Evidence, patient preferences and patient-centred care
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EDITORIAL Evidence, patient preferences and patient-centred careFew healthcare providers would argue against being patient- and family-centred in our care. While this is an obvious ethic to assert, it is challenging to live up to. Most modern defi- nitions of evidence-based healthcare include patient prefer- ences and values as part of clinical decision-making. 1,2 Yet descriptions of evidence-based practice do not explicitly integrate the role of patient preferences in the steps or phases of the process. 3 Rather, the stages generally involve stating a specific question, searching for and appraisal of information, synthesis of the included works, application of the best evidence in decision-making and evaluation of out- comes. Clinicians, armed with the best available evidence, use their clinical expertise to intervene. Presumably, clients patiently await the scientist’s, reviewer’s and guideline developer’s verdict before becoming part of the decision that affects their health and well-being. This approach is common but inconsistent with the intent of evidence-based healthcare. When clients are viewed as consumers, they use informa- tion at the end of healthcare supply chain just like a pur- chaser of technology or any other product. This leaves them with far fewer options to influence their own care than if they were involved in each stage of the knowledge supply chain. That is, clients could become true partners if they were engaged when researchers discover and test, reviewers synthesise, guideline developers translate and clinicians use knowledge. Models that integrate the best available evidence with patients’ and families’ preferences are emerging. 3,4 However, evidence related to how to best integrate patients and their families in evidence-based decision-making and how to encourage healthcare providers to include them in shared decision-making lags. 4 While patient preferences in the evidence-based decision-making process may be desirable, much remains to be learned about how to realise this ethic. In this issue, authors have reviewed the effect of traditions that reflect a clinician-centred practice. For example, Moola and Lockwood reviewed the effectiveness of the manage- ment or prevention of hypothermia within the adult perio- perative environment. 5 They found that active rewarming strategies are more effective than passive rewarming and that multiple strategies may be optimal in prolonged surger- ies or older surgical patients. They urge future researchers to conduct stronger trials to answer the remaining questions. Perhaps, there is also opportunity for the knowledge users (clinicians and patients) to become active participants in the planning, conduct, analysis and interpretation of this work to address both the urgent clinician-centric and the patient- centred questions and outcomes. If clinicians and patients become part of the research, review and guideline teams, both their preferences and knowledge needs might be met more effectively and efficiently. The Canadian Institutes of Health Research identify six opportunities for knowledge translation throughout the research, dissemination, contex- tualisation and application of knowledge cycle. 6 If knowl- edge users become part of the cycle, they may be less likely to be left with constrained choices than they are as end of supply chain consumers. Jayasekara reviewed the effectiveness of educational com- ponents and strategies associated with insulin pump therapy on outcomes like glycaemic control, complications and knowledge. 7 Clearly, the researchers sought to find effective methods to empower clients through education. Their ulti- mate goal was to enable patients to better self-manage their insulin pumps and diabetes. Yet Jayasekara found only a few studies and these used a heterogeneous mix of educational and training efforts. The review supports, although with limited confidence, recommendations about the content of teaching but little research about how patients with an insulin pump prefer to learn about managing them. Perhaps the next step is to include patients with insulin pumps in the design of the research question and methods. Ciufo, Hader and Holly reviewed visitation models in adult critical care units within a context of patient- and family- centred care. 8 One might guess that given the review ques- tion, they would have found research that clearly centred on the patients’ and families’ preferences. Despite a thorough and exhaustive search, one of Ciufo, Hader and Holly’s main findings is that nurses believe that even though visiting is important, flexible and fluid visiting hours can impede work flow. 8 The review aptly revealed the tension between nurses’ understanding the patients’ and families’ needs and prefer- ences and the nurses wanting to control visitation. The reviewers integrated quantitative and qualitative evidence in their comprehensive review to better answer both questions of effectiveness and meaning. Healthcare providers need more comprehensive systematic reviews that will reveal the evidence to inform our understanding of patient and family preferences. National policy-makers are calling for clinicians and organisations to shift their focus on patient and family pref- erences and satisfaction. In the United States, patient satis- faction with care is beginning to influence how providers and organisations will be reimbursed. In the fall of 2012, the Centers for Medicare and Medicaid Services will adjust reim- bursement for services based on patient satisfaction scores. 9 Value-based purchasing supports the goals of the ‘Partner- ship for Patients’ aimed at improving the quality and safety of healthcare for Americans. Patient satisfaction scores will determine part of the value of care and subsequent doi:10.1111/j.1744-1609.2011.00183.x Int J Evid Based Healthc 2011; 9: 335–336 © 2011 The Author International Journal of Evidence-Based Healthcare © 2011 The Joanna Briggs Institute
Transcript of Evidence, patient preferences and patient-centred care
E D I T O R I A L
Evidence, patient preferences and patient-centred carejbr_183 335..336
Few healthcare providers would argue against being patient-and family-centred in our care. While this is an obvious ethicto assert, it is challenging to live up to. Most modern defi-nitions of evidence-based healthcare include patient prefer-ences and values as part of clinical decision-making.1,2 Yetdescriptions of evidence-based practice do not explicitlyintegrate the role of patient preferences in the steps orphases of the process.3 Rather, the stages generally involvestating a specific question, searching for and appraisal ofinformation, synthesis of the included works, application ofthe best evidence in decision-making and evaluation of out-comes. Clinicians, armed with the best available evidence,use their clinical expertise to intervene. Presumably, clientspatiently await the scientist’s, reviewer’s and guidelinedeveloper’s verdict before becoming part of the decisionthat affects their health and well-being. This approach iscommon but inconsistent with the intent of evidence-basedhealthcare.
When clients are viewed as consumers, they use informa-tion at the end of healthcare supply chain just like a pur-chaser of technology or any other product. This leaves themwith far fewer options to influence their own care than ifthey were involved in each stage of the knowledge supplychain. That is, clients could become true partners if theywere engaged when researchers discover and test, reviewerssynthesise, guideline developers translate and clinicians useknowledge.
Models that integrate the best available evidence withpatients’ and families’ preferences are emerging.3,4 However,evidence related to how to best integrate patients and theirfamilies in evidence-based decision-making and how toencourage healthcare providers to include them in shareddecision-making lags.4 While patient preferences in theevidence-based decision-making process may be desirable,much remains to be learned about how to realise this ethic.
In this issue, authors have reviewed the effect of traditionsthat reflect a clinician-centred practice. For example, Moolaand Lockwood reviewed the effectiveness of the manage-ment or prevention of hypothermia within the adult perio-perative environment.5 They found that active rewarmingstrategies are more effective than passive rewarming andthat multiple strategies may be optimal in prolonged surger-ies or older surgical patients. They urge future researchers toconduct stronger trials to answer the remaining questions.Perhaps, there is also opportunity for the knowledge users(clinicians and patients) to become active participants in theplanning, conduct, analysis and interpretation of this workto address both the urgent clinician-centric and the patient-centred questions and outcomes. If clinicians and patientsbecome part of the research, review and guideline teams,
both their preferences and knowledge needs might be metmore effectively and efficiently. The Canadian Institutes ofHealth Research identify six opportunities for knowledgetranslation throughout the research, dissemination, contex-tualisation and application of knowledge cycle.6 If knowl-edge users become part of the cycle, they may be less likelyto be left with constrained choices than they are as end ofsupply chain consumers.
Jayasekara reviewed the effectiveness of educational com-ponents and strategies associated with insulin pump therapyon outcomes like glycaemic control, complications andknowledge.7 Clearly, the researchers sought to find effectivemethods to empower clients through education. Their ulti-mate goal was to enable patients to better self-manage theirinsulin pumps and diabetes. Yet Jayasekara found only a fewstudies and these used a heterogeneous mix of educationaland training efforts. The review supports, although withlimited confidence, recommendations about the content ofteaching but little research about how patients with aninsulin pump prefer to learn about managing them. Perhapsthe next step is to include patients with insulin pumps in thedesign of the research question and methods.
Ciufo, Hader and Holly reviewed visitation models in adultcritical care units within a context of patient- and family-centred care.8 One might guess that given the review ques-tion, they would have found research that clearly centred onthe patients’ and families’ preferences. Despite a thoroughand exhaustive search, one of Ciufo, Hader and Holly’s mainfindings is that nurses believe that even though visiting isimportant, flexible and fluid visiting hours can impede workflow.8 The review aptly revealed the tension between nurses’understanding the patients’ and families’ needs and prefer-ences and the nurses wanting to control visitation. Thereviewers integrated quantitative and qualitative evidence intheir comprehensive review to better answer both questionsof effectiveness and meaning. Healthcare providers needmore comprehensive systematic reviews that will reveal theevidence to inform our understanding of patient and familypreferences.
National policy-makers are calling for clinicians andorganisations to shift their focus on patient and family pref-erences and satisfaction. In the United States, patient satis-faction with care is beginning to influence how providersand organisations will be reimbursed. In the fall of 2012, theCenters for Medicare and Medicaid Services will adjust reim-bursement for services based on patient satisfaction scores.9
Value-based purchasing supports the goals of the ‘Partner-ship for Patients’ aimed at improving the quality and safetyof healthcare for Americans. Patient satisfaction scores willdetermine part of the value of care and subsequent
doi:10.1111/j.1744-1609.2011.00183.x Int J Evid Based Healthc 2011; 9: 335–336
© 2011 The AuthorInternational Journal of Evidence-Based Healthcare © 2011 The Joanna Briggs Institute
reimbursement. ‘Patient as partner’ is a key theme in severalof the provisions embedded in the 2010 Affordable CareAct.10 In addition to the emphasis on value and quality, theact established a new non-governmental organisation calledthe Patient-Centered Outcome Research Institute. The gov-ernance and methodology groups have been established forless than 1 year. Fundamental to their goals is that compara-tive effectiveness research ‘should consider comprehensivemeasures, addressing patient preferences, health outcomesand quality of life’, and there should be an emphasis onpatients as partners in evidence-based decision-making.10
Perhaps the United States lags behind other nations whohave already engaged patients in the generation, synthesisand translation of evidence. Americans and citizens aroundthe world need greater influence and engagement duringthe decision-making and work of scientists, reviewers andclinicians in order to direct and speed the transfer of theevidence. Comprehensive reviews like those in this issue willbe more robust and informative when knowledge users arepartners rather than ‘supply chain’ recipients.
Lisa Hopp PhD RNProfessor, School of Nursing, Purdue University Calumet
Director, Indiana Center for Evidence-Based Nursing Practice:A JBI Collaborating Center, Hammond, IN, USA
References1. DiCenso A, Cullum N, Ciliska D. Implementing evidence-based
nursing: some misconceptions. Evid Based Nurs 1998; 1: 38–9.
2. Muir-Gray JA. Evidence-Based Health Care: How to Make HealthPolicy and Management Decisions. New York: Churchill Living-stone, 1997.
3. Sidani S, Epstein D, Miranda J. Eliciting patient treatment pref-erences: a strategy to integrate evidence-based and patient-centered care. Worldviews Evid Based Nurs 2006; 3: 116–23.
4. Légaré F, Ratté S, Stacey D et al. Interventions for improving theadoption of shared decision making by healthcare professionals.Cochrane Database Syst Rev 2010; (5): CD006732. DOI:10.1002/14651858.CD006732.pub2.
5. Moola S, Lockwood C. Effectiveness of strategies for the man-agement and/or prevention of hypothermia within the adultperioperative environment. Int J Evid Based Healthc 2011; 9:337–45.
6. Sudsawad P. Knowledge translation: introduction to models,strategies, and models. 2007. National Center for the Dissemi-nation of Disability Research [Online]. Accessed 12 Oct 2011.Available from: http://www.ncddr.org/kt/products/ktintro/
7. Jayasekara R. The effect of educational components and strat-egies associated with insulin pump therapy (IPT): a systematicreview. Int J Evid Based Healthc 2011; 9: 346–61.
8. Ciufo D, Hader R, Holly C. A comprehensive systematic reviewof visitation models in adult critical care units within the contextof patient- and family-centered care. Int J Evid Based Healthc2011; 9: 362–87.
9. Centers of Medicare and Medicaid. Administration implementsaffordable care act provision to improve care, lower costs. 2011.US Department of Health and Human Resources [Online].Accessed 12 Oct 2011. Available from: http://www.hhs.gov/news/press/2011pres/04/20110429a.html
10. Patient Protection and Affordable Care Act of 2010, Pub. L. No.111–148, 111th Cong-148, pp. 727–745 (March 23, 2010).
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© 2011 The AuthorInternational Journal of Evidence-Based Healthcare © 2011 The Joanna Briggs Institute
