Journal of evaluation in clinical practice
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Evidence of mechanisms plays an important role in medical decision-making, but this role is less well articulated than that of clinical trial evidence. A new book, Evaluating Evidence of Mechanisms in Medicine: Principles and Procedures, provides a framework and resources for explicitly evaluating evidence of mechanisms when assessing claims of efficacy and external validity. This review outlines the overall approach of the book, the contribution it makes to evidence evaluation in medicine and makes some suggestions for further work that will aid implementation of the framework into clinical decision-making.
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Shared decision-making (SDM) is a collaborative process through which patients and clinicians work together to arrive at a mutually agreed-upon treatment plan. The use of SDM has gathered momentum, with it being legally mandated in some areas; however, despite being a ubiquitously applicable intervention, its maturity in use varies across the specialties and requires an appreciation of the nuanced and different challenges they each present. It is therefore our aim in this paper to review the current and potential use of SDM across a wide variety of specialties in order to understand its value and the challenges in its implementation. ⋯ SDM has been demonstrated to improve decision quality in many scenarios across all of these specialties. There are, however, many challenges to its successful implementation, including the need for high-quality decision aids, cultural shift, and adequate training. SDM represents a paradigm shift towards more patient-centred care but must be implemented with continued people centricity in order to realize its full potential.
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The patient-centred medical home (PCMH) is an innovative approach to health care reform. Despite a well-established process for recognizing PCMH practices, fidelity to, and/or adaptation of, the PCMH model can limit health care and population health improvements. This study explored the connection between fidelity/adaptation to the PCMH model with implementation successes and challenges through the experiences of family and internal medicine PCMH physicians. ⋯ There remains significant variability in PCMH characteristics across the United States and Canada. This qualitative analysis uncovered factors contributing to fidelity/adaptation to the PCMH model in two academic PCMH clinics. For the PCMH to achieve the Triple Aim promise of improved patient health and experience at a reduced cost, policy must support fidelity to core elements of the PCMH.
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Clinical guidelines are an increasingly common part of medical practice. The desire to standardize practices may seem a noble one, but overzealous application can make guidelines seem restrictive, leading to resentment or, worse, disregard. ⋯ Or where guidelines restrict access to services, utilitarianism might seem a better fit. Here, clinical practice guidelines are examined in terms of these theories of normative ethics, and it is argued that in fact, the process of writing and implementing guidelines is more accurately modelled through the lens of virtue ethics.
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Shared decision-making takes many forms, involving different kinds of agents who share the requirement that they must have sufficient decision-making capacity for the decision in question. Advance care planning (ACP) is commonly viewed as a form of shared decision-making between carers and patients who anticipate losing decision-making capacity. What is unclear in this situation is the identity status of an individual who has become mentally incapacitated and how to evaluate their rights and interests. ⋯ Yet, an ACP framework based on narrative identity and the relevant capacities to construct such narratives results in more demanding capacity requirements than current medico-legal practice requires. The law thus espouses conflicting views as to who can be an appropriate decision-making authority for patient care. I therefore conclude that the law governing medical care needs to be clearer about how to resolve the identity problem and revisit its position on ACP or supported decision-making for those who have only focally preserved decision-making capacity.