Journal of evaluation in clinical practice
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Precision medicine (PM) raises a key question: How do we know what works when the number of people with a health problem becomes small or one (n = 1)? We here present a formative case from Norway. The Norwegian Board of Health Supervision was faced with a cancer patient, who had improved after treatment with a drug in the private health sector but was refused continued treatment in the public health service due to lack of clinical trial evidence. The Board overturned this decision, arguing that the drug had been unambiguously documented to work in the individual case. We aim to provide an in-depth analysis of this case and The Board's decision and thereby to illustrate and elucidate key epistemological and ethical issues and developments in PM. ⋯ A framework that is more based on abductions and evidence arising in the individual case has problems in creating quantifiable, reliable and generalisable evidence, and in promoting transparency and accountability. PM currently lacks clear criteria for deciding what works in an individual, posing ethical challenges.
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Adherence rates to guidelines show room for improvement, and increase in adherence to guidelines may potentially lead to better outcomes and reduced costs of treatment. To improve adherence, it is essential to understand the considerations of physiotherapists regarding the assessment and management of low back pain (LBP). The purpose of this study is to gain insight in the considerations of Dutch physiotherapists on adherence to the national physiotherapy guideline in the treatment of patients with LBP. ⋯ To improve adherence, the guideline should provide more information about addressing psychosocial prognostic factors, and Dutch physiotherapists might be trained in communication skills to better address patient expectations. A more extensive implementation process is warranted for the next guideline to increase the physiotherapists' knowledge of evidence-based treatment.