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Chiropractic Journal of Australia : CJA June 2013
Chiropractic Journal of Australia Volume 43 Number 2 June 2013 65 For instance, a diagnosis of ‘mechanical low back pain’ is essentially a vague term, as it has a number of elements to consider which may or may not be present in a particular case. Another example would be in trauma cases. Apart from the many variables that can be involved in them, there are the individual patient factors to consider. These include all combinations of the individual nature of patients, the severity of the presenting condition, duration and forms of previous care, age, general health, previous injuries, previous surgery, medications, patient compliance, plus other variations which refect practical considerations in each and every case. One formula does not ft all situations. It has been stated by Hawk that patient-centred care "... operates through a practitioner-patient partnership in which the patient's preferences and values are respected in their choice of treatment and management plans." She goes on to question whether practitioners fail "to approach each patient as an individual" where "each individual's response to an injury...can be quite different from that of other individuals" In essence, one size should not be made to ‘ft all.’ 38 Although extracted from an unrelated paper, another example by Dandona, typifies what this paper seeks to portray; "Personalized medicine is the tailoring of the diagnosis, prevention, and treatment to the characteristics of each individual patient." 39 In addition, relevant observations originated from the Sydney-based Clinical Excellence Commission when Luxford opined that "We need to move beyond questioning whether the patient knows anything about quality care when they see it..." and further "...in the face of mounting evidence, improving patient experience is not only 'nice' but necessary." 40 It is therefore essential to at least question the appropriateness of defnitive formula of recommendations for all cases with a similar diagnosis? Limitations in Current System As outlined, there are a variety of opinions concerning the application and appropriateness regarding aspects of the current advocacy towards EBP for health professionals. Currently, there is a move towards subjective patient feed- back, with a reduced emphasis on the more formal studies like RCTs. 13,23,24-27,28-32,41,42 While EBP is seemingly ideal, areas of debate that deserve to be noted include the fact that:- • Varied guidelines exist. One could recognise a contradiction of EBPs if one considers a medical model, a physiotherapy model and a chiropractic model of evidence. All would consist of different recommendations for the same condition. Surely if there was a scientifc base for treatment only one model would exist. • Varied forms of hierarchy of evidence classifcation exist. Again, surely only one hierarchical model is necessary. But which model is a practitioner to choose to substantiate his treatment approach! • The hierarchy of evidence in one model can confict with other guidelines Hierarchies of evidence have been somewhat infexibly used and criticised for some decades. The CEBM “levels of evidence” were frst produced in 1998 for Evidence-Based On Call to make the process of fnding appropriate evidence feasible and its results explicit. These 'levels' were revised in light of new concepts and data. This is another example of how criteria for EBP can change in a relatively short time.33 • The evidence may be out of date as it takes time to ‘flter’ through to practitioners. For instance, in 2012, it has been deemed that a key heart test has not been updated in 60 years. The once respected Framingham Score method has now been noted for limitations in assessing certain cardiac conditions. Such lapses can occur in other areas leading to weakened supporting evidence.43 • Evidence may be presented in a way that makes it problematical, ambiguous, indistinct, contradictory or diffcult for a busy doctor to use. One can often fnd conficting evidence and complexity of choice. • How reliable is the evidence, and who determines the hierarchy of it when it changes? • It would seem that emphasis in EBP recommendations are themselves essentially based on opinion. Who is to decide on opinion? It would be up to a practitioner to seek out evidence to support his/her case if they were challenged. The alternative is for there to be an established evidence depository, but as discussed, there are too many variables for this. • It is virtually impossible to enforce adherence to EBP. Non-usage or misuse is usually only revealed if there has been a reported transgression, complaint, or third- party payer inquiry. • Evidential systems and discussions may be an onerous textbook size in length (Sackett8, Haneline24, Yeomans44). These may be out of date by the time they go to print, even if they were cutting edge at the time of writing. • Many patients may present with multiple conditions that do not ft EBP models. • By enforcing strict EBP, clinical autonomy may be compromised, even if the practitioner obtains excellent clinical results for a particular condition. " The intent of this criterion is that GPs are free, within the parameters of evidence based care, to make decisions that affect the clinical care they provide, rather than having these decisions imposed upon them. Section 3 of the AMA Code of Ethics (2004) outlines the importance of professional independence and argues that to provide high quality healthcare, doctors must safeguard clinical independence and professional integrity from increased demands from society, third parties, individual patients and governments."45 PATIENT-ORIENTED EBP ROME
CJA March 2013
CJA September 2013