Dissertations / Theses on the topic 'Evidence-based medicine'
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Mann, Abbey. "Evidence Based Medicine." Digital Commons @ East Tennessee State University, 2018. https://dc.etsu.edu/etsu-works/6442.
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Blunt, Christopher. "Hierarchies of evidence in evidence-based medicine." Thesis, London School of Economics and Political Science (University of London), 2015. http://etheses.lse.ac.uk/3284/.
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Hierarchies of evidence are an important and influential tool for appraising evidence in medicine. In recent years, hierarchies have been formally adopted by organizations including the Cochrane Collaboration [1], NICE [2,3], the WHO [4], the US Preventive Services Task Force [5], and the Australian NHMRC [6,7]. The development of such hierarchies has been regarded as a central part of Evidence-Based Medicine (e.g. [8-10]), a movement within healthcare which prioritises the use of epidemiological evidence such as that provided by Randomised Controlled Trials (RCTs). Philosophical work on the methodology of medicine has so far mostly focused on claims about the superiority of RCTs, and hence has largely neglected the questions of what hierarchies are, what assumptions they require, and how they affect clinical practice. This thesis shows that there is great variation in the hierarchies defended and in the interpretations they are, and can be, given. The interpretative assumptions made in using hierarchies are crucial to the content and defensibility of the underlying philosophical commitments concerning evidence and medical practice. Once this variation is been identified, it becomes clear that the little philosophical work that has been done so far affects only some hierarchies, under some interpretations. Modest interpretations offered by La Caze [11], conditional hierarchies like GRADE [12-14], and heuristic approaches such as that defended by Howick et al. [15,16] all survive previous philosophical criticism. This thesis extends previous criticisms by arguing that modest interpretations are so weak as to be unhelpful for clinical practice; that GRADE and similar conditional models omit clinically relevant information, such as information about variation in treatments’ effects and the causes of different responses to therapy; and that heuristic approaches lack the necessary empirical support. The conclusion is that hierarchies in general embed untenable philosophical assumptions: principally that information about average treatment effects backed by high-quality evidence can justify strong recommendations, and that the impact of evidence from individual studies can and should be appraised in isolation. Hierarchies are a poor basis for the application of evidence in clinical practice. The Evidence-Based Medicine movement should move beyond them and explore alternative tools for appraising the overall evidence for therapeutic claims.
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Conocimiento, Dirección de Gestión del. "Evidence Based Medicine Reviews - EBMR." Wolters Kluwer, 2004. http://hdl.handle.net/10757/655292.
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Kerry, Roger. "Causation in evidence based medicine." Thesis, University of Nottingham, 2017. http://eprints.nottingham.ac.uk/40494/.
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Evidence based medicine (EBM) offers an established framework for the generation, interpretation, and utilisation of information in medicine and the health sciences. Central to the practice of EBM is, I argue, the notion of causation. This thesis makes an original contribution to the philosophy of EBM through a unique identification of a causal theory in EBM, and then by demonstrating a reconceptualised theory of causation better suited to evidence based person centred care. PART 1 of this thesis demonstrates that a very specific idea of causation can be witnessed within the structure of EBM. This idea is typically Humean. Through a consideration of the structure and textual narrative of EBM, it is proposed that the framework substantiates central and canonical claims. These claims relate to the core activity of EBM being the informing of clinical decision-making through the transference of causal claims from prioritised research methods. I argue that a Humean notion of causation is problematic for the central and canonical claims, thereby presenting a paradox – EBM is structured to inform clinical decision-making about causation but is inhibited from doing so by the way this very structure conceptualises causation. In PART 2 I argue for a reconceptualisation of causation that offers some solutions to the problems identified in PART 1. This theory relates to a dispositionalist ontology and takes causes to be derived from properties of an individual and as being things that merely tend towards an effect. Causes are seen as complex and context-sensitive, and whereby a traditional Humean account sees these factors as challenges to its epistemological reading, causal dispositionalism takes them as its starting point. To present this theory, desiderata are developed from existing narratives on EBM and elements of the theory set against these. In conclusion, I argue that if medicine and health care desire a framework of practice that is both evidence based and person centred, its causal theory must be reconceptualised. Causal dispositionalism offers an encouraging reconceptualisation.
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Vere, Joseph. "Evidence based medicine : a critical analysis." Thesis, University of Sheffield, 2018. http://etheses.whiterose.ac.uk/20659/.
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Evidence based medicine uses hierarchies of evidence to justify knowledge claims that are made. These knowledge claims are important because they dictate which treatment interventions are provided and funded, medicolegal standards and the medical research agenda. It is therefore interesting that different hierarchies can be used as this suggests that knowledge claims can be justified in different ways. This thesis presents a critical analysis of evidence based medicine, using the method of analytical philosophy, to improve understanding of the concept. The thesis is divided into two sections. In the first section a systematic review and thematic analysis of hierarchies of evidence is presented; the arguments used to rank systematic reviews, randomised controlled trials and expert opinion within hierarchies are analysed, and the properties used to rank different study designs are analysed. Five factors, independent of study design, that have influenced the development of hierarchies are then presented and it is argued that a lack of theoretical support for hierarchies has led to their proliferation. In the second section the claims that evidence based medicine is rational, science and a new Kuhnian paradigm are analysed. It is argued that evidence based medicine can be substantively rational but this means that knowledge claims can be both rational and inconsistent dependent upon any value commitments that are held. It is then argued that evidence based medicine cannot be science because it does not use scientific method and it cannot be a new Kuhnian paradigm because it is not science, it was not preceded by a revolutionary crisis and it is not incommensurable with previous versions of medicine. The analysis presented strips evidence based medicine of power and has important implications for the status of knowledge claims that are made.
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Rychetnik, Lucie. "Matters of Judgement: Concepts of evidence among teachers of medicine and public health." Thesis, The University of Sydney, 2001. http://hdl.handle.net/2123/2076.
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Introduction The aim of this study was to examine how the term “evidence” was conceived and used among academics and practitioners who teach medicine and public health. The rationale for the study was the widespread debate in the 1990s about evidence in health care. Methods Qualitative data were collected between 1996 to 1999. The core data came from unstructured interviews with researchers and practitioners linked to the Faculty of Medicine, University of Sydney. Other sources of data were: participant observation of group interactions in the Faculty of Medicine and at national and international conferences about evidence in health care; discourse in health care literature; and Internet posting to an international “evidence-based health” Email discussion list. The Grounded Theory method was adopted to analyse and interpret these data. The process involved systematic coding of the data to develop conceptual categories. These categories were employed to formulate propositions about the topic of evidence and how it was conceived and used by the study participants. Results Researchers and practitioners often discussed evidence from a “realist” view: that is they valued scientifically derived and rigorously substantiated knowledge about the natural world. Yet despite their widely shared epistemological perspectives, study participants presented several diverse concepts of evidence. Their ideas were also dynamic and evolving, and often influenced by the developing (local and international) debates and controversies about evidence-based medicine (EBM). Grounded Theory analysis leads to the selection of a core “social process”. This is a core conceptual category that draws together the ideas observed in the data, and that is adopted to present the study findings. In this study, “judgement” was identified as the core social process to underpin all examined reflections and discussions about evidence. Study participants defined the concept of evidence through a combination of description and appraisal. Evidence was described in three ways, i.e.: as a “measure of reality”, by its “functional role”, or as a “constructed product”. Evidence was also appraised on three “dimensions”, i.e.: “benchmarked”, “applied” and “social” dimensions of evidence. Participants invoked these concepts of evidence differently when forming their own judgements about medical or public health knowledge; when making decisions about clinical practice; and when using argument and persuasion to influence the judgements of others. Many researchers and practitioners also modified their judgements on evidence in the light of EBM. This was based on perceptions that EBM had become a dominant rhetoric within health care, which had the potential to channel the flow of resources. This led to an increasing consideration of the “social dimension” of evidence, and of the social construction and possible “misuse” of the term evidence. Conclusions The concept of evidence is presented in this study as a multi-dimensional construct. I have proposed that the three descriptions and three dimensions of evidence presented in this study, and recognition of the way these may be invoked when forming and influencing judgments, can be used as a basis for communicating about evidence in medicine and public health among colleagues and with students. There are significant gaps in knowledge (based on empirical research) about the social dimension of evidence. Particularly, in situations where researchers and practitioners wish to employ the concept of evidence to influence others’ medical and public health practice and wider social policy.
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Rychetnik, Lucie. "Matters of Judgement: Concepts of evidence among teachers of medicine and public health." University of Sydney, 2001. http://hdl.handle.net/2123/2076.
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Doctor of Philosophy (PhD)Introduction The aim of this study was to examine how the term “evidence” was conceived and used among academics and practitioners who teach medicine and public health. The rationale for the study was the widespread debate in the 1990s about evidence in health care. Methods Qualitative data were collected between 1996 to 1999. The core data came from unstructured interviews with researchers and practitioners linked to the Faculty of Medicine, University of Sydney. Other sources of data were: participant observation of group interactions in the Faculty of Medicine and at national and international conferences about evidence in health care; discourse in health care literature; and Internet posting to an international “evidence-based health” Email discussion list. The Grounded Theory method was adopted to analyse and interpret these data. The process involved systematic coding of the data to develop conceptual categories. These categories were employed to formulate propositions about the topic of evidence and how it was conceived and used by the study participants. Results Researchers and practitioners often discussed evidence from a “realist” view: that is they valued scientifically derived and rigorously substantiated knowledge about the natural world. Yet despite their widely shared epistemological perspectives, study participants presented several diverse concepts of evidence. Their ideas were also dynamic and evolving, and often influenced by the developing (local and international) debates and controversies about evidence-based medicine (EBM). Grounded Theory analysis leads to the selection of a core “social process”. This is a core conceptual category that draws together the ideas observed in the data, and that is adopted to present the study findings. In this study, “judgement” was identified as the core social process to underpin all examined reflections and discussions about evidence. Study participants defined the concept of evidence through a combination of description and appraisal. Evidence was described in three ways, i.e.: as a “measure of reality”, by its “functional role”, or as a “constructed product”. Evidence was also appraised on three “dimensions”, i.e.: “benchmarked”, “applied” and “social” dimensions of evidence. Participants invoked these concepts of evidence differently when forming their own judgements about medical or public health knowledge; when making decisions about clinical practice; and when using argument and persuasion to influence the judgements of others. Many researchers and practitioners also modified their judgements on evidence in the light of EBM. This was based on perceptions that EBM had become a dominant rhetoric within health care, which had the potential to channel the flow of resources. This led to an increasing consideration of the “social dimension” of evidence, and of the social construction and possible “misuse” of the term evidence. Conclusions The concept of evidence is presented in this study as a multi-dimensional construct. I have proposed that the three descriptions and three dimensions of evidence presented in this study, and recognition of the way these may be invoked when forming and influencing judgments, can be used as a basis for communicating about evidence in medicine and public health among colleagues and with students. There are significant gaps in knowledge (based on empirical research) about the social dimension of evidence. Particularly, in situations where researchers and practitioners wish to employ the concept of evidence to influence others’ medical and public health practice and wider social policy.
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Ivander, Christin, and My Olsson. "Webbplats för kursen EBM : Evidence Based Medicine." Thesis, Blekinge Tekniska Högskola, Sektionen för teknokultur, humaniora och samhällsbyggnad, 2005. http://urn.kb.se/resolve?urn=urn:nbn:se:bth-3757.
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Vi har gjort vårt kandidatarbete på en webbyrå i Stockholm som heter Boman Communication. Där har vi gjort en databasdriven webbplats i flash och asp. Webbplatsen är ett komplement till en kurs som heter EBM. Kursen EBM hålls av myndigheten SBU som i sin tur är en kund till Boman. Målgruppen för EBM och därmed också webbplatsens målgrupp är bland annat professorer och läkare inom medicin och vård. På kursen tar man upp riktlinjer för hur man botar olika sjukdomar eller skador. Webbplatsen innehåller information om och till kursen. Den är uppdelad i tre delar: Allmän, Före kursen och Efter kursen. Den allmänna delen är till för att väcka ett intresse för kursen hos besökaren. Denna del kommer alla åt. De två övriga delarna kräver inloggning och är bara till för dem som anmält sig på kursen. Inloggningen är datumstyrd vilket innebär att när kursen inte har varit ännu kommer man till delen före kursen och när kursen har varit kommer man till delen efter kursen. Före kursen hittar man information på webbplatsen som man bör ta del av för att förereda sig till kursen, man kan även finna information om föreläsarna och övriga kursdeltagare. Efter kursen är webbplatsen uppdaterad med en sida för dokumentation som föreläsarna har rekommenderat, här finns även en utvärdering som kursdeltagarna uppmanas att fylla i. Vi har framförallt använt oss av programmen Macromedia Flash MX 2004 och Macromedia Dreamweaver MX 2004 men även program som Adobe Photoshop CS, Adobe Illustrator CS.Detta är en reflektionsdel till en digital medieproduktion.
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Smith, Luisa J. "Evidence-based medicine in equine clinical practice." Thesis, University of Glasgow, 2006. http://theses.gla.ac.uk/5004/.
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The principles of Evidence-Based Medicine (EBM) have been well documented in the medical literature, with many examples of the successful application of these principles to the clinical environment. Despite this widespread acceptance of these principles throughout the medical profession, there has been resistance to adopt such an approach in the veterinary profession. To date, there are. few examples in the literature of the application of the principles of evidence-based medicine to either clinical or scientific research. The aim of this study was to design a series of investigations of equine diseases, and implement them at three private equine hospitals. A variety of study designs were used, providing different classes of evidence when using the classification system proposed by Yusuf et al. (1998). The main focus of this investigation was to ascertain whether it was possible to apply the ethos of EBM to the veterinary profession, and provide good quality research and evidence form private practice. It was found that 85.6% of horses (95% c.l. 81.3 to 89.3) treated for septic arthritis were successfully discharged from the hospital, with 65% of these horses (95% C.l. 57.9 to 71.6) able to return to their previous level of athletic function. When considering those horses treated for septic digital tenosynovitis, 87.8% survived to be discharged from the hospital. However, the prognosis for future soundness was poorer than that achieved following resolution of septic arthritis, with only 50% of horses treated for septic digital tenosynovitis able to return to their previous level of athletic function. Racing Thoroughbreds, both neonates and mature horses, were identified as an important subset of the population. It was found that the occurrence of septic arthritis in neonatal Thoroughbreds significantly reduced the likelihood of those foals going on to make at least one start on a racecourse, with those foals being 3.5 times less likely to start on a racecourse when compared to their siblings. In contrast, when considering mature Thoroughbred racehorses it was found that the occurrence of septic arthritis did not affect the likelihood that they would make at least one start on a racecourse when compared to their siblings, or be able to achieve an Official Rating awarded by the British Horseracing Board's handicappers equal to, or higher than, either the highest rating achieved prior to the onset of sepsis in cases in which horses had raced previously, or equal to the highest rating achieved by their siblings. In a controlled, randomised trial it was found that 31.6% (95% c.l. 17.5 to 48.7) of horses wearing a belly band following an exploratory laparotomy developed incisional complications, compared with 76.6% (95% c.I. 62.0 to 87.7) of horses where no belly band was used. If a belly band was used following an exploratory laparotomy, the risk of developing post-operative incisional complications was reduced by 45% compared to those cases where no belly band was used. Following a clinical audit of elective surgical procedures at three private equine hospitals, there was found to be a higher rate of post-operative complications, when compared to results reported in both the medical and small animal veterinary literature. It was concluded that it was possible to apply the ethos of EBM to the veterinary profession, and provide good quality research and evidence from research performed in private practice. However, in order to be able to achieve sufficient case numbers to provide answers that are directly relevant to practice-based clinical situations, multi-centre studies are likely to be the best way forward.
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Yip, Yun-chi, and 葉潤芝. "Barriers to implement evidence-based Chinese medicine." Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2011. http://hub.hku.hk/bib/B46373524.
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Waters, Donna. "Evidence : the knowledge of most worth." University of Sydney, 2006. http://hdl.handle.net/2123/1903.
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Doctor of PhilosophySimilar to their colleagues throughout the world, nurses and midwives in New South Wales (NSW), Australia, welcome evidencebased practice (EBP) as a means to improve patient or client outcomes. This thesis explores the way nurses and midwives understand evidence for EBP and aims to determine whether members of these professions currently have the knowledge and skills necessary to implement evidence‐based care. Three separate studies were conducted to explore NSW nurses’ readiness for EBP. Attitudes, knowledge and skill were investigated using an EBP questionnaire returned by 383 nurses. The views of 23 nursing opinion leaders were elicited during qualitative in‐depth interviews, and their ideas on maximising the potential for future nurses to confidently engage in EBP were explored. Current approaches to teaching EBP in undergraduate nursing programs were investigated by examining documents issued by NSW nursing education providers. The results demonstrate many differences between the ways NSW nurses currently understand evidence for EBP, and a range of approaches to teaching EBP in undergraduate nursing programs. Under current conditions, nurses graduating from universities in NSW commence practice with varying levels of preparation for EBP and enter into a professional arena that is itself struggling to cope with the concepts and language of this approach to improving healthcare. v Evidence for the effectiveness of EBP is slowly accumulating and despite some small positive signs, the collective results of this thesis suggest that current educational approaches are not capable of producing the kind of results that are both necessary and desirable for the promotion of evidence‐based nursing practice in NSW. Articulating a commitment to EBP, using a common language and a consistent approach are among the recommendations made for the future promotion of EBP in nursing education.
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Turner, Andrew James. "Evidence-based medicine, "placebos" and the homeopathy controversy." Thesis, University of Nottingham, 2012. http://eprints.nottingham.ac.uk/12577/.
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Homeopathic treatment has been available on the UK’s National Health Service (NHS) since 1948. In recent years the continued provision of homeopathy through the NHS has been increasingly questioned as part of the ascendency of evidence-based medicine (EBM). Indeed, in 2009 the House of Common’s Science and Technology committee commenced an ‘Evidence Check’ inquiry into Government policy supporting the NHS provision of homeopathic treatments. The controversy over whether homeopathic treatments ‘really’ work and whether they should be available through the NHS has generated much debate: at the heart of the controversy are questions about the nature of evidence in medicine, the validity of randomised trials and the nature and utility of ‘placebo effects’. Critics of homeopathy put forward the simple argument that best available evidence shows homeopathic treatments to be equivalent to placebo, and therefore conclude that it should not be available through publically funded healthcare. This thesis presents a critical examination of the concepts of EBM and ‘placebos’ and re-evaluates their role in the controversy around homeopathy. This thesis examines what kind of foundation the EBM philosophy of evidence provides for the arguments made in the controversy, and the role that ‘placebos’ play as both an evidential and normative standard. There are two basic arguments: first, that the arguments justifying the EBM philosophy of evidence are fundamentally unclear, but also that the interpretation given to EBM, in debates about homeopathy, cannot be sustained. Second, that the concept of ‘placebos’ should be abandoned entirely: a framework is developed for talking about the effectiveness of treatments that removes much confusion about the epistemological and ethical standards that effective treatments should be held to. In addition to attempting to provide conceptual clarity to the controversy, the main conclusion is that the Science and Technology Committee have (on the basis of their own assumptions) understated their evidential arguments, by ignoring mechanistic evidence for whether homeopathic treatments are effective, and they have overstated their ethical arguments, they do not provide good reasons to remove provision of homeopathic treatment through the NHS.
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Costanzo, Pierluigi. "Strategies for cardiovascular prevention by evidence based medicine." Thesis, University of Hull, 2015. http://hydra.hull.ac.uk/resources/hull:14574.
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Cardiovascular prevention aims to early identify patients at higher risk of developing a cardiovascular event, Prompt identification and treatment of those can potentially reduce the risk of events to occur. The purpose of this study was to assess the efficacy of drug therapy in primary and secondary cardiovascular prevention using the evidence based medicine approach. In the first part of this thesis, the focus is on the role of two main surrogate end points for cardiovascular events, for which the prognostic role is still unclear (serial measurement of carotid intimamedia thickness (IMT) and left ventricular hypertrophy (LVH)). In the second part, the efficacy of drug therapy strategies for cardiovascular events prevention is assessed for three topics lacking of clear evidence: 1) Calcium Channel Blockers (CCBs) and clinical outcomes 2) The role of Ace Inhibitors (ACE-Is) vs Angiotensin Receptor Blockers (ARBs) in patients without left ventricular systolic dysfunction 3) The efficacy of statin therapy in primary prevention according to the gender. Literature review was performed by collecting all the articles relevant to the objectives of the study. A meta-regression analysis was performed to test the relationship between serial IMT or LVH changes and clinical outcomes. A meta-analysis was performed to calculate the overall estimates of effect of ACE-Is vs ARBs in patients without heart failure, of CCBs in hypertension or coronary artery disease and of statins in primary prevention according to gender. A publication bias test and sensitivity analysis were also performed. The results showed that neither carotid IMT or LVH change predict the risk of cardiovascular events. Furthermore, CCBs reduced the risk of myocardial infarction and were more effective than ACE-Is in preventing stroke, however they are possibly less effective than other medications in preventing heart failure. In patients without heart failure, ARBs were not as effective as ACE-is in reducing cardiovascular outcomes. Finally, statins in primary prevention of coronary heart disease appeared more effective in men than in women.
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Brown, Bernadette. "Clinician-Led Improvement in Cancer Care (CLICC): Complementing Evidence-Based Medicine with Evidence-Based Implementation." Thesis, The University of Sydney, 2016. http://hdl.handle.net/2123/15660.
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This thesis explores whether a multifaceted intervention implemented through the NSW Agency for Clinical Innovation (ACI) Urology Clinical Network can improve the rates of referral of men with high-risk prostate cancer post-radical prostatectomy for consideration for adjuvant radiotherapy in line with clinical practice guideline recommended care. It comprises seven iterative studies that address urologists’ knowledge, attitudes and equipoise for the use of adjuvant radiotherapy for high-risk prostate cancer, the development of a clinical network embedded intervention and the evaluation of this intervention within a step-wedge cluster randomised trial ‘Clinician-Led Improvement in Cancer Care (CLICC)’ (NHMRC Partnership Grant 1011474; Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910). The thesis found some evidence that the CLICC intervention resulted in desired practice change. Results are presented within the context of the CLICC conceptual program logic framework and are interpreted in relation to knowledge, attitudes and beliefs in the wider urological community. The thesis concludes with consideration of how findings could be translated to the implementation of other clinical practice guideline recommendations.
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Conocimiento, Dirección de Gestión del. "Guía de acceso para Evidence Based Medicine Reviews (EBMR)." Wolters Kluwer, 2021. http://hdl.handle.net/10757/655292.
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Flores, Sepulveda Luis Jose. "Clinical judgement in the era of evidence based medicine." Thesis, King's College London (University of London), 2017. https://kclpure.kcl.ac.uk/portal/en/theses/clinical-judgement-in-the-era-of-evidence-based-medicine(d05f12b7-05fd-45a2-b1ff-78060d1d8520).html.
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“Evidence Based Medicine” (EBM) urges that medical recommendations be based on the best research evidence, rather than on clinical judgement. While I strongly endorse attention to relevant research evidence, I argue that the related downplaying of clinical judgement is a step backwards. This is because actual models of EBM encourage physicians to focus exclusively on research probabilities and so to neglect relevant information about patients. I call this feature of EBM the “Problem of Extra Information” (PEI), and contend that it leads to predictions and prescriptions based on the wrong probabilities. The PEI has been largely neglected by EBM, which has construed the challenge of clinical care as a matter of developing better research evidence, and of reminding physicians to attend to patients’ preferences and values. And although meritorious attempts have been made to connect research with individuals through sophisticated methodological improvements, these only address the PEI partially, and do not eliminate the need for clinical discretion. In this dissertation I contend that, in response to the PEI, clinical medicine requires a more Discretionary Approach (DA). This approach recognizes that the objective probabilities that matter for clinical recommendations are those in the reference class defined by everything the physician knows about the patient, and argues that the central role for judgment in clinical practice is to estimate these probabilities. So understood, the DA has two main advantages over the EBM approach: prudential adequacy and evidential flexibility. My defence of the DA consists of addressing criticisms of the role ascribed to judgment and clinical experience within this approach. The final two chapters of this doctoral dissertation complement my arguments with two meta-analytical empirical studies: one which compares “therapeutic guidelines based on evidence” with “usual care” with respect to patients’ outcomes, and another which examines the relative predictive performance of statistical models and physicians’ judgment in the context of diagnosis and prognosis. These studies refute previous evidence cited against judgment and vindicate the plausibility of the Discretionary Approach to clinical care.
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Tudiver, Fred, Jeri Ann Basden, and Ivy A. Click. "Bringing Family Medicine Residents into the Future: Integrating Evidence-Based Quality Improvement into a Family Medicine Residency." Digital Commons @ East Tennessee State University, 2010. https://dc.etsu.edu/etsu-works/6404.
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Deppe, Maren. "Umsetzung der "evidence based medicine" anhand der perkutanen transforaminalen Sequestektomie." [S.l.] : [s.n.], 2004. http://www.diss.fu-berlin.de/2004/217/index.html.
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Rexhepi, Hanife. "Improving healthcare information systems : A key to evidence based medicine." Licentiate thesis, Högskolan i Skövde, Institutionen för informationsteknologi, 2015. http://urn.kb.se/resolve?urn=urn:nbn:se:his:diva-11019.
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Delivering good quality care is a complex endeavor that is highly dependent on patient information and medical knowledge. When decisions about the care of a patient are made, they must, as far as possible, be based on research-derived evidence rather than on clinical skills and experience alone. Evidence based medicine (EBM) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise as well as patient values and preferences to guide healthcare decisions. Following the principles of EBM, healthcare practitioners are required to formulate questions based on patients’ current clinical status, medical history, values and preferences, search the literature for answers, evaluate the evidence for its validity and usefulness, and finally apply the information to the patient. Information systems play a crucial role in the practice of evidence based medicine, by allowing healthcare practitioners to access clinical evidence and information about the patients’ health as they formulate their patient-care strategies. However, current information systems solutions are far from this perspective for various reasons. One of these reasons is that existing information systems do not support a seamless flow of patient information along the patient process. Due to interoperability issues, healthcare practitioners cannot easily exchange patient information from one information system to another and from one healthcare practitioner to another. Consequently, vital information that is stored in separate information systems and which could present a clear and complete picture of the patient cannot be easily accessed. All too often, units have to operate without knowledge of the problems addressed by other healthcare practitioners from other units, the services provided, medications prescribed, or preferences expressed in those previous situations. The practice of EBM is further complicated by current information systems that do not support practitioners in their search and evaluation of current evidence in everyday clinical care. Based on a qualitative approach, this work aims to find solutions for how future healthcare information systems can support the practice of EBM. By combining existing research on process orientation, knowledge management and evidence based medicine with empirical data, a number of recommendations have been initiated. These recommendations aim to support healthcare managers, IT–managers and system developers in the development of future healthcare information systems, from a process-oriented and knowledge management perspective. By following these recommendations, it is possible to develop information systems that facilitate the practice of evidence based medicine, and improve patient engagement.
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Poerschke, Gabriele. "Key issues of evidence-based vaccinology as illustrated by pneumococcal vaccine development." Thesis, Click to view the E-thesis via HKUTO, 2001. http://sunzi.lib.hku.hk/hkuto/record/B3197076X.
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Yuen, Kam-tong. "How to promote evidence-based practice (EBP) in clinical oncology by the continuous quality improvement approach." Click to view the E-thesis via HKUTO, 2005. http://sunzi.lib.hku.hk/hkuto/record/b39724323.
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Yuen, Kam-tong, and 袁錦堂. "How to promote evidence-based practice (EBP) in clinical oncology by the continuous quality improvement approach." Thesis, The University of Hong Kong (Pokfulam, Hong Kong), 2005. http://hub.hku.hk/bib/B39724323.
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Kelly, Gregory Patrick. "Influences that affect the clinical reasoning of paediatric occupational therapists : the importance of articulating personal models of practice." Thesis, University of Ulster, 2003. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.270450.
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Polaha, Jodi, Jennifer Funderburk, Andrea Auxier, and Jeff Goodie. "Evidence Based? Prove It! Real World Strategies for Showing Your Work.. Works!" Digital Commons @ East Tennessee State University, 2014. https://dc.etsu.edu/etsu-works/6581.
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Do you want to demonstrate the significance or vaIue of your integrated program? In this presentation, four researchers will tell their stories about how they collected good data in "real world" clinic settings. Practical recommendations will be provided for getting started in program evaluation in a way that will impact not only your developing program but also the field of integrated care. The audience will have the opportunity to frame their own questions and begin developing methods with feedback.
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Maigeh, Elias Peterson. "The perceived attitudes, knowledge and barriers towards evidence-based practice (EBP) amongst physiotherapists in the United Republic of Tanzania." Thesis, University of the Western Cape, 2004. http://etd.uwc.ac.za/index.php?module=etd&.
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There has recently been an increased pressure in all-healthcare disciplines to provide interventions that are scientific, safe, efficient and cost-effective. Evidence-based practice is said to be the current best approach to address these attributes. All healthcare professionals including physiotherapists need to adopt it. Numerous physiotherapy studies have been carried out to ascertain the attitudes towards, knowledge of, engagement in as well as the barriers of evidence-based practice. These studies were mostly carried out in the developed countries and almost none in the devloping African countries. By means of an exploratory cross-sectional study, deploying both quantitative and qualitative methods, this study investigated the Tanzanian physiotherapists attitudes towards the concept of evidence-absed practice. The study also examined the knowledge that they possess, that could enable them engage in evidence-based related activities. In addition, this study explored the barriers they experience while practicing evidence-based practice.
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Wagh, Sunil Dinakarpandian Deendayal. "Semantic templates for summarizing the results from evidence based medicine analysis." Diss., UMK access, 2006.
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Thesis (M.S.)--School of Computing and Engineering. University of Missouri--Kansas City, 2006."A thesis in computer science." Typescript. Advisor: Deendayal Dinakarpandian. Vita. Title from "catalog record" of the print edition Description based on contents viewed Jan. 29, 2007. Includes bibliographical references (leaves 47-51). Online version of the print edition.
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Denagamage, Thomas Nishantha. "Application of evidence-based medicine to veterinary science and food safety." [Ames, Iowa : Iowa State University], 2008.
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Pope, Catherine Jane. "Assessing evidence based medicine : an investigation of the practice of surgery." Thesis, London School of Hygiene and Tropical Medicine (University of London), 1999. http://researchonline.lshtm.ac.uk/682272/.
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Objectives: The thesis seeks to provide an analysis of surgical work and decision making, to identify the basis of the widely observed variation in surgical practice and to indicate what surgeons see as the source(s) of that variation. Against this background, it examines the strengths and limitations of the approach promoted by the evidence-based medicine movement to surgical work. Methods: A qualitative study of surgical practice by urological and gynaecological surgeons in England and the USA involved in the treatment of female urinary stress incontinence. Depth interviews with 29 English surgeons and five American surgeons. Interviews were recorded and transcribed. Observation of 23 operations and additional ethnographic data collection at the hospitals and clinics where these surgeons worked. The observational data consist of near verbatim notes. All these data were analysed using the constant comparative approach described by Glaser and Strauss (1967). A variant of the split-half technique was used to test emerging themes. Results: Surgical practice is contingent: it is dependent on a range of variables, and, it is serendipitous. Three categories of contingency are identified (case, surgeon and external contingency). It is argued that surgical practice entails the complex interplay of these conditional factors and chance happenings. In order to learn to deal with contingency, surgeons learn or acquire practice skills through first hand experience. The thesis explores the role of the surgical apprenticeship and models of learning used by surgeons. Conclusion: The nature of surgical practice presents some fundamental challenges to EBM. The contingent and experiential features of surgical work raise serious doubts about the applicability of EBM to surgery.
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Grenet, Guillaume. "Challenges in personalized evidence-based medicine, applications in type 2 diabetes." Thesis, Lyon, 2019. https://n2t.net/ark:/47881/m62f7ms7.
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La médecine basée sur les preuves requiert des essais cliniques randomisés, qui permettent d'estimer un effet moyen du traitement. La personnalisation de l'estimation de l'effet du traitement nécessite l'estimation du risque spontané de la maladie (biomarqueur pronostique), la recherche de facteurs modifiant l'effet du traitement (biomarqueur théranostique). Des critères de substitution sont également proposés, dont la mesure devrait permettre d'évaluer l'effet du traitement sur l'événement clinique. La prise en charge des patients présentant un diabète de type 2 repose sur les médicaments hypoglycémiants. Plusieurs d'entre eux ont été associés à différents effets indésirables graves. Des études évaluant leur bénéfice cardiovasculaire sont nécessaires. La prise en charge de ces patients inclue également la prise en charge de l'hypertension artérielle. Celle-ci est basée sur des médicaments antihypertenseurs, dont l'intensité est ajustée au niveau de pression artérielle recherché. Cette stratégie basée sur la cible soulève plusieurs questions. Enfin, plusieurs biomarqueurs prédictifs de différents effets des médicaments hypoglycémiants ont été étudiés chez des patients présentant un diabète de type 2, avec des résultats contrastés. Une difficulté majeure dans la validation de biomarqueur théranostique est la puissance statistique nécessaire pour détecter une interaction dans un essai clinique randomisé. L'objectif de cette thèse était d'estimer les effets moyens des traitements hypoglycémiants sur les complications cardiovasculaires ; d'évaluer un potentiel critère de substitution ; et d'étudier les caractéristiques des études cliniques évaluant des biomarqueurs théranostiques. La première partie présente une méta-analyse en réseaux comparant les effets des hypoglycémiants contemporains chez des patients avec un diabète de type 2, sur la mortalité totale, cardiovasculaire et les évènements cardiovasculaires majeurs. Nous avons confirmé la supériorité des gliflozines et des agonistes du récepteur au GLP1 par rapport au traitement contrôle et aux inhibiteurs de la DPP4. Nous avons montré le besoin de comparaisons directes entre les différentes classes, notamment pour préciser la place de la metformine dans la stratégie thérapeutique. La deuxième partie présente une méta-régression évaluant l'association entre la diminution de la pression artérielle par des médicaments antihypertenseurs et les évènements cardiovasculaires majeurs. Nous avons confirmé la relation entre la baisse de la pression artérielle et le risque d'accident vasculaire cérébrale. Il n'y avait pas d'association avec la mortalité totale, la mortalité cardiovasculaire, les infarctus du myocarde. La troisième partie présente une comparaison statistique du plan expérimental en cross-over par rapport au plan en bras parallèle, concernant leur capacité à évaluer un marqueur théranostique. Nous avons montré que l'intérêt du cross-over, pour réduire le nombre de sujet nécessaire, dépend de la corrélation intra-sujet de la mesure du critère de jugement choisi, de façon similaire à l'estimation de l'effet propre du traitement. Ce travail met en lumière le besoin de comparaisons des médicaments hypoglycémiants sur les complications cardiovasculaires, et la difficulté d'évaluer une balance bénéfice—risque d'un traitement. Des approches de méta-analyses sur données individuelles permettraient de mieux estimer l'impact du contrôle glycémique sur les complications cardiovasculaires. L'accès aux technologies de séquençage du génome à haut débit permettrait d'identifier des facteurs pronostiques et théranostiques. Finalement, nous proposons une extension du modèle d'effet, qui permet d'appréhender la balance bénéfice—risque d'un traitement en fonction de différents biomarqueurs. L'évaluation d'un effet traitement moyen ou stratifié doit s'inscrire dans une vision globale de la balance bénéfice—risque du médicament concernéEvidence based medicine requires randomized clinical trials for estimating a mean treatment effect. The personalization of this treatment effect needs prognostic biomarker for assessing the spontaneous risk of the disease and the absolute benefit of the treatment; and the search for potential theranostic biomarker, associated with a different relative treatment effect. Surrogate endpoints are also proposed, as their measure would reflect the treatment effect on the clinical outcome of interest. Taking care of patients with type 2 diabetes is based on hypoglycemic drugs. Several of them have been retrospectively associated with serious adverse events. They need to be assessed with cardiovascular outcome trials. Taking care of those patients also include handling other cardiovascular risk factor, as high blood pressure. Antihypertensive treatment is based on a “target to treat” strategy, which raise several questions. Finally, many theranostic biomarkers of the hypoglycemic drugs effect have been studied, with conflicting results. Statistical power is a high challenge in randomized trial looking for such interaction. We aimed to provide a mean treatment effect estimation of hypoglycemic drugs on cardiovascular outcomes and to explore potential tools for personalizing the treatment effect estimation. The first part of this thesis reports a network meta-analysis assessing the contemporary hypoglycemic drugs in type 2 diabetes patients on overall mortality, cardiovascular mortality and major adverse cardiovascular events. We confirmed the superiority of SGLT2 inhibitors and of GLP1 receptor agonists compared to control and to DPP4 inhibitors. We also showed the need for direct comparison, especially for clarifying the position of metformin in the pharmacological strategy. The second part of this thesis reports a meta-regression analysis, assessing the association between the decrease in blood pressure through antihypertensive drugs and the risk of cardiovascular events. We confirmed the association between the blood pressure control and the risk of stroke, but did not find any association regarding overall mortality, cardiovascular mortality and myocardial infarction. The third part reports a statistical comparison of the parallel group design and the cross-over design, regarding their capacity to assess a potential theranostic biomarker. We showed that the advantage of the cross-over for reducing the sample size lead on the intra-subject correlation, as already known for estimating the treatment effect. Finally, we highlighted the need for comparisons of hypoglycemic drugs for preventing macrovascular events. We emphasized pitfalls in estimating benefit—risk balance. Individual patient data meta-analyses would help better assessing the effect of glucose control on macrovascular events. High-throughput genome sequencing technologies would help to identify both prognostic and theranostic biomarkers. Lastly, we proposed an extended version of the effect model, which allow to grasp the benefit—risk balance of a treatment, according to different biomarkers. To conclude, assessing a mean and a stratified treatment effect should be conducted taking into account the global benefit—risk balance estimation
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Holt, Jim. "Evidence-Based Nutritional Recommendations: Vitamins C and E." Digital Commons @ East Tennessee State University, 2015. https://dc.etsu.edu/etsu-works/6463.
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Bowers, Candice Andrea. "Barriers to implementation of evidence-based practices in a critical care unit." Thesis, Nelson Mandela Metropolitan University, 2013. http://hdl.handle.net/10948/d1013612.
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Over the last three decades there has been a greater need for health care practitioners to base their decision on the best available in order to optimise quality and cost-effective patient care. Evidence-based practice necessitates guideline development, education and review in order to achieve improved patient outcomes. However, initiatives that endeavour to disseminate and implement evidence-based practice have faced barriers and opposition. Barriers that might hamper the implementation of evidence-based practice include characteristics of the evidence itself, personal, institutional or organizational factors. The research study explored and described the barriers to implementation of evidence-based practices in a critical care unit. Based on the data analysis, recommendations were made to enhance the implementation of evidence-based practices in the critical care unit. A quantitative, explorative, descriptive and contextual research design was used to operationalize the research objectives. The target population comprised professional nurses in the critical care unit. Non-probability sampling was used to obtain data by means of a structured self-administered questionnaire. Descriptive data analysis was applied, using a statistical programme and the aid of a statistician. The results are graphically displayed using bar graphs and tables. Recommendations for nursing practice, education and research were made. Ethical principles have been maintained throughout the study.
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Al-Ojaimi, Abdulkarim. "Evidence based models for evaluating operating room performance." Thesis, Cardiff University, 2012. http://orca.cf.ac.uk/47338/.
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The operating room (OR) within a hospital environment is one of the most expensive functional areas, yet the use of the OR also provides hospitals with an essential source of income. However, at present, there are variations on how to evaluate the performance of ORs, since there is no clear and full explanation of the concept and methods used for evaluation. The overall aim of this thesis is to develop an evidence based Operating Room Assessment Framework (ORAF) to evaluate Operating Room performance with clear and complete guidelines that can be used by operating room managers, directors or any other medical professionals to evaluate operating room performance, determine OR planning and scheduling efficiency, OR workload and OR utilization. The resulting Operating Room Assessment Framework will assist targeted healthcare professionals in their quest to evaluate, monitor and improve overall Operating Room efficiency. The OR management systems of eight tertiary and teaching hospitals in three countries (Japan, Canada and Saudi Arabia) have been examined from 2010 to 2012, which include more than 98,500 procedures. The Operating Room Assessment Framework (ORAF) involves three important elements of Operating Room performance, namely: OR scheduling level, the type of OR workload, and OR utilization. These elements can simply be read to reach the end result, which includes three types of scheduling levels: under scheduling, ideal scheduling and over scheduling; five types of OR workload: OR total workload (the gross workload), OR actual workload, over workload, unnecessary workload and unexpected workload; and three types of OR utilization: underutilization, ideal utilization, and 100% utilization with over workload. Through the validation process in different hospital contexts, the ORAF has proven its ability to perform satisfactorily, with accuracy, in line within the research’s objectives.
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Tahiri, Hassani Youssef. "Improving breast reconstruction outcomes: an evidence-based analysis." Thesis, McGill University, 2011. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=103554.
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Background: As breast reconstruction evolves, plastic surgeons continue to find ways to improve their reconstruction' outcomes. The aim of our study is to demonstrate how plastic surgery research impacts and improves current surgical practices. For instance, we designed three clinical studies which illustrate how research can affect current popular surgical practices, not only during the pre-operative period, but also intra-operative and post-operative periods. Methods: In the first study, we performed a meta-analysis to evaluate first the safety and efficacy of Thoracic ParaVertebral Block (TPVB) for breast surgery, and then to compare TPVB to General Anesthesia (GA) with regards to postoperative pain, nausea and vomiting, opioid consumption and length of hospital stay. To do so, an electronic and manual search of English- and French- language articles on TPVB in breast surgery (published up to June 2010) was performed. Two levels of screening were used to identify relevant articles. The Mantel-Haenszel method (fixed effect) was used to perform the meta-analysis.In the second study, we performed a systematic review to evaluate the existing literature, comparing the use of drains or not in reduction mammaplasty. We assessed first, if there is enough evidence to reach a conclusion regarding the routine use of drains after reduction mammaplasty, and then, if there is a need for more randomized control trials. To do so, we searched PubMed, EMBASE, the Cochrane Central Database of Clinical Trials (CENTRAL) on the Cochrane Library and Science Citation Index Expanded for original articles and reviews from January 1980 to June 2009. Finally, in the third study, we are presenting our clinical experience of using subcutaneous breast tissue expansion prior to reconstruction with Deep Inferior Epigastric Perforator (DIEP) flaps, and we are showing how our new technique eliminates the patch-like appearance of the skin paddle. We developed this technique; surgical technique that was never described or presented before. Over the past 2 years (January 2008 – January 2010), five patients underwent breast reconstruction using this three-stage approach. Retrospective analysis of patients' characteristics, breast history, surgical stay, complications and outcomes were performed. Results: Our first study demonstrated that pre-operative TPVB provides effective anesthesia for ambulatory / same-day breast surgery and can result in significant benefits over GA. However further studies are required to determine if these advantages would still persist if an optimal technique for outpatient GA is employed. Adjunctive ultrasonography may contribute to improve the safety of TPVB in breast surgery and requires further investigation.Our second study, we demonstrated that although placement of intra-operative drains after reduction mammaplasty is common practice, it should not be used routinely in reduction mammaplasty. Further randomized controlled trials are not warranted. Finally, our third study demonstrated how innovation in plastic surgery research can improve the final, post-operative aesthetic outcome. Subcutaneous breast tissue expansion followed by DIEP flap reconstruction can be performed safely, offering patients a completely autologous breast reconstruction with low morbidity, as well as eliminating the classical patch-like appearance of flap reconstructions.Conclusion:These three different studies illustrate how plastic surgery research can have an impact on breast reconstruction outcomes. The first two studies demonstrate with a strong level of evidence (meta-analysis and systematic review, respectively) that established pre-operative and post-operative factors can be changed for the benefit of the patient. Finally, we demonstrated how surgical technique innovation can improve the post-operative outcome.Contexte: Avec l'évolution de la chirurgie reconstructive du sein, les chirurgiens plasticiens continuent de trouver des moyens d'améliorer leurs reconstructions. Le but de notre étude est de démontrer, à travers trois études cliniques, comment la recherche en chirurgie plastique peut améliorer les pratiques chirurgicales courantes, durant les périodes pré-, intra- et postopératoires. Méthodes: Lors de notre première étude, nous avons effectué une méta-analyse afin d'évaluer la sécurité d'utilisation et l'efficacité des Blocs Thoraciques Para-Vertébraux (BTPV) pour la chirurgie du sein, en comparaison à l'Anesthésie Générale (AG). Pour cela, nous avons effectué une recherche électronique et manuelle d'articles écrits en anglais et français sur les BTPV en chirurgie du sein (publiés jusqu'en Juin 2010). Deux niveaux de sélection d'articles ont été utilisés. La méthode de Mantel-Haenszel (effets fixes) a été utilisée pour effectuer la méta-analyse. Lors de notre seconde étude, nous avons effectué une revue systématique afin d'évaluer la littérature existante qui compare l'utilisation de drains ou non lors des réductions mammaires. Pour cela, nous avons cherché Pub Med, EMBASE, le "Cochrane Central Database of Clinical Trials (CENTRAL) on the Cochrane Library" et le "Science Citation Index Expanded" pour les articles et revues de Janvier 1980 à Juin 2009. Finalement, lors de notre troisième étude, nous présentons notre expérience sur l'utilisation d'expanseurs sous cutanés de seins avant une reconstruction avec un lambeau basé sur la perforante de l'artère inferieure épigastrique profonde (lambeau DIEP). Nous démontrons comment notre nouvelle technique élimine l'apparence de patch du lambeau DIEP sur le sein. Nous avons développé cette technique; technique chirurgicale qui n'a jamais été décrite ou présentée auparavant. Au courant des deux dernières années (Janvier 2008 – Janvier 2010), cinq patients ont bénéficié de cette approche à trois étapes. Une analyse rétrospective des caractéristiques médicales des patients, de leur pathologie mammaire, de leurs hospitalisations, des complications et de leurs résultats, a été effectuée. Résultats: Notre première étude a démontré que les BTPV en préopératoire permettent une anesthésie effective pour les cas-de-jour de chirurgie du sein et démontrent des bénéfices supérieurs à l'AG. Cependant, plus d'études sont à faire afin de déterminer si ces avantages perdurent si une technique optimale pour une AG pour patients non-hospitalises est employée. L'échographie pourrait contribuer à améliorer la morbidité possible associée avec les BTPV en chirurgie du sein et devrait être étudiée en profondeur. Notre seconde étude a démontré que même si le placement routinier de drains en intra-opératoire après réduction mammaire est une pratique très populaire, cela ne devrait pas être utilisé de manière routinière après les réductions mammaires. Plus d'études randomisées contrôlées ne sont pas requises. Finalement, notre troisième étude a démontré comment l'innovation en recherche en chirurgie plastique peut améliorer le résultat final, postopératoire. L'expansion mammaire sous-cutanée suivie par reconstruction avec lambeau DIEP peut être effectuée en toute sécurité et offre aux patients une reconstruction mammaire totalement autologue, avec une faible morbidité, tout en éliminant l'apparence en forme de patch des reconstructions mammaires autologues classiques. Conclusion: Ces trois différentes études illustrent bien comment la recherche en chirurgie plastique peut affecter les résultats en reconstruction mammaire. Nos deux premières études démontrent avec un niveau d'évidence très élevé (méta-analyse puis revue systématique) que des pratiques préopératoires et intra-opératoires établies peuvent être modifiées au bénéfice des patients. Finalement, nous avons démontré comment une technique chirurgicale innovatrice peut améliorer les résultats postopératoires.
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Beniuk, Kathleen. "Integrating evidence-based medicine and service design : a study of emergency department crowding." Thesis, University of Cambridge, 2012. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.610514.
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Lin, Enxuan. "Some new developments in data transformation and meta-analysis with small number of studies." HKBU Institutional Repository, 2019. https://repository.hkbu.edu.hk/etd_oa/636.
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Meta-analysis is an important statistical tool for systematic reviews and evidence-based medicine. Extracting the observed effect sizes, assessing the magnitude of heterogeneity, choosing the suitable statistical model, and interpreting the summary effect size are four key steps in meta-analysis. It is known that each of the above steps has its own unique characteristics and may require some specific attention. As an example, the observed effect sizes from individual studies may not be reported in the same scale and hence cannot be combined directly. Another example is on selecting a model for meta-analysis from the common-effect model and the random-effects model. When a meta-analysis contains only few studies, the common-effect model and the random-effects model will often lead to misleading or unreliable results. In the first part of the thesis, we give a brief introduction on evidence-based medicine, systematic reviews and meta-analysis. We will also show their practical importance, display their relationships, and present a motivating example for conducting a meta-analysis. In Chapter 2, we first review the common effect sizes in meta-analysis for both continuous data and binary data. How to combine different categories of effect sizes is a critical issue after extracting the observed effect sizes from the clinical studies in the literature. For continuous data, researchers have recently proposed methods that transform the five number summary to the sample mean and standard deviation (Hozo et al., 2005; Wan et al., 2014; Luo et al., 2018). For binary data, the transformation from the odds ratio (OR) to the relative risk (RR) in the cohort study was proposed by Zhang and Yu (1998). To the best of our knowledge, however, there is little work in the literature that converts OR to RR in the case-control study. In view of this, we establish a new formula for this transformation to fulfill the gap. The performance of the new method will be examined through simulations and real data analysis. Our method and formulas can not only handle meta-analyses with different effect sizes, but also offer some insights for medical researchers to further understand the meaning of OR and RR in both cohort and case-control studies. In Chapter 3, we first give a brief introduction on the three available models in meta-analysis: the common-effect model, the random-effects model, and the fixed-effects model. When a meta-analysis contains only few studies, the common-effect model and the random-effects model will often lead to misleading or unreliable results. In contrast, the fixed-effects model is capable to provide a good compromise between the existing two models. In this chapter, we propose to further improve the estimation accuracy of the average effect in the fixed-effects model by assigning different weight for each study as well as fully utilizing the information in the within-study variances. Through theory and simulation, we demonstrate that the fixed-effects model can serve as the most convincing model for meta-analysis with few studies. And most importantly, with a total of three models, we expect that meta-analysis can be conducted more flexibly, more meaningfully, and more accurately. In Chapter 4, we first give a brief introduction on the heterogeneity in meta-analysis. We then review the methods for quantifying heterogeneity in three directions as follows: the tests for heterogeneity, the estimates of the between-study variance, and the measures of the impact of heterogeneity. Note that most existing methods were derived under the assumption of known within-study variances. In practice, however, a direct use of the reported within-study variance estimates may largely reduce the power of the tests and also lower the accuracy of the estimates, especially when the sample sizes in some studies are not sufficiently large. To overcome this problem, we propose a family of shrinkage estimators for the within-study variances that are able to borrow information across the studies, and derive the optimal shrinkage parameters under the Stein loss function. We then apply the new estimates of the within-study variances to some well-known methods for measuring heterogeneity. Simulation studies and real data examples show that our shrinkage estimators can dramatically reduce the estimation bias and hence improve the exiting literature. Keywords: Common-effect model, Effect size, Fixed-effects model, Heterogeneity, Meta-analysis, Odds ratio, Random-effects model, Relative risk, Risk ratio
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Eckermann, Simon Economics Australian School of Business UNSW. "Hospital performance including quality: creating economic incentives consistent with evidence-based medicine." Awarded by:University of New South Wales. School of Economics, 2004. http://handle.unsw.edu.au/1959.4/22011.
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This thesis addresses questions of how to incorporate quality of care, represented by disutility-bearing effects such as mortality, morbidity and re-admission, in measuring relative performance of public hospitals. Currently, case-mix funding and performance, measured with costs per case-mix adjusted separation, hold hospitals accountable for costs, but not effects, of care, creating economic incentives for quality of care minimising cost per admission. To allow an appropriate trade-off between the value and cost of quality of care a correspondence is demonstrated between maximising net benefit and minimising costs plus decision makers??? value of disutility events, where effects of care can be represented by disutility events and hospitals face a common comparator. Applying this correspondence to performance measurement, frontier methods specifying disutility events as inputs are illustrated to have distinct advantages over output specifications, allowing estimation of: 1. economic efficiency conditional on the value of avoiding disutility events. 2. technical, scale and congestion sources of net benefit efficiency; 3. best practice peers over potential decision makers??? value of quality; and 4. industry shadow price of avoiding disutility events. The accountability this performance measurement framework provides for effects and cost of quality of care are also illustrated as the basis for moving from case-mix funding towards a funding mechanism based on maximising net benefit. Links to evidence-based medicine in health technology assessment are emphasised in illustrating application of the correspondence to comparison of multiple strategies in the cost-disutility plane, where radial properties as shown to provide distinct advantages over comparison in the cost-effectiveness plane. The identified performance measurement and funding framework allows policy makers to create economic incentives consistent with evidence-based medicine in practice, while avoiding incentives for cream-skimming and cost-shifting. The linear nature of the net benefit correspondence theorem allows simple inclusion of multiple effects of quality, whether expressed as not meeting a standard, functional limitation or disutility directly. In applying the net benefit correspondence theorem to hospitals a clinical activity level is suggested, to allow correspondence conditions to be robustly satisfied in identification of effects with decision analytic methods, adjustment for within DRG risk factors and data linkage to effects beyond separation.
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Kelly, Ann Horton. "Evidence-based medicine and pragmatic populations : fact-making in human subjects research." Thesis, University of Cambridge, 2007. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.612720.
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Bowden, Adelle. "Maximising the impact of evidence-based medicine on equine health and welfare." Thesis, University of Nottingham, 2018. http://eprints.nottingham.ac.uk/52194/.
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Evidence-based veterinary medicine (EVM) has the potential to improve welfare of equine patients in primary care practice by ensuring that decision making at the point of care is underpinned by credible research. Patient focussed care requires consideration of a combination of evidence, veterinary judgement, experience and owner associated variables to ensure the best possible outcomes for the animal, whilst maximising the impact of EVM on equine health and welfare. A holistic approach to development and implementation of EVM, that involves horse owners, other equine stakeholders and veterinary surgeons, will ensure that all parties involved in decision making on behalf of equine patients are engaged in evidence-based decisions. The central aim of the thesis was to determine how advances in evidence-based veterinary medicine had the potential to achieve the greatest impact on equine health and welfare. The objectives were to: • Review methods of implementing evidence-based medicine in clinical practice and determine their suitability for veterinary medicine. • Describe the prevalence and outcome of conditions seen for ‘out of hours’ primary assessment in equine practice. • Investigate horse owner perception, understanding and approach to the most common emergency conditions. • Identify paucities in the knowledge and resources available to equine owners and highlight the information required to implement and facilitate evidence-based decision making. • Use an evidence-based approach to develop and disseminate an educational resource for horse owners to improve understanding of an emergency condition and equine welfare associated with that specific disease. The first section of the thesis aimed to identify a common emergency condition with a major welfare impact, which would become a focus for research in subsequent studies. A combination of methods were used in these chapters including a retrospective case study of ‘out of hours’ case records from two practices over a three year period, and a mixed methods online survey of opinions and experiences of equine yard owners. In the retrospective case study, colic (abdominal pain) was the most common condition seen as an ‘out of hours’ emergency at both veterinary practices, accounting for approximately a third of the ‘out of hours’ caseload. The three most common reasons for ‘out of hours’ visits for both practices were colic (35%), wounds (20%) and lameness (11%). The majority of cases seen ‘out of hours’ required a single treatment for resolution of the presenting problem (58%), whilst 26% needed multiple treatments. An online survey consisting of open and closed questions was distributed to UK livery yard owners. The survey investigated participants’ demographics and experiences, their opinion of the most common emergency conditions in the horse, and decision-making in emergency situations. Descriptive analysis of data included frequency ranking and categorisation of free text responses. There were 104 survey participants. The majority had kept horses for more than ten years (97%), and had previous experience of emergency conditions (99%), predominantly of colic (96%) and wounds (92%). Participants considered that the most common emergency conditions were colic (98%), wounds (49%) and fractures (22%), and the most concerning conditions were colic (94%), lameness (36%) and wounds (21%). Factors important in emergency decision making were: degree of pain, likelihood of condition resolving, and severity of disease. The results of these studies provided the impetus for using colic as the focus for the next phases of work within this thesis. The second section of the thesis investigated veterinary practitioners’ and horse owners’ approaches to horses with abdominal pain, with the aim of identifying where knowledge or resources were good or were variable or lacking. The subset of horses with abdominal pain from the ‘out of hours’ retrospective case series were explored to describe how these animals presented to veterinary surgeons, how they were diagnosed, treated and the outcomes. The clinical signs associated with a ‘critical’ outcome of colic were determined using univariate logistic regression. In the retrospective case series, 941 cases presented with signs of abdominal pain; 23.9% (n=225/941) cases were categorised as ‘critical’, and 18% (n=168/941) were euthanased. Fifteen variables from the case presentation significantly correlated with a critical case (p < 0.01) and were therefore incorporated into the multivariate model. The final multivariable model included three variables significantly associated with the likelihood of a case being classified as ‘critical’: increased heart rate (p < 0.01), abnormal mucous membrane colour (p < 0.01) and absence of borborygmi in at least one quadrant (p < 0.01). These were considered to be essential clinical parameters associated with the differentiation of critical cases of colic, and therefore should be included in the veterinary assessment of the condition. To investigate horse owners’ opinions and experiences, a mixed methods survey was distributed to investigate owner knowledge, experience and approaches to colic through open and closed questions and clinical scenarios. The survey also aimed to highlight knowledge and resource gaps that may affect the welfare and outcomes of horses with abdominal pain. The horse owner survey identified that owners had variable and often limited knowledge of colic and were frequently poor at recognising some of the clinical and behavioural manifestations of the condition. This study also identified the need for an all-encompassing educational resource for horse owners underpinned by scientific evidence in an accessible and functional format. Developing evidence-based resources for veterinary practitioners and horse owners was beyond the scope of what could be achieved within this thesis. Educational colic resources for horse owners (‘REACT’) were collaboratively developed and disseminated by Nottingham Equine Colic Project (including the author of the thesis) and The British Horse Society. Current evidence and literature on methods of incorporating evidence into clinical decision making were reviewed within the thesis, specifically accounting for the difficulties faced in veterinary medicine. Future work is needed to develop evidence-based resources on colic for veterinary surgeons to ensure that scientifically underpinned decisions are made at the point of care. The work contained within this thesis highlighted the importance of the owner in the recognition of disease and instigation of veterinary intervention. It is crucial that both equine owners and veterinary surgeons are considered in equal measure when investigating decision making on behalf of a horse. Owners are the gatekeepers of animal care and welfare and therefore there is a requirement that they are included in research and the development of educational material. Veterinary directed studies are commonplace, however the benefits of such research are questionable if the horse owner does not present their animal for veterinary attention. The legacy of this study will likely be the inclusion of horse owners in the development of evidence-based educational campaigns.
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Marshall, Iain James. "Evidence-based medicine and the patient : the example of cardiovascular disease prevention." Thesis, King's College London (University of London), 2016. https://kclpure.kcl.ac.uk/portal/en/theses/evidencebased-medicine-and-the-patientthe-example-of-cardiovascular-disease-prevention(ef1297fe-7b0f-419d-8e33-04141cc27744).html.
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Background: Patient ideas about cardiovascular diseases (CVDs) differ widely from those of clinicians. The failure to understand these explanatory models has been suggested to be a key barrier to effective CVD prevention. Nonetheless, currently available decision-support interventions for cvd prevention have had limited patient involvement in their development. Aims: Through four studies, this thesis seeks to use qualitative and quantitative methods to identify barriers and recommend best practices for supporting decisions in cvd prevention: both for education, and communicating the risk of benefit and harm from treatment. Methods: Study i analyses data from the South London Stroke Register, examining factors associated with the diagnosis and treatment of risk factors prior-to-stroke. Study ii systematically reviews qualitative studies of patient perspectives on hypertension and medication taking. Study iii systematically reviews randomized controlled trials (RCTs) and qualitative studies examining the effectiveness of different strategies for communicating cvd risk. Study iv is a qualitative study of patient perspectives on CVD risk in two south London general practices. Results: Study i found low but increasing prescribing rates of all preventative medication classes; prescribing did not differ by ethnicity or socio-economic status. Study ii included 52 qualitative studies. Participants experienced hypertension as symptomatic and strongly associated with stress. Many actively avoided medication, or self-adjusted medication use at times of lower stress or symptoms; concerns about serious adverse effects were widespread. Study iii included 23 RCTs, and found communicating CVD risk did not affect clinical outcomes, and only modestly improved decision quality; different formats produced similar results. Four qualitative studies found the risks were widely perceived as too small or distant to merit taking action. Study iv found many did not trust cvd risk estimates, perceiving they were not applicable to them as individuals, and omitted pertinent personal characteristics.
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Schultz, Abby, L. Crosnoe-Shipley, Brett T. Morgan, and Ivy A. Click. "Improving Evidence-Based Contraceptive Management Among Clinicians in Rural Tennessee." Digital Commons @ East Tennessee State University, 2017. https://dc.etsu.edu/etsu-works/6384.
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Polaha, Jodi. "Dissemination of Evidence Based Treatments to Rural Communities: Exploring the Role of Telehealth." Digital Commons @ East Tennessee State University, 2013. https://dc.etsu.edu/etsu-works/6684.
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Camacho-Walsh, Mercedes. "Evidence-Based Practice| Reducing Unnecessary Antibiotic Prescriptions for Pediatric Pharyngitis." Thesis, Saint Peter's University, 2018. http://pqdtopen.proquest.com/#viewpdf?dispub=10742646.
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The purpose of this project was to decrease of the rate of unnecessary antibiotic prescribing for pharyngitis by implementing an evidence-based training session for physicians in an outpatient pediatric setting. The PICOT question explored was, "For health providers treating children aged 4–15 presenting with sore throat, will the use of a power point training session presenting the rapid antigen detection test (RADT) with reflexive culture, combined with the ICE (ideas, concern and expectations) method, improve knowledge and reduce antibiotic prescribing compared to RADT alone in a 20 day period?"
The provider study group consisted of four pediatricians and one family practice physician ranging from 32–72 years old. Their pre-test (34.63%) and post-test (53.75%) knowledge scores were significantly different ( t = –2.3822, df = 6, p < 0.05). A total of 125 cases were sampled, 64 pre-intervention and 61 post-intervention. Pearson’s Chi Square analysis revealed homogeneity between both the groups in age (X2 = 0.94, df = 1, p = 0.33), gender (X2 = 0.64, df = 1, p = 0.42), and ethnicity (X2 = 1.29, df = 2, p = 0.53) and a decrease in overall antibiotic prescribing rates from 40.6% (n = 26) to 27.9% (n = 17). Although this was not a significant statistical reduction (p = .13), further analysis using a binomial test revealed statistically different rates of success in the accuracy of diagnosis and associated antibiotic prescribing pre-intervention (79.7%) compared to 96.7% post-intervention (p = .00; 95% CI [88.7, 99.6]). Unnecessary antibiotic exposure was reduced by 17.2%.
The most common ICE elements were thought of possible strep infection (39), viral or other infection (26), concern for pain (24), infecting other family members (14), fever (14), expectation to get better (32), test for strep (18), and pain relief (9). Only 2 of the 5 cases in the post-intervention group (n = 61) who expressed desire for antibiotics received them.
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White, Elizabeth, Brandon Mizell, Jodi Polaha, Leigh Johnson, David W. Stewart, Patricia Jessee, and G. Zimmer. "Evidence-Based Heart Failure Management Process Implementation at a Residency Teaching Family Medicine Clinic." Digital Commons @ East Tennessee State University, 2017. https://dc.etsu.edu/etsu-works/6567.
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Background/Purpose: The American College of Cardiology/American Heart Association/Heart Failure Society of America guidelines for management of heart failure were recently updated to include use of sacubitril/valsartan due to its ability to reduce mortality and hospitalizations over the current standard of therapy. Based on these guideline updates, a champion research team at East Tennessee State University (ETSU) Family Medicine Associates worked to create and implement a process that identified patients with systolic heart failure and provided access to medications with mortality and morbidity benefits. The objective of this study is to improve provider knowledge of evidence-based heart failure pharmacotherapy and to assess provider acceptability of a process implemented at ETSU Family Medicine Associates.
Methodology: This study was approved by the Institutional Review Board. On December 21, 2016 the champion research team presented a didactic session to all providers at ETSU Family Medicine Associates. Immediately prior to the education session, providers completed a pre-education clinical knowledge assessment on heart failure pharmacotherapy. A one-hour didactic session then followed focusing on evidence-based medication management of systolic heart failure and introduction of the new process being implemented. Following the presentation, providers completed a post-education clinical knowledge assessment and a pre-implementation process acceptability survey. Providers were then scheduled to complete a post-implementation process acceptability survey at two months post-process implementation and quarterly thereafter. A McNemars Test will be used to determine if statistically significant differences exist among pre- and post-education clinical knowledge assessments and pre- and post-implementation process acceptability surveys.
Presentation Objective: Discuss the process implemented to improve provider knowledge of heart failure pharmacotherapy and improve patient access to evidence-based pharmacotherapy options.
Self-Assessment: Did the one-hour didactic session improve provider knowledge of heart failure pharmacotherapy?
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Luo, Dehui. "Statistical learning of median in meta-analysis." HKBU Institutional Repository, 2017. https://repository.hkbu.edu.hk/etd_oa/469.
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As one of the most recommended strategies in decision making of contemporary medicine, evidence-based medicine (EBM) is attracting more and more attention. For EBM, the scientific evidences are obtained mainly from the randomized controlled trials (RCTs), systematic review and meta-analysis. In particular, meta-analysis can help researchers statistically combine several independent studies for a same clinical problem. In meta-analysis, Cohen's d and Hedges' g are among the most commonly used effect size measurements for continuous data. To compute these mean difference criteria, the sample mean and standard deviation are two conventional statistics reported in the literature. However, some other clinical studies may instead report the median, minimum and maximum values, and/or sample quartiles. Such a situation requires researchers to estimate the sample mean and standard deviation from these reported summary statistics. We note, however, that most existing estimators in the literature have some serious limitations. For this, we propose to improve the existing methods and extend them to three frequently encountered scenarios. In this thesis, we developed the optimal sample mean estimators, the normality test statistics and the updated Cohen's d mean difference criterion for three commonly encountered scenarios in meta-analysis. In Chapter 1, we gave a brief introduction on evidence-based medicine, meta-analysis and the summary data. In Chapter 2, we introduced our optimal estimators of the sample mean under the three scenarios, respectively. In Chapter 3, we proposed several methods for testing the normality of the underlying data. And in Chapter 4, we proposed to improve the famous Cohen's d and its relevant parameters. To assess the practical performance of our newly proposed methods, we also chose a few real data at the end of each chapter as illustrating examples. Numerical results of those studies indicated that our proposed methods have satisfactory performance both in theory and in practice. Following our new methodology, we also recommended an improved procedure for medical researchers to conduct meta-analysis. For illustration, we chose a meta-analysis in Chapter 5 on the effect of phytosterols to plasma CRP level (Rocha et al., 2016) to compare the results obtained from our recommended procedure and from the original methods. The results showed that our recommended procedure may lead to distinctly different results for a same clinical problem. To conclude the thesis, we expect that our newly proposed methods can be regarded as "rules of thumb" and will soon be widely applied in meta-analysis and evidence-based medicine.
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Wieten, Sarah Elizabeth. "What counts as 'what works' : expertise, mechanisms and values in Evidence-Based Medicine." Thesis, Durham University, 2018. http://etheses.dur.ac.uk/12606/.
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My doctoral project is a study of epistemological and ethical issues in Evidence-Based Medicine (EBM), a movement in medicine which emphasizes the use of randomized controlled trials. Much of the research on EBM suggests that, for a large part of the movement's history, EBM considered expertise, mechanisms, and values to be forces contrary to its goals and has sought to remove them, both from medical research and from the clinical encounter. I argue, however, that expertise, mechanisms and values have important epistemological and ethical roles to play and can be incorporated into the current EBM movement.
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de, Wet Wouter. "Knowledge, attitude and perception of private practitioners based in Gauteng, South Africa, regarding evidence-based practice." Thesis, Stellenbosch : Stellenbosch University, 2010. http://hdl.handle.net/10019.1/20441.
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Thesis (MMed) -- Stellenbosch University, 2010.Bibliography
Background: Evidence-based medicine (EBM) involves the care of patients using the best available evidence from the results of good quality clinical research to guide clinical decision making 1 – 3. By incorporating the principles of Evidence-based Medicine (EBM), the family practitioner would be able to treat a patient according to the best clinical research available. This principle is implemented widely in the USA, Canada, the United Kingdom and Europe. In South Africa, however, EBM is not yet as widely incorporated into family practice. This is so despite the plethora of websites available to practitioners and the relative ease with which applicable research evidence can be found. Very few published studies are available regarding EBM or Evidence–based Practice (EBP) in the South African context. The findings of this study would thus highlight reasons and/ or barriers preventing family practitioners from implementing EBM in their respective practices. This could also lead to further research into possible methods of implementation of EBM into South African family practices. Aim: The aim of the study was to describe the perceptions, knowledge and attitudes of private practitioners regarding evidence based practice and to identify the barriers encountered in evidence based practice. Methods A questionnaire survey of general practitioners in Gauteng, South Africa, was conducted. Questionnaires were distributed to a random sample of practitioners in the Gauteng region. Two hundred and twenty one (221) practitioners participated in the survey and responded to questionnaires mailed to them. The questionnaire was mailed, faxed or e-mailed to the practitioners, which they then completed and returned for statistical analysis. Study design The study design is that of quantitative, statistical analysis (descriptive cross-sectional survey). Setting General practitioners were randomly selected from a list of practitioners in the Gauteng Province. Doing a nationwide survey would have been a mammoth undertaking. It was therefore decided to limit the research to one province and therefore it was only concentrated on practitioners practicing in the Gauteng area. Results It is interesting to note that of the two hundred and twenty one participants in this study; only 10% of the practitioners were against using EBM in their practices. This, however, stands in stark contrast to the 56% of practitioners who do not implement EBM in their practices or make use of the EBM principle at all. The major barriers preventing practitioners from implementing EBM is depicted in the following graph: Lack of time and the training in aspects of Evidence-based medicine were the main barriers preventing the full scale implementation of EBM in family practices in Gauteng. Conclusion Participating Gauteng doctors were in principle, very positive towards the implementation of EBM in their respective practices. Most of the participants agreed that EBM would benefit their patients’ care and treatment. Very few of the participants, however, make use of EBM in practice. A lack of training and time constraints were the main barriers with regards to the implementation of EBM. Proper training of medical students at undergraduate level at faculties of health sciences, would go a long way assisting prospective doctors in mastering the concept of EBM and increasing their overall awareness of EBM. Further definitive research would assist in establishing whether such awareness would be associated with improved implementation of evidence in the form of evidence based guidelines in practice.
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Cheah, Su-Yin. "Methotrexate, cyclosporin and sulfasalazine in the treatment of rheumatoid arthritis : a systematic review." Thesis, University of Nottingham, 1999. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.285683.
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Muttiah, Nimisha. "Controversial therapy and evidence-based practice the clinicians' perspective /." Bowling Green, Ohio : Bowling Green State University, 2008. http://rave.ohiolink.edu/etdc/view?acc%5Fnum=bgsu1206325052.
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Sjögren, Petteri. "Randomised clinical trials and evidence-based general dentistry /." Linköping : Univ, 2004. http://www.bibl.liu.se/liupubl/disp/disp2004/med865s.pdf.
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Rogerson, Thomas Edward. "Evidence based testing and outcomes in transplantation." Thesis, The University of Sydney, 2014. http://hdl.handle.net/2123/12859.
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The use of diagnostic tests is central to the practice of modern medicine, but knowing which test to use, and when, can be problematic. To make evidence-based diagnoses, clinicians need efficient ways of accessing diagnostic studies, interpreting the results of several studies, and checking the applicability of studies to their own setting. The aim of this thesis was to explore solutions to these problems by addressing a specific clinical question; What is the best screening test for latent tuberculosis in patients undergoing transplantation? In a study of diagnostic filter performance in MEDLINE, we found that current ‘specific’ clinical queries limit for diagnosis (used in PubMed and Ovid SP) missed up to 80% of studies in nephrology journals. Other filters (Deville 2000 Broad, Deville 2000 Balanced, Haynes 2004 Balanced, and Vincent 2003 Narrow) had similar specificity to the ‘specific’ clinical queries limit, but identified a greater proportion of the total evidence. Using systematic review methodology, we found that current available data was inadequate to determine whether interferon gamma release assays performed better, worse or the same as the tuberculin skin test for diagnosing tuberculosis in candidates for solid organ transplant. Current international guidelines recommend using either the tuberculin skin test or an interferon gamma release assay, or both in combination. Our findings support these guidelines. We conducted a cross-sectional descriptive of candidates for kidney transplantation and found that despite a high prevalence of risk factors among the group, less than a quarter of candidates were screened for latent tuberculosis before transplant, and only 36% of the 101 patients with risk factors for tuberculosis were tested. This study demonstrates that candidates for kidney transplant are at increased risk of tuberculosis and highlights the need for a nation-wide tuberculosis screening protocol in work-up for transplant.