Journal of evaluation in clinical practice
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Randomized trials are considered the gold standard when assessing the efficacy of new therapeutic agents. In clinical situations where no standard of care therapy is approved, randomized trials usually compare experimental agents to either a placebo or an open-label nonintervention arm (i.e., best supportive care). We surveyed Canadian medical oncologists to understand their attitudes towards each design. ⋯ Canadian medical oncologists participating in this survey are divided in their opinions regarding the acceptability of an open-label design in randomized-controlled trials, where no standard therapy is approved. Clearer guidance from regulatory bodies on the adequacy of different trial designs is needed.
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Clinical guidelines produced by cardiology societies (henceforth referred to simply as 'clinical guidelines') recommend thromboprophylaxis with oral anticoagulants (OACs) in patients with atrial fibrillation (AF) who have moderate-to-high stroke risk. However, deviations from these recommendations are observed, especially in the primary healthcare setting. The primary aims of this study were to evaluate the self-reported use of AF clinical guidelines and risk stratification tools among Australian general practitioners (GPs), and their perceptions regarding the available resources. ⋯ Among our small sample of Australian GPs, most did not access thromboprophylaxis-related information directly from AF-specific clinical guidelines developed by cardiology societies. Although the majority reported using formal stroke and bleeding assessment tools, these were typically used on OAC initiation only. More focus is needed on formal risk reassessment as clinically indicated and at regular review.
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It is generally believed that evidence from low quality of evidence generate inaccurate estimates about treatment effects more often than evidence from high (certainty) quality evidence (CoE). As a result, we would expect that (a) estimates of effects of health interventions initially based on high CoE change less frequently than the effects estimated by lower CoE (b) the estimates of magnitude of effect size differ between high and low CoE. Empirical assessment of these foundational principles of evidence-based medicine has been lacking. ⋯ We found that low-quality evidence changes more often than high CoE. However, the effect size did not systematically differ between the studies with low versus high CoE. The finding that the effect size did not differ between low and high CoE indicate urgent need to refine current EBM critical appraisal methods.
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Over the last decade, policy changes have prompted Canadian medical education to emphasize a transformation to competency-based education, and subsequent development of evaluation tools. The pandemic provides a unique opportunity to emphasize the value of reflexive monitoring, a cyclical and iterative process of appraisal and adaptation, since tools are influenced by social and cultural factors relevant at the time of their development. ⋯ The results illustrate that reflection promotes the validity and usefulness of the data collected to inform policy performance and other initiatives.
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Ward rounds (WRs) are complex social processes. Done well, WR discussions and decisions contribute to timely, safe, effective progression of care. However, literature highlights medical dominance; marginalisation or absence of other perspectives, safety risks and suboptimal resource use. This study examined leadership behaviours and what supported good interprofessional WRs, defined as enabling interprofessional collaboration and decision making which progresses patient care in a safe and timely manner. Deepening appreciation of this art should support learning and improvements. ⋯ Whilst everyone contributes to the joint effort of delivering a good WR, WR leadership is key. It ensures effective use of time and diverse expertise, and coordinates contributions rather like a conductor working with musicians. Although WR needs and approaches vary across contexts, the key leadership activities we identified are likely to transfer to other settings.