Journal of evaluation in clinical practice
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Multicenter Study
GPs' perceptions of multiple-medicine use in older patients.
Multiple-medicine use (polypharmacy) is a growing problem for older patients, prescribers and health policy makers. The general practitioner (GP) is most often the main professional care provider; hence, improvements of treatment can only be carried out in concordance with GPs. The aim of this study was, therefore, to explore GPs' perspectives of treating older users of multiple medicines, using a qualitative approach. ⋯ The GPs felt insecure although surrounded by clinical practice guidelines. There is a need for policy makers to appreciate this paradox, as the problem is likely to grow in size and proportion. GPs must be empowered to handle the increasing proportion of older users of multiple medicines with individual agendas, receiving care from multiple specialists.
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Conflict-of-interest (COI) policies have played a vital role in protecting the integrity of science as well as protecting patients' welfare. However, the usefulness of these policies could be enhanced by addressing gaps in disclosure requirements, especially insofar as these gaps may impede the intended neutrality of COI policies. For example, current COI policies have not addressed potential conflicts created by indirect industry funding, such as when pharmaceutical companies provide general funding to researchers' academic departments or to medical educational programmes. Nor do they address the consequent creation of climates of opinion, which may marginalize important criticisms and undermine progress on this important policy issue. ⋯ Taking the position that a more adequate system of checks and balances is needed, the authors offer specific recommendations for improving current policies and for addressing the issue of indirect support.
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Data about health care organizations (HCOs) are not useful until they are interpreted. Such interpretations are influenced by the theoretical lenses used by the researcher. ⋯ We suggest that the task of interpreting research observations of HCOs could be improved if researchers take into account that the systems they study are CASs with non-linear relationships among diverse, learning agents. Our analysis points out how interpretation of research results might be shaped by the fact that HCOs are CASs. We described how learning is, in fact, the result of interactions among diverse agents and that learning can, by itself, reduce or increase agent diversity. We encouraged researchers to be persistent in their attempts to reason about complex systems and learn to attend not only to structures, but also to processes and functions of complex systems.
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Rationale, aims and objectives Evidence-based medicine (EBM) claims to be based on 'evidence', rather than 'intuition'. However, EBM's fundamental distinction between quantitative 'evidence' and qualitative 'intuition' is not self-evident. The meaning of 'evidence' is unclear and no studies of quality exist to demonstrate the superiority of EBM in health care settings. ⋯ Results EBM's strict distinction between admissible evidence (based on RCTs) and other supposedly inadmissible evidence is not itself based on evidence, but rather, on intuition. In other words, according to EBM's own logic, there can be no 'evidentiary' basis for its distinction between admissible and inadmissible evidence. Ultimately, to uphold this fundamental distinction, EBM must seek recourse in (bio)political ideology and an epistemology akin to faith.
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Rationale Extensive research has been conducted on clinical reasoning to gain better understanding of this process. Clinical reasoning has been defined as the process of thinking critically about the diagnosis and patient management. However, most research has focused on the process of diagnostic reasoning. ⋯ Subsequently, these processes adapt the therapy script continuously. Conclusions A hypothetical model of therapeutic reasoning has been developed in order to improve medical education, training and refresher courses with regard to therapeutic decision making. Future research should empirically test the validity of this hypothetical model in different phases of the medical education continuum.