PROBLEM DELINEATION AND CRITICAL PROBLEMATIZATION
Peter Wyer MD Associate Clinical Professor of Medicine Columbia University College of Physicians & Surgeons Chair, Section on Evidence Based Health Care, New York Academy of Medicine
Four Dimensions of Health Care Policy (Guidelines)
Implementation
Delivery
Evidence From Research
Paolo Freire
"Repetimos que o conhecimento não se estende do que se julga sabedor até aqueles que se julga não saberem; o conhecimento se constitui nas relações homem-mundo; relações de transformação, e se aperfeiçoa na problematização crítica destas relações.“ Paolo Freire
Cartesion Thinking vs Problematization
Case 1: Surviving Sepsis Guideline • Practice category 1: “initial resuscitation” • Considered ‘early goal directed therapy’ protocol • Looked at individual components separately
including monitoring SvcO2 via a special device
• Research on bundle components very indirect • Gave 1C recommendation to EGDT Intensive Care Med 2008;34:17-60
Alan E. Jones, MD; Michael D. Brown, MD, MSc; Stephen Trzeciak, MD, MPH. Critical Care Medicine 2008
Case 2: Implementation of EGDT • Major NYC medical center • Well championed effort • Strong interest in institution across service lines • Broke down because of resistance to use of special
catheter for SvcO2 and associated monitoring requirements
Case 3: a patient with atrial fibrillation • Major NYC medical center ED • 65 yo female presents in paroxysmal a fib • Family insists: “shock her-the drugs never work” • Would like to be D/C after cardioversion • Institutional culture favors drugs and admission • Chief resident later does search for evidence on
comparative efficacy of anti-arrhythmic drug classes in achieving conversion
Constructivist Remedies
The SIMPLE Model of Constructed Action and Evidence Assimilation
Silva, J Eval Clin Pract. 2010, In Press
Actions, then information ACTION DOMAIN THERAPY
DIAGNOSIS
PROGNOSIS
HARM
Ask
Ask
Ask
Ask
Acquire
Acquire
Acquire
Acquire
Appraise
Appraise
Appraise
Appraise
Apply
Apply
Apply
Apply
PACT: A Tool of Representation • Therapy • Diagnosis • Prognosis • Harm
Knowledge Transfer or Evidence Assimilation
Monitor Knowledge Use
Knowledge Inquiry
Synthesis
Adapt Knowledge to Local Context
Products/ Tools
Identify Problem Identify, Review, Select Knowledge
Evaluate Outcomes
no wle dge
Assess Barriers/Facilitators to Knowledge Use
KNOWLEDGE CREATION
Tai lor ing K
Select, Tailor, Implement Interventions
Sustain Knowledge Use
Evidence Based Quality Improvement Steps
Problematization
Evidence Need
What is the actual effectiveness of care?
... what is the expected mortality...?
What should be done that is not been done?
Catheter? ATB? Fluids?
What are the barriers?
Number of personnel needed? etc
Select, tailor, implement
What are the strategies to modify it?
Does this strategy modify behavior?
Monitor
What are the outcomes?
What are the main important outcomes?
Scan Identify, review select knowledge
Identify barriers
The Dimensions of Health Care Policy (Guidelines)
Implementation
Delivery
Evidence From Research
Research for Patient Care • Comparative effectiveness • Practice based and participatory research
shape the research questions & methodology As Iain Chalmers: “…. research should address health problems of importance to populations and the interventions and outcomes considered important by patients and clinicians.” e.g.: The research priorities of patients with osteoarthritis of the knee favoured more rigorous evaluation of physiotherapy and surgery and assessment of educational coping strategies. 9% wanted more research on drugs: 80% of RCTs on patients like this are drug evaluations
help with data collection, tools development, selection of outcome measures Most rheumatoid arthritis patients, when asked, indicated that fatigue was the dominant symptom of concern – not pain, as researchers had assumed In the UK, researchers seeking funding for RCTs must demonstrate that patients have been given an opportunity to provide input on the outcomes to be measured in the trial Canada is developing a core set of validated patientreported cancer care outcomes
SUMMARY • Scientifically informed, effective care,
requires “critical problematization” across all parties • If the problem is wrong, the question is wrong; if the question is wrong, evidence based methods and resources are misguided • Pedagogical tools to guide problem delineation are a needed component at all faces of evidence-based research and practice