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Chiropractic Journal of Australia : CJA June 2013
64 Chiropractic Journal of Australia Volume 43 Number 2 June 2013 Compliance by both the practitioners and the patients, as well as time delays in evidence becoming available, are further weaknesses in the “system”. Further, particularly in the manual clinical health sciences, it has been noted that placebos-based studies are diffcult to apply in striving for the true placebo control base value.6,7,32 These represent further anomalies suggesting that there are still serious gaps in the way EBP should be applied. Confusing Models of the Hierarchy and Plethora of Evidence Classifcation In 2009 the Centre for Evidence Based Medicine at Oxford University compiled a table for evidence classifcation,33 this table lists 10 levels of evidence which classify the 5 categories of:- Therapy Prevention Aetiology Harm Prognosis Diagnosis Differential Diagnosis/Symptom Prevalence Study Economic and Decision Analysis [Of note, there is no category for a patient’s own assessment of their outcome -- i.e. the result that counts. (“The operation went perfectly but the patient worse off."-PLR)] The Centre has since compiled a further version for 2011 with 46 sub-categories. It is quite different the 2009 version. In Queensland the Department of Health has established its own classifcation or hierarchy of six levels (I-VI) of evidence for the following clinical assessments.34 The 'lowest' level is for Case Studies with either pre or post-test outcomes. These levels are classifed further for each level under the following categories:- Intervention Diagnosis Prognosis Aetiology Screening. [Again, there is no specifc summary or classifcation for the patient to express their own satisfaction or outcome -- an essential opinion. -- PLR] The Department of Health and Aging, Therapeutic Goods Administration has a 35 page booklet on the topic – the "Guidelines for Levels and Kinds of Evidence to Support Indications and Claims for Non-registrable Medicines; Including Complementary Medicines, and other Listable Medicines." While this is not quite relevant to chiropractic, it does typify the expectations of a bureaucracy which is quite onerous for clinicians.35 In researching this topic, more than 30 versions of evidence classifcation were encountered. One web site portrayed various pyramids of evidence -- at least. While the pyramids have a mixture of meta-analyses, systematic reviews or double-blinded-placebo-controlled categories at the apex, a few of the ‘lowest’ levels are worth noting in order to portray the wide range of opinions. 36 Example 1. (AIDA) Level 5 - Methodological Verifcation and Validation Studies Level 4 - Anecdotal Evidence (including independent user and validation studies Example 2 (Yale University School of Medicine) Level 7 - Background Information/Expert Opinion Level 6 - Case Controlled Studies/Case series/Reports Example 3. (Evidenced-based Nursing) Level 6 -Editorial/Expert Opinion Example 4 (University of North Carolina) Level 7 -- Personal communication Level 6 -- Case series/Case Reports Example 5 (Hartford Institute of Geriatric Nursing) Level 6 - Opinion of Respected Authorities Example 6 (Evidenced-based Veterinary Medicine) Level 10 - Invitro Research Level 9 - Ideas, Editorials, Opinions. Example 7 (Refreshing Dentistry) Level 6. - Expert opinion without explicit critical appraisal. Theories based on physiology or plausibility, bench top research and animal studies. "Though the evidence at the bottom of the pyramid is considered "low-level" it still has the potential to be an important link to the higher levels of evidence and add to the cumulative body of evidence on topic. For example, physicians in the 1980's began to observe some odd symptoms developing in certain populations of men. They began to report their fnding in case report studies. The clinical presentations they reported on would later be known as HIV/ AIDS." (From: Principles of evidence-based dentistry) Example 8. (Penn State University)37 These diverse recommendations raise the question as to how clinicians are meant to keep up with changing criteria, and which method should they chose to substantiate their 'evidence' if called upon. The academic versions seem quite impractical and demanding for clinicians. It is almost as though the patient should not have a say in how they have responded. This supports the position that outcomes assessments should encompass a measure of subjective patient input. Needs of the Individual Patient Potentially, there are many variables in virtually every patient presentation. They do not necessarily ft neatly into categories amenable to a fxed formula. Patients presenting with seemingly the same condition do not necessarily respond to the same mode of care or in the same time frame. PATIENT-ORIENTED EBP ROME
CJA March 2013
CJA September 2013