Journal of Evaluation in Clinical Practice

Kunkler, I. H.

doi: 10.1046/j.1365-2753.1997.00001.xpmid: 9406104

Wide variations still exist in the UK in the management of common cancers in adults. Comprehensive high‐quality audit data are needed to relate variations in outcomes to differences in clinical management. The management of cancer in the elderly is often difficult due to co‐morbidity. Access to oncological advice should be available to all patients irrespective of age. Development of and adherence to nationally agreed treatment protocols is a key measure in reducing variations in treatment and in outcomes for patients with cancer.

Elwood, J. Mark

doi: 10.1046/j.1365-2753.1997.00002.xpmid: 9406105

Contrasting conclusions on the efficacy of routine breast cancer screening in younger women, under age 50, have been produced by expert and influential groups, particularly in the United States. In an international workshop in 1993, and again at a consensus development conference in 1997, the National Institutes of Health and the National Cancer Institute concluded that evidence for efficacy was uncertain, and routine screening could not be recommended. The 1997 conference concluded that the individual decision had to be made by each woman and her health care provider. In contrast, the American Cancer Society has advocated routine screening, despite accepting that the randomized trial evidence does not clearly support it. The decision of the 1997 NCI consensus conference has been rejected by the director of the NCI, and a similar controversy occurred in 1993. On two occasions, US Senate subcommittees have affirmed support for screening and criticized the conclusions of expert groups. In this paper, the arguments raised in these discussions, and the differing ways in which scientific evidence has been assessed, are discussed.

Davies, Huw Talfryn Oakley; Crombie, Iain Kinloch

doi: 10.1046/j.1365-2753.1997.00003.xpmid: 9406106

Interest in outcomes is universal. To patients, good outcomes represent their highest hopes for therapy; to health care professionals, good outcomes are the desired end‐point of a complex web of care. More recently, politicians and health care managers too have shifted their emphasis away from health service activity and towards what is termed ‘health gain’. The rise of the outcomes movement appears irresistible. However, the difficulties in interpreting outcomes data will not go away. Outcomes measured using routine data are subject to numerous biases and many practical difficulties. Despite recent statistical, methodological and technological advances, comparisons of outcomes at best provide us with weak evidence of either the effectiveness or the quality of health care. And sometimes they may frankly mislead. The apparent intuitiveness of outcomes monitoring has broad public appeal. But enthusiasm for outcomes needs to be tempered with a clear understanding of their limitations.

Upshur, Ross

doi: 10.1046/j.1365-2753.1997.00004.xpmid: 9406107

This paper argues that Gödel's proof does not provide the appropriate conceptual basis on which to counter the claims of evidence‐based medicine. The nature of, and differences between, deductive, inductive and abductive inference are briefly surveyed. The work of the American logician C.S. Peirce is introduced as a possible framework for a theory of clinical reasoning which can ground the claims of both evidence‐based medicine and its critics.

Clarke, Michael J.; Stewart, Lesley A.

doi: 10.1046/j.1365-2753.1997.00005.xpmid: 9406108

Systematic reviews of randomized controlled trials often provide the most reliable information on which to base treatment policy. However, to be reliable, such reviews need to contain a high proportion of all the relevant randomized evidence. This relates both to the need to find all trials and the need to analyse data on all participants. One way to achieve this is through a collaboration in which those responsible for the trials supply data on each randomized patient for an individual patient data meta‐analysis. However, such projects require more time and resources than more conventional reviews and are still rare. This paper illustrates how they can help to achieve the aim of using complete data in a systematic review.

Leape, Lucian L.

doi: 10.1046/j.1365-2753.1997.00006.xpmid: 9406109

Evidence from various sources indicates that a substantial number of hospitalized patients suffer treatment‐caused injuries. Most of these injuries result from errors. Yet physicians and other health professionals have been reluctant to admit and address the problem of errors, both because of feelings of guilt and from the desire to avoid punishment or disapproval by colleagues. Research in cognitive psychology and human factors has shown that most errors result from defects in the systems in which we work. These are failures in the design of processes, tasks, training, and conditions of work that make errors more likely. Meaningful reduction of errors requires correction of these systems failures. Barriers to reduction of errors include the complexity of health care systems, difficulties in information access, tolerance of stylistic practices, and fear of punishment that inhibits reporting. Most institutions also lack effective methods for detecting and quantifying errors. Significant improvements in error reduction will require major commitments by organizational leadership and the recognition that errors are evidence of deficiencies in systems, not deficiencies in people.

Herman, Joseph

doi: 10.1046/j.1365-2753.1997.00007.xpmid: 9406110

Some of the weaknesses of the randomized controlled trial (RCT) are pointed out, among them unavoidable biases, the possibility of coming to erroneous conclusions by the ‘luck of the draw’ and the fact that most such experiments lack a doctor/patient relationship and are of little assistance in clinical decision making. An exaggerated propensity on the part of the medical profession to regard the RCT as the only ‘scientific’ method for research into therapeutics is noted. The potential advantages of post‐marketing surveillance of new interventions in a physician‐centred manner are outlined. Such a data base could ultimately be expanded into a data base that records all activity in a given practice. The PACE strategy, employed by haematologists in the north of England, and the sentinel practice primary care research networks used by family doctors contain elements of the system proposed here. However, each possesses disadvantages that limit its applicability to special cases. Random choice of practices for any particular observational study of a new intervention could lend it some of the features of an experiment.

Hasson, Jack

doi: 10.1046/j.1365-2753.1997.00008.xpmid: 9406111

The theory of ‘necessary fallibility’, originated by Gorovitz & MacIntyre (1976, In Science, Ethics and Medicine, Hastings Center, NY), explains a major unfamiliar reason for unavoidable errors in medicine. A brief historical review is presented of autopsy studies assessing the accuracy of clinical diagnoses, and of changing perceptions of the public and physicians leading to the current misconception in the USA that all errors are avoidable. It is suggested that a prospective autopsy study is needed to test the theory of ‘necessary fallibility’. Validation of this theory would benefit an understanding of medical fallibility by the public and physicians, and challenge current practices in the management of malpractice and patient injury.

Kazandjian, Vahe A.

doi: 10.1046/j.1365-2753.1997.00009.xpmid: 9406112

Fowler, P. B. S.

doi: 10.1046/j.1365-2753.1997.00010.xpmid: 9406113

Academic medicine often seems to be swayed more by fashion than science. Establishment team consensus is only needed where there is ambiguity. Evidence‐based medicine is a new term for informed decision making and facilitated learning is purported to do away with authoritarian indoctrination. Problems that arise from the emphasis on team decisions, evidence‐based medicine and facilitated learning are discussed.