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Teaching EBHC to health professionals is expected to increase EBHC knowledge, attitude, skills and practice and ultimately result in improving patient outcomes. Current evidence lacks evaluation of EBHC training on patient outcomes - evidence is not from a randomized trial but a before-after study.
Teaching EBHC to health professionals is expected to increase EBHC knowledge, attitude, skills and practice and ultimately result in improving patient outcomes. Current evidence lacks evaluation of EBHC training on patient outcomes - evidence is not from a randomized trial but a before-after study.
Teaching EBHC to health professionals is expected to increase EBHC knowledge, attitude, skills and practice and ultimately result in improving patient outcomes. Current evidence lacks evaluation of EBHC training on patient outcomes - evidence is not from a randomized trial but a before-after study.
Does teaching evidence-based health care to health professionals
improve patient outcomes? Introduction Evidence-based medicine (EBM) is defined as the integration of best research evidence with clinical expertise and patient values (1). This concept has gained some acceptance in many academic, clinical and healthcare spheres. It is a self-directed lifelong learning process where patient care generates the need for current, relevant and valid research-based health care information. The practice of EBM generally consists of five steps: first, converting information required into answerable research questions; then, locating the best evidence that answers the question; critical appraisal of the evidence for its usefulness and validity; application of the appraisal results in clinical practice; and evaluation of performance (2). In order to allow for an all-inclusive approach to health care delivery, evidence-based health care (EBHC) has replaced EBM in most recent literature. Glasziou et al in 2008 suggested that EBHC become an essential part of the educational curriculum for all health professionals (3). For effective application of EBHC and consequent enhancement in health care quality, learning of research principles as well as application of an evidence-based approach are essential (3). Teaching EBHC to health professionals is expected to increase EBHC knowledge, attitude, skills and practice and ultimately result in improving patient outcomes. Current evidence lacks evaluation of EBHC training on patient outcomes. An overview of systematic reviews published recently revealed the range of outcomes assessed in many systematic reviews included EBHC knowledge, skills, attitudes and behavior with a focus on critical appraisal skills (4). Although EBHC training has been shown to increase appropriate treatment (5), this evidence is not from a randomized trial but a before-after study. This weakens the causal interpretations that can be drawn from the study. Evaluating the effect of teaching EBHC to health professionals on patient outcomes is fraught with challenges. These are similar to those encountered when undertaking patient outcomes research in medical education. Some of these limitations will be covered in the succeeding paragraphs. Dilution This describes a situation where the impact of the education of a health professional e.g., medical doctor is gradually reduced as it gets filtered through other members of the healthcare team such as nurses, pharmacists and physiotherapists involved in the health provision 1
pathway (6). Each of these could correct erroneous behaviors of a health professional, or prevent appropriate behaviors from resulting in significant appreciable patient outcome. In the end, these factors dilute the healthcare professionals actions (7) and weaken the effect of the teaching activities. Inadequate Sample Size Medical education research studies that evaluate patient outcomes are often under-powered due to inadequate sample size. As a result of imperfect measurements and diluted effects, what would be required is an intervention that has a large effect size or a very large sample size. Short of these, any findings from these studies will most likely not be statistically significant. Establishing a causal link It has been shown that studies which use patient outcomes often have a lot of bias associated with them and have poor generalizability (8). As a result, limited inferences and conclusions can be drawn from these studies. Most commonly employed study designs in medical education research using patient outcomes include cross-sectional and cohort designs. These types of study designs typically do not facilitate the establishment of a strong causal link between the education intervention and patient outcomes as randomized studies would (8). Selection of potentially biased outcomes This occurs when the patient outcomes selected by the investigators do not fully reflect the field of interest. Many important patient outcomes are not easily measured (9). This results in the reporting of outcomes that are more easily measured and not outcomes that best reflect the goals of the medical educational curriculum. To mitigate against this, some sections have called for linking important patient outcomes with more accessible (surrogate) outcomes (6). Because bridging an educational activity causally to important patient outcomes through a single link can be challenging, it has been suggested that two or more links be used (6). For instance, demonstrating that improvement in critical appraisal skills of an oncologist is associated with longer survival in cancer patients implies that critical appraisal skills could be used in successive research as surrogate outcomes. The use of surrogate outcomes is not without its challenges (10). The underlying principle is that there must be a strong correlation between the surrogate outcome chosen and the patient outcome.
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Conclusion Teaching EBHC to the 21 st century healthcare professional is non-negotiable. The speed of the increase in knowledge has made the acquisition of EBHC skills as essential as the basic clinical skills themselves. The ultimate goal being the improvement of patient outcomes such as longer survival, shorter duration of illness, reduced incidence of disease, etc. However, establishing a relationship between the teaching of EBHC and these important patient outcomes has proven difficult to do. Challenges include dilution by healthcare provision pathways, inadequate powering of studies, as well as failure to establish a causal link and potential bias in the selection of outcomes (6). Overcoming these challenges requires the development of novel study design methods which take these factors into account with or without the use of surrogate outcomes, randomized studies, larger sample size or intervention effect size and adjusting for the confounding effects of other factors involved in the healthcare provision pathway (11). Establishing a strong causal relationship between teaching EBHC to health professionals and improved patient outcomes will result in increased funding and acceptance of these educational activities in many spheres of the academic, clinical, and healthcare communities.
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References 1. Sackett, D L; Strauss, S E; Richardson, W S, et al. Evidence-based medicine: how to practice and teach EBM. London : ChurchillLivingstone, 2000. 2. A, Akobeng. Principles of evidence based medicine. s.l. : Arch Dis Child, 2005. 837-840. 3. Glasziou, P, Burls, A and Gilbert, R. Evidence based medicine and the medical curriculum. s.l. : BMJ, 2008. a1253. 4. Young, T; Rohwer, A; Volmink, J; Clarke, M. What Are the Effects of Teaching Evidence-Based Health Care (EBHC)? Overview of Systematic Reviews. s.l. : PLoS ONE 9(1), 2014. e86706. doi:10.1371/journal.pone.0086706. 5. Straus, S E; Ball, C; Balcombe, N; Sheldon, J; McAlister, F A. Teaching evidence-based medicine skills can change practice in a community hospital. s.l. : J Gen Intern Med, 2005. 340-3. 6. Cook, D A and West, C P. Perspective: Reconsidering the focus on "outcomes research" in medical education: a cautionary note. s.l. : Acad Med, 2013. 162-7. 7. Shea, J A. Mind the gap: Some reasons why medical education research is different from health services research. s.l. : Medical Education, 2001. 319-320. 8. Hulley, S B; Cummings, S R; Grady, D; Hearst, N; Newman, T B. Designing Clinical Research: An Epidemiologic Approach. 2nd ed. Philadelphia, Pa : Lippincott Williams & Wilkins, 2001. 9. Landon, B E; Normand, S L; Blumenthal, D; Daley, J. Physician clinical performance assessment: Prospects and barriers. s.l. : JAMA, 2003. 1183-1189. 10. Boden, W E, Probstfield, J L and Anderson, T et al AIM-HIGH Investigators. Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. s.l. : New England Journal of Medicine, 2011. 2255-2267. 11. Chen, F M, Bauchner, H and Burstin, H. A call for outcomes research in medical education. s.l. : Acad Med, 2004. 955-60.