidence for practical clinical purposes? • What constitutes evidence? • What is the best evidence? • What is the most benefcial form of evidence? • Where is it obtained? • Do patients have access to it? ABSTRACT: Introduction: Reservations are emerging as to the suitability of a strict, highly researched evi- dence base for clinical health care. While such an evidence base is considered essential, there is growing support for a more patient centred system. Background: Questions surrounding the previously accepted gold standard are outlined together with suggestions that the roles of empirical and anecdotal evidence as well as patient input may need to carry greater weight in EBP. Review: Some grounds for even considering change is presented, these include the confusing plethora of hierarchical evidential models, the individual consideration of each patient, as well as limitations in the currently adopted system. Not only are there different models of evidential levels, but also these levels change from time to time over the decades .Patient Satisfaction: Per- sonalised patient feedback is suggested as critical. It is generally the patient that initiates a visit to a health practitioner. So, if it is important to listen to a patient at that initial consultation, surely it is just as important to listen to them during, and particularly at the end of it. Summary: Patient involvement in more personalised feedback data could essentially lead to a challenge to the theories of current evidential hierarchical levels. Calls have also been recognised for a greater emphasis to be placed on anecdotal and empirical evidence in such models. Conclusion: This presentation has sought to review, and construct a case for modifying and merging the current, generally accepted standards in EBP with a broader patient-involved base. Recommen- dations: A model incorporating a Visual Analogue Scale of patient self-assessment (30%) and practitioner assessment (30%) is offered, together with a weighted evidence formula (anecdotal and empirical 20% and formal evidence 20%) as well as an adopted assessment format. While the offered transcript is intended to open discussion on the topic, at this early stage additional research is also recommended regarding the form that any modifcations may take. A Critical Analysis of Evidence-Based Practice - Moving Towards a More Patient-Oriented EBP Model PETER L. ROME Peter L. Rome, DC (Ret) Melbourne,Victoria Received 8 November 2012, revised version accepted 30 January 2013 Chiropr J Aust 2013;43: 61-71. INDEX TERMS: (MeSH): EVIDENCE-BASED PRACTICE; PATIENT SATISFACTION;(OTHER): PATIENT FEEDBACK; CLINICAL RECORDS. • How is best practice determined? • When was it obtained? • Who determines what is acceptable evidence? Other reservations were expressed in a guideline manual for EBP by the Australian NH&MRC in 2003, under the heading Limitations of Findings.3 A further critical issue is to consider the fact that recent papers tend to challenge what has long been regarded as the benchmark standard, that of Randomised Controlled Trials (RCTs) whether placebo-based and/or blinded. In addition, the important aspect of patient satisfaction is receiving renewed prominence as patients’ preferences are being taken into account in clinical decision making.4,5 Opinions now emerging query whether academic studies, especially manual therapies, can necessarily be totally appropriate for clinical practices, particularly placebo- based studies. They question the fact that a number of other variables need to be taken into consideration in practical clinical settings and that these factors do not necessarily ft under hard and fast guidelines. Determining a suitable placebo for manual therapies is apparently proving to be controversial.6,7
CJA March 2013
CJA September 2013