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----- Original Message ----- From: Sent by NCBI To: ibra@zadar.net Sent: Sunday, July 02, 2006 10:00 AM Subject: pubmed Search Results This message contains search results from the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM). Do not reply directly to this message. Sender's message: Sent on Sunday, 2006 Jul 02 GMT Select 23 document(s) Entrez pubmed Results Items 1 - 23 of 23 1: Med Teach. 2006 Jun;28(4):318-25. Related Articles, Books, LinkOut Evidence-based medicine: discrepancy between perceived competence and actual performance among graduating medical students. Caspi O, McKnight P, Kruse L, Cunningham V, Figueredo AJ, Sechrest L. Rabin Medical Center, Petah Tikva, Israel. ocaspi@ahsc.arizona.edu Since at the time of graduation from medical school physicians are expected to demonstrate adequate professional competence including mastery of critical appraisal skills, we conducted a preliminary, cross-sectional, web-based study to examine the extent to which fourth year medical students in the US are competent in core areas of evidence-based medicine (EBM). Using self-assessment instruments, subjects (n = 150) were asked to demonstrate their ability to understand the practical meaning of key methodological and data analysis constructs as they relate to patient care, to rate their perceived competence in core areas of EBM and to disclose their attitudes toward critical appraisal of the literature and EBM. The mean score in our cohort was 55% suggesting that students may have knowledge gaps that interfere with their ability to critically appraise the medical literature. There was an apparent chasm between subjects' perceived competence and their actual performance on the assessment instrument. These findings, if corroborated in larger studies, (1) suggest that better education in EBM is needed so as to avoid the possibility that patient care may inadvertently be jeopardized; and (2) cast doubt on the use of self-assessed knowledge as a proxy for actual skills with respect to EBM and medical decision-making. PMID: 16807169 [PubMed - in process] -------------------------------------------------------------------------------- 2: Med Teach. 2006 Jun;28(4):313-7. Related Articles, Books, LinkOut Teaching evidence-based medicine to undergraduate medical students: a course integrating ethics, audit, management and clinical epidemiology. Rhodes M, Ashcroft R, Atun RA, Freeman GK, Jamrozik K. Imperial College, UK. m.rhodes@imperial.ac.uk A six-week full time course for third-year undergraduate medical students at Imperial College uniquely links evidence-based medicine (EBM) with ethics and the management of change in health services. It is mounted jointly by the Medical and Business Schools and features an experiential approach. Small teams of students use a problem-based strategy to address practical issues identified from a range of clinical placements in primary and secondary care settings. The majority of these junior clinical students achieve important objectives for learning about teamwork, critical appraisal, applied ethics and health care organisations. Their work often influences the care received by patients in the host clinical units. We discuss the strengths of the course in relation to other accounts of programmes in EBM. We give examples of recurring experiences from successive cohorts and discuss assessment issues and how our multi-phasic evaluation informs evolution of the course and the potential for future developments. Publication Types: a.. Comment PMID: 16807168 [PubMed - in process] -------------------------------------------------------------------------------- 3: Med Teach. 2006 Jun;28(4):303-4. Related Articles, Books, LinkOut What is EBM and how should we teach it? Glasziou P. Centre for Evidence-Based Medicine, University of Oxford, Old Road Campus, Old Road, Headington, Oxford OX3 7LF, UK. paul.glasziou@public-health.oxford.ac.uk PMID: 16807165 [PubMed - in process] -------------------------------------------------------------------------------- 4: Adm Policy Ment Health. 2006 Jun 28; [Epub ahead of print] Related Articles, Books, LinkOut Desired Attributes of Evidence Assessments for Evidence-based Practices. Leff HS, Conley JA. Department of Psychiatry at Cambridge Health Alliance, Human Services Research Institute and Harvard Medical School, 2336, Massachusetts Avenue, Cambridge, MA, 02140, USA, sleff@hsri.org. In this paper we describe three approaches to assessing evidence for stakeholders interested in evidence-based practices: narrative reviews, systematic reviews (including meta-analyses), and registries. We then compare the approaches in terms of the degree to which they posses desired attributes of evidence assessments. Our review suggests that hybrid approaches that combined the best features of all three should be pursued to further the use of evidence-based practices, and that such hybrids are possible given the capacity of the World Wide Web. We conclude by stressing the need for empirical research on evidence assessments. PMID: 16804745 [PubMed - as supplied by publisher] -------------------------------------------------------------------------------- 5: Home Health Care Serv Q. 2006;25(1/2):149-165. Related Articles, Books, LinkOut Barriers and Facilitators to Replicating an Evidence-Based Palliative Care Model. Davis EM, Jamison P, Brumley R, Engu 0237 Danos S. , 2364 Duane St, No 5. Recognition of the difficulties involved in replicating evidence- based interventions is well documented in the literature within the medical field. Promising research findings are often not translated into practice, and if they are, there is a significant time gap between study conclusion and practice adoption. The purpose of this article is to describe the barriers and facilitators encountered by two managed care organizations while replicating an evidence-based end of life in-home palliative care model. Using Diffusion of Innovation Theory as a theoretical framework, results from focus groups and interviews with the project's clinical, administrative and research teams are presented and recommendations made for improving translational efforts. The process of replicating the end of life in-home palliative care model clearly illustrated the key elements required for successfully diffusing innovation. These key elements include marketing and communication, leadership, organizational support and training and mentorship. This qualitative process study provides clear, real world perspectives of the myriad of challenges encountered in replicating an evidence-based project. PMID: 16803742 [PubMed - as supplied by publisher] -------------------------------------------------------------------------------- 6: Home Health Care Serv Q. 2006;25(1-2):95-113. Related Articles, Books, LinkOut Moving Evidence-Based Interventions to PopulationsA Case Study Using Social Workers in Primary Care. Geron SM, Keefe B. , Institute for Geriatric Social Work, 232 Bay State Rd, Boston, MA, 02215. This article describes a study to expand a proven evidence- based practice for depression to a population-based intervention for frail older adults. Problem-Solving Therapy (PST) has been proven effective in reducing depression and other mental health conditions in cognitively intact adults in many studies. The current study employs a randomized controlled trial to test the effectiveness of a social work intervention for frail older adults that uses PST to address depression and other psychosocial issues. The intervention employs Master's trained social workers integrated into a large primary care practice. The study population is comprised of home-dwelling older adults with multiple chronic conditions, a recent history of unnecessary hospitalizations, and no more than mild cognitive impairment. PMID: 16803740 [PubMed - in process] -------------------------------------------------------------------------------- 7: Home Health Care Serv Q. 2006;25(1-2):75-94. Related Articles, Books, LinkOut Translating evidence-based physical activity interventions for frail elders. Wieckowski J, Simmons J. , 732 Mott St, Suite 150. The population shift to an older America has initiated a great deal of interest in the impact of evidence-based physical activity interventions on older adults. Physical activity for older adults has tremendous benefits and is recognized as one of the most powerful health interventions for improving seniors' ability to function and remain independent in the face of active health problems and yet the majority of all older adults remain largely sedentary. To date, few programs have been developed that apply these important research findings in physical activity to frail older adults living in the community. The purpose of this article is to review past and current trends addressing increasing physical activity in the frail elderly population at home. An exemplary model of integrating an evidence-based intervention into community-based care management programs is described. Barriers encountered when implementing evidence-based physical activity interventions with frail elderly at home and recommendations for future work in this area are discussed. PMID: 16803739 [PubMed - in process] -------------------------------------------------------------------------------- 8: Home Health Care Serv Q. 2006;25(1-2):33-54. Related Articles, Books, LinkOut Implications of Translating Research into PracticeA Medication Management Intervention. Alkema GE, Frey D. , Leonard Davis School of Gerontology, 3715 McClintock Ave. Through programs such as the Administration on Aging's Evidence-Based Prevention Initiative, researchers and practitioners are developing translational research studies seeking to implement rigorously tested, evidence-based interventions in new practice settings and evaluate the continuing effectiveness of these interventions. One such translational study is the Community-Based Medications Management Intervention (CBM Intervention), a collaborative effort to implement a medication management screening and intervention protocol in community-based waiver care management programs. The overall goals of the CBM Intervention are to implement an evidence-based medication management intervention in a California Medicaid waiver care management program, and to evaluate the effect of client-, intervention-, and organizational-level characteristics on resolving identified medication problems. This article presents the need for improved medication management in a frail, community-dwelling, older adult population and describes the CBM Intervention as an example of translating an evidence-based practice beyond its original efficacy trial in a home healthcare program into a care management program. It discusses critical factors involved in translating research into practice using a translational research framework, Promoting Action on Research Implementation in Health Services (PARIHS). Our experience suggests that although implementing research into practice can positively impact client care, professional skill enhancement and organizational effectiveness, this is very challenging work requiring signification facilitation for successful outcomes. PMID: 16803737 [PubMed - in process] -------------------------------------------------------------------------------- 9: Home Health Care Serv Q. 2006;25(1/2):13-31. Related Articles, Books, LinkOut Moving from Tacit Knowledge to Evidence-Based PracticeThe Kaiser Permanente Community Partners Study. Engu 237 Danos SM, Jamison PM. , 732 Mott St, Suite 150, Long Beach, CA, 90808, senguidanos@picf.org. For several decades both medical and social work practices have failed to consistently include measures to determine the effectiveness of their care and practices. This is especially true of care management practices. With the growth and aging of our population, this is of particular concern when many of our resources for older adults are channeled into services such as geriatric care management. This article describes a randomized controlled trial that tested the effectiveness of four levels of geriatric care management. Results from this study did not support the tacit knowledge of the clinicians in terms of the effectiveness of their practices. This article describes the study methods and results, and how evidence from this study impacted subsequent service provided by geriatric care managers. PMID: 16803736 [PubMed - as supplied by publisher] -------------------------------------------------------------------------------- 10: Home Health Care Serv Q. 2006;25(1-2):1-11. Related Articles, Books, LinkOut Evidence-Based Health PracticeKnowing and Using What Works for Older Adults. Altpeter M, Bryant L, Schneider E, Whitelaw N. , 720 Martin Luther King Jr Blvd, Campus Box 1030, Chapel Hill, NC, 27599-1030, mary_altpeter@unc.edu. Community-based health care agencies are facing demands for improved outcomes, cost-effective programming, and higher customer sa tisfaction. Implementing evidence-based health interventions and programs can help to address these challenges. This article provides an overview of evidence-based health practice, including the definition and advantages of this approach, other key terms and concepts inherent to evidence-based practice, and the tasks and steps necessary to its implementation. The article concludes with a list of resources to help health care providers learn about, plan, and implement evidence-based health interventions and programs. PMID: 16803735 [PubMed - in process] -------------------------------------------------------------------------------- 11: Cost Eff Resour Alloc. 2006 Jun 27;4(1):12 [Epub ahead of print] Related Articles, Books, LinkOut Economic evaluation of a clinical protocol for diagnosing emergency patients with suspected pulmonary embolism. Gospodarevskaya EV, Goergen SK, Harris AH, Chan T, Decampo JF, Wolfe R, Gan ET, Wheeler MB, McKay J. ABSTRACT: OBJECTIVE: To estimate the amount of cost-savings to the Australian health care system from implementing an evidence-based clinical protocol for diagnosing emergency patients with suspected pulmonary embolism (PE). Setting: Emergency department of a Victorian public hospital with 50,000 presentations in 2001-2002 METHOD: A cost-minimisation study used the data collected in a controlled clinical trial of a clinical protocol for diagnosing patients with suspected PE. The number and type of diagnostic tests in a historic cohort of 185 randomly selected patients, who presented to the emergency department with suspected PE during an eight month period prior to the clinical trial (January 2002 -August 2002) were compared with the number and type of diagnostic tests in 745 patients who presented to the emergency department with suspected PE from November 2002 to August 2003. Current Medicare fees per test were used as unit costs to calculate the mean aggregated cost of diagnostic investigation per patient in both study groups. A t-test was used to estimate the statistical significance of the difference in the cost of resources used for diagnosing PE in the control and in the intervention group. RESULTS: The trial demonstrated that diagnosing PE using an evidence-based clinical protocol was as effective as the existing clinical practice. The clinical protocol offers the advantage of reducing the use of diagnostic imaging, resulting in an average cost savings of at least $63.30 per patient. If extrapolated to the whole of Australia this could represent an annual savings between $3.1 million to $3.7 million. PMID: 16803623 [PubMed - as supplied by publisher] -------------------------------------------------------------------------------- 12: Psychol Rev. 2006 Jul;113(3):554-83. Related Articles, Books, LinkOut Conceptualizing changes in behavior in intervention research: the range of possible changes model. De Los Reyes A, Kazdin AE. Department of PsychologyYale University, New Haven, CT, US. An international movement has focused on identifying evidence-based interventions that were developed to change psychological constructs and that are supported by controlled studies. However, inconsistent findings within individual intervention studies and among multiple studies raise critical problems in interpreting the evidence, and deciding when and whether an intervention is evidence-based. A theoretical and methodological framework (Range of Possible Changes [RPC] Model) is proposed to guide the study of change in intervention research. The authors recommend that future quantitative reviews of the research literature use the RPC Model to conceptualize, examine, and classify the available evidence for interventions. Future research should adopt the RPC Model to both develop theory-driven hypotheses and conduct examinations of the instances in which interventions may or may not change psychological constructs. ((c) 2006 APA, all rights reserved). PMID: 16802881 [PubMed - in process] -------------------------------------------------------------------------------- 13: Ann Allergy Asthma Immunol. 2006 Jun;96(6):826-33. Related Articles, Books, LinkOut Interpreting quality-of-life data: methods for community consensus in asthma. Wyrwich KW, Metz SM, Kroenke K, Tierney WM, Babu AN, Wolinsky FD. Department of Research Methodology, Saint Louis University, St Louis, Missouri 63108, USA. wyrwichk@slu.edu BACKGROUND: Change in health-related quality of life (HRQoL) is an important outcome in asthma treatment. Patient and provider consensus on how to determine thresholds for identifying important improvements and declines, however, has not been achieved. OBJECTIVE: To search for consensus in clinically important difference (CID) thresholds for HRQoL change from 3 points of view: (1) an expert panel of physicians who treat patients with asthma and measure the HRQoL of their patients, (2) asthmatic patients, and (3) the primary care physicians (PCPs) of these asthmatic patients. METHODS: The expert panel used Delphi and consensus methods to agree on CID levels for the Asthma Quality of Life Questionnaire and the Medical Outcomes Study 36-Item Short-Form Health Survey, version 2.0. A total of 396 patients attending midwestern primary care clinic sites completed these interviews bimonthly for 1 year. The 46 PCPs treating these patients completed baseline assessments on each patient's asthma and then evaluated the change in each patient's condition at subsequent office visits during the next year. RESULTS: The patient-perceived estimates were consistent with results of previous studies but were notably lower than those derived from the expert panel and the PCPs. The Short-Form Health Survey generally did not provide sufficient sensitivity to detect important changes. CONCLUSIONS: Although consensus on the interpretation of change in HRQoL measures was not achieved, this evidence-based approach demonstrates the value of patient and physician perspectives and the need for improved dialogue and understanding to optimize the HRQoL of patients with asthma. PMID: 16802770 [PubMed - in process] -------------------------------------------------------------------------------- 14: Med Klin (Munich). 2006 Mar 22;101 Suppl 1:115-8. Related Articles, Books, LinkOut [Quality assurance and guidelines in intensive care medicine] [Article in German] Graf J. Klinik fur Anasthesie und Intensivtherapie, Klinikum der Philipps-Universitat Marburg. jgraf@gmx.de Although validated instruments are readily available for structured outcome assessment, this has been rarely employed in German intensive care units yet. Analysis of the effectiveness or efficiency of intensive care medicine without systematic assessment of outcomes and underlying structures and processes is impossible. Detailed knowledge of outcomes is mandatory, when continuous quality improvement is warranted. In the future, German intensive care units should implement regular outcome assessment to allow objective comparisons considering the particular case mix. Evidence-based guidelines may facilitate both, development of objectives, and assessment of outcomes. Owing to the advancement of medicine regular updates of guidelines are mandatory. Moreover, targets for the quality assessment need to be adjusted accordingly. This finally leads toward a continuous quality improvement process. PMID: 16802534 [PubMed - in process] -------------------------------------------------------------------------------- 15: Ann Oncol. 2006 Jul;17 Suppl 8:viii9-viii14. Related Articles, Books, LinkOut World Health Organization cancer priorities in developing countries. Ngoma T. Ocean Road Cancer Institute, Dar es Salaam, Tanzania. The burden of cancer in developing countries is growing and threatens to exact a heavy morbidity, mortality, and economic cost in these countries in the next 20 years. The unfolding global public health dimensions of the cancer pandemic demand a widespread effective international response. The good news is that the majority of cancers in developing countries are preventable, and the efficacy of treatment can be improved with early detection. Currently, the knowledge exists to implement sound, evidence-based practices in cancer prevention, screening/early detection, treatment, and palliation. It is estimated that the information at hand could prevent up to one-third of new cancers and increase survival for another one-third of cancers detected at an early stage. To achieve this, knowledge must be translated into action. To facilitate the call to action in the fight against cancer, the World Health Organization (WHO) has developed a comprehensive approach to cancer control. The WHO has produced many valuable guidelines and resources for the effective implementation of national cancer control programs. Several milestones in the WHO's efforts include the Framework Convention for Tobacco Control, and global strategies for diet and exercise, reproductive health, and cervical cancer. This review examines the strategies and approaches that have successfully resulted into global action to confront the rising global burden of cancer in the developing world. PMID: 16801342 [PubMed - in process] -------------------------------------------------------------------------------- 16: Ann Oncol. 2006 Jul;17 Suppl 8:viii24-viii31. Related Articles, Books, LinkOut Cancer initiatives in developing countries. Mellstedt H. Department of Oncology, Cancer Center Karolinska, Karolinska University Hospital, Stockholm, Sweden. The coming decades will bring dramatic increases in morbidity and mortality from cancer in the developing world. The burden of cancer is increasing globally, with an expected 20 million new cases per year in 2020, half of which will be in low- and middle-income countries. Despite an already overwhelming burden of health problems, developing countries must somehow address this cancer pandemic and their alarming share of cancer illness. Many large-scale and innovative worldwide initiatives have been launched in the fight against cancer. These programs represent colossal efforts to expand resources for health education among people and healthcare workers in developing countries and to increase awareness of cancer prevention. Many novel evidence-based and culturally-relevant programs are being implemented for screening and early prevention of common cancers. Several key initiatives are supporting clinical research, guideline development, oncology training, and appropriate technology transfer, such as access to electronic medical literature. Treatment programs are expanding access and quality of radiologic and pharmacologic therapies for cancer. These initiatives represent an unprecedented level of and cooperation among international agencies, governmental and nongovernmental organizations, international foundations, scientific societies, local institutions, and industry. This review examines the scope of need in response to the increasing burden of cancer in the developing world and major initiatives that have been created to respond to these needs. PMID: 16801336 [PubMed - in process] -------------------------------------------------------------------------------- 17: Sex Health. 2006 May;3(2):79-85. Related Articles, Books, LinkOut The role of contact efficacy in evaluating sexual health promotion--evidence-based outreach work within a public sex environment. Frankis JS, Flowers P. Glasgow Caledonian University, Scotland, UK. j.frankis@gcal.ac.uk BACKGROUND: This paper explores the role of contact efficacy in evidence-based health promotion by evaluating a public sex environment (PSE) based sexual health outreach program. The service operated in situ from a dedicated mobile unit to promote sexual health among PSE users. METHODS: A cross-sectional survey (response rate 56%) measured socio-demographics, sexual health behaviours and outreach-service use among men sampled within the PSE (n = 216). RESULTS: Most participants were aware of the service and two-thirds had contacted them. Men who had not completed hepatitis A vaccination (odds ratio (OR) = 2.02), who had ever received money for sex (OR = 2.07) or who reported a diagnosed mental health disorder(s) (OR = 2.38) were significantly more likely to have contacted the service. Although 89% of service users perceived the intervention positively, only 26% felt it had contributed to sexual behaviour changes. CONCLUSIONS: The 'mobile-unit' outreach model contacted a large proportion of PSE users, specifically men who had greater health needs. We advocate the adoption of this outreach model over traditional PSE-based outreach approaches. Contact efficacy evaluation is useful to assess ongoing health interventions. However, caution must be exerted when interpreting certain contact efficacy results. Since causality may not always be inferred, triangulation with other evaluative methodologies is recommended. PMID: 16800392 [PubMed - in process] -------------------------------------------------------------------------------- 18: Bull World Health Organ. 2006 Jun;84(6):504. Epub 2006 Jun 21. Related Articles, Books, LinkOut Evidence-based reproductive health care. Colomar M, Cafferata ML, Belizan JM. Perinatal Research Unit, Hospita l de Clinicas, Montevideo, Uruguay. PMID: 16799737 [PubMed - in process] -------------------------------------------------------------------------------- 19: Paediatr Respir Rev. 2006;7 Suppl 1:S90-2. Epub 2006 Jun 5. Related Articles, Books, LinkOut What are we learning from genetic cohort studies? Custovic A, Simpson A. Academic Division of Medicine and Surgery South, University of Manchester, North West Lung Centre, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK. Although genetic component of as thma has been well recognised, genetics alone cannot explain the rise in asthma prevalence. This increase is likely a consequence of environmental factors increasing the risk in genetically susceptible individuals. As wheezing illness usually begins within months of birth, prospective birth cohorts with detailed measures of environmental exposures and objective measures of disease are essential to study gene-environment interactions in the development of different wheeze phenotypes. Such studies will enable identification of children at increased risk of disease because of a genetic predisposition when exposed to a particular environmental factor. Tailor-made evidence-based strategies for prevention of asthma and atopic sensitization applicable to individuals at risk (rather than the whole population) will then be developed to reduce the risk of asthma and allergy development. PMID: 16798609 [PubMed - in process] -------------------------------------------------------------------------------- 20: Int J Med Inform. 2006 Jun 21; [Epub ahead of print] Related Articles, Books, LinkOut Critical incidents and journey mapping as techniques to evaluate the impact of online evidence retrieval systems on health care delivery and patient outcomes. Westbrook JI, Coiera EW, Sophie Gosling A, Braithwaite J. Centre for Health Informatics, Cliffbrook Campus, University of New South Wales, Kensington 2052, Australia. BACKGROUND: Online evidence retrieval systems are a potential tool in supporting evidence-based practice. Effective and tested techniques for assessing the impact of these systems on care delivery and patient outcomes are limited. PURPOSE AND METHODS: In this study we applied the critical incident (CI) and journey mapping (JM) techniques to assess the integration of an online evidence system into everyday clinical practice and its impact on decision making and patient care. To elicit incidents semi-structured interviews were conducted with 29 clinicians (13 hospital physician specialists, 16 clinical nurse consultants (CNCs)) who were experienced users of the online evidence system. Clinicians were also asked questions about how they had first used the system and how their use and experiences had changed over time. These narrative accounts were then mapped and scored using the journey mapping technique. RESULTS: Clinicians generated 85 critical incidents. Three categories of impact were identified: impact on clinical practice, impact on individual clinicians and impact on colleagues through the dissemination of information gained from the online evidence system. One quarter of these included specific examples of system use leading to improvements in patient care. Clinicians obtained an average journey mapping score of 22 out of a possible score of 36, demonstrating a good level of system integration. Average scores of doctors and CNCs were similar. However individuals with the same scores often had very different journeys in system integration. CONCLUSIONS: The CI technique provided clear examples of the way in which system use had influenced practice and care delivery. The JM technique was found to be a useful method for providing a quantification of the different ways and extent to which, clinicians had integrated system use into practice, and insights into how system use can influence organisational culture. The development of the journey mapping stages provides a structure by which the program logic of a clinical information system and its desired outcomes can be made explicit and be based upon users' experiences in everyday practice. Further work is required using this technique to assess its value as an evaluation method. PMID: 16798071 [PubMed - as supplied by publisher] -------------------------------------------------------------------------------- 21: BMC Med Res Methodol. 2006 Jun 24;6(1):29 [Epub ahead of print] Related Articles, Books, LinkOut Circular Instead of Hierarchical: Methodological Principles for the Evaluation of Complex Interventions. Walach H, Falkenberg T, Fonnebo V, Lewith G, Jonas WB. ABSTRACT: BACKGROUND: The reasoning behind evaluating medical interventions is that a hierarchy of methods exists which successively produce improved and therefore more rigorous evidence based medicine upon which to make clinical decisions. At the foundation of this hierarchy are case studies, retrospective and prospective case series, followed by cohort studies with historical and concomitant non-randomized controls. Open-label randomized controlled studies (RCTs), and finally blinded, placebo-controlled RCTs, which offer most internal validity are considered the most reliable evidence. Rigorous RCTs remove bias. Evidence from RCTs forms the basis of meta-analyses and systematic reviews. This hierarchy, founded on a pharmacological model of therapy, is generalized to other interventions which may be complex and non-pharmacological (healing, acupuncture and surgery). DISCUSSION: The hierarchical model is valid for limited questions of efficacy, for instance for regulatory purposes and newly devised products and pharmacological preparations. It is inadequate for the evaluation of complex interventions such as physiotherapy, surgery and complementary and alternative medicine (CAM). This has to do with the essential tension between internal validity (rigor and the removal of bias) and external validity (generalizability). SUMMARY: Instead of an Evidence Hierarchy, we propose a Circular Model. This would imply a multiplicity of methods, using different designs, counterbalancing their individual strengths and weaknesses to arrive at pragmatic but equally rigorous evidence which would provide significant assistance in clinical and health systems innovation. Such evidence would better inform national health care technology assessment agencies and promote evidence based health reform. PMID: 16796762 [PubMed - as supplied by publisher] -------------------------------------------------------------------------------- 22: Curr Opin Obstet Gynecol. 2006 Aug;18(4):433-9. Related Articles, Books, LinkOut Pitfalls in systematic reviews. Farquhar C, Vail A. aCochrane Menstrual Disorders and Subfertility Group, Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand bBiostatis tics Group, University of Manchester, Manchester, UK. PURPOSE OF REVIEW: The term 'evidence-based medicine' means integrating individual clinical expertise with the best available external clinical evidence from systematic research. An important source for those who wish to practise evidence-based medicine is the systematic review. Systematic reviews, however, are not without their pitfalls. This review will consider the problems and challenges for researchers and users of systematic reviews. RECENT FINDINGS: Failure to adequately assess study quality, funding bias, publication bias, reliance on outcomes that provide no help in clinical decision-making, analysis errors and the incorrect use of evidence statements are all common pitfalls in systematic reviews. SUMMARY: There are several steps in completing a systematic review. These include developing the clinical question, searching for all available literature, study selection, assessment of study quality, data extraction, data analysis, interpreting the results, implications for practice and further research, and finally updating the review in a timely manner. Authors of systematic reviews need to be aware of these problems and attempt to address them so that research evidence may be of clinical value to both providers and consumers of healthcare. PMID: 16794425 [PubMed - in process] -------------------------------------------------------------------------------- 23: BMJ. 2006 Jul 1;333(7557):19. Epub 2006 Jun 22. Related Articles, Books, LinkOut Patients' own assessments of quality of primary care compared with objective records based measures of technical quality of care: cross sectional study. Rao M, Clarke A, Sanderson C, Hammersley R. Department of Health and Human Sciences, University of Essex, Colchester CO4 3SQ. OBJECTIVE: To investigate the relation between older patients' assessments of the quality of their primary care and measures of good clinical practice on the basis of data from administrative and clinical records. DESIGN: Cross sectional population based study using the general practice assessment survey. SETTING: 18 general practices in the Basildon primary care trust area, south east England. PARTICIPANTS: 3487 people aged 65 or more. MAIN OUTCOME MEASURES: Correlations between mean practice scores on the general practice assessment survey and three evidence based measures on survey of case records (monitoring for, and control of, hypertension, and vaccination against influenza). RESULTS: 76% of people (3487/4563) responded to the general practice assessment survey. Correlations between patient assessed survey scores for technical quality and the objective records based measures of good clinical practice were 0.22 (95% confidence interval -0.28 to 0.62) for hypertension monitored, 0.30 (-0.19 to 0.67) for hypertension controlled, and -0.05 (-0.50 to 0.43) for influenza vaccination. CONCLUSIONS: Older patients' assessments are not a sufficient basis for assessing the technical quality of their primary care. For an overall assessment both patient based and records based measures are required. PMID: 16793783 [PubMed - in process] --------------------------------------------------------------------------------