When Evidence and Practice Collide

[Guest guest]

Here is a link, and some excerps, would be good for everyone to read and think

about. Very good article. G.Smalling, Newberg

Volume 28, Issue 8, Pages 551-553 (October 2005)

4 of 21

When Evidence and Practice Collide

D. Mootz, DC

http://www.journals.elsevierhealth.com/periodicals/ymmt/article/PIIS016147540500\

2265/fulltext

" Evidence Appropriatism "

This is how EBP was meant to be. Evidence is used by all to better inform the

choices patients have in making clinical decisions with their physicians, not to

regulate them. End users have an appreciation of the strengths and limitations

of varying qualities of evidence. Evidence suitability trumps evidence

hierarchies, and the end users have real-time access to high-quality

information. Guidelines are living documents refined regularly with new

information and experience. Evidence is a tool to improve practice specifically

and how we administer health care generally. It also is a tool that may require

you to change what you do.

" Evidence Nihilism "

This represents the perspective that one cannot act until definitive evidence is

available. From such a vantage point, the absence of evidence qualifies as

evidence against, as does conflicting evidence. Although it sounds extreme,

there are situations (such as when making a coverage decision regarding a

procedure with high risk of adverse outcome) where more rigorous standards may

be appropriate. However, this approach can sometimes be applied in default

fashion to the detriment of various clinical situations.

" Evidence Agendaism "

This strategy reflects the selective use of evidence to bolster one's

preconceived notions. For example, a payer might seek out and act on evidence

that favors their business need while ignoring that which does not. Capping a

chiropractic benefit or restricting coverage for known best practices under the

auspices of " following a guideline " comes to mind. It may be a practical

business decision to make, but " blaming the evidence " illustrates this strategy.

Likewise, providers may promulgate and promote studies that emphasize a

miniscule, marginal advantage (eg, a small improvement in pain in the absence of

any functional improvement) or benefits out of context. Citing beneficial cost

studies that used assumptions of noncoverage in a Canadian province to a US

payer that already has a moderately robust chiropractic benefit might be an

example. " Agendaism " may be naïve or overt. Of course, when evidence does

appropriately challenge one's own preconceived notions, the challenged party

might wrongly assume agendaism on the part of the challenger.

The evidentiary contest in which the health care system now finds itself

requires all parties to improve their understanding and application of evidence.

Adapting behavior to aptly grapple with what evidence tells us is perhaps the

highest priority. Clinicians must build time and routine into their workday to

consider evidence in individual care decisions, as well as constructively engage

administrative efforts to apply evidence to their decision making. Because it is

change, it is challenging, but the evolution is straightforward.

Within a clinical setting, becoming a consumer of research information is really

as easy as searching a free online database such as PubMed for articles on a

couple clinical conditions seen in the past week. Reading through abstracts on

recent literature may reveal new best practices or shed light on practices that

are not useful. Development of an " evidence culture " will prepare chiropractors

for adapting to the changes facing health care. Fig 2 outlines several examples

of what practitioners can do, individually and collectively, to increase their

comfort level with evidence and, thus, recognize its value and limitations for

practice.