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Background: This position paper highlights the opportunistic integral role of the pharmacist across the patient pathway utilizing cardiovascular care as an example. The paper aims to highlight the potential roles that pharmacists worldwide can have (or already have) to provide efficient patient care in the context of interprofessional collaboration. Methods: It results from a literature review and experts seeking advice to identify existing interventions and potential innovative interventions. We developed a conceptual framework highlighting seven critical phases in the patient pathway and for each of those listed some of the initiatives identified by our experts worldwide. Results: Existing pharmacists' interventions in each of these phases have been identified globally. Various examples in the area of prevention and self‐management were found to exist for long; the contribution for early detection and subsequently to timely diagnosis were also quite clear; integration of care was perhaps one of the areas needing greater development, although interventions in secondary care were also quite common. Tertiary care and end of life interventions were found to often be left for other healthcare professionals. Conclusion: On the basis of the findings, we can argue that much has been done but globally consider that pharmacists are still an untapped resource potentially useful for improved patient care. [ABSTRACT FROM AUTHOR]

Objective To disentangle the concepts of primary health care and primary care as well as their conceptual and empirical ramifications for progressive transformation. Methods over 400 international and interdisciplinary abstracts and papers with 96 annotated bibliography abstracts of literature across multiple dimensions relating to the knowledge base around mechanisms in PHC development were reviewed. The text is confronted with the reality, as it exists in the field and makes the case for complexity perspectives to assess this phenomenon in its context. Conclusion PHC complexity is an important analytical tool to interrogate the ways in which this phenomenon is socially constructed as well as in the matrices in which it is embedded. It is also a potent analytical tool to assist in the deconstruction of prevalent linear thinking built around PHC as a whole. [ABSTRACT FROM AUTHOR]

Approaches to time management in general practices characteristically focus on objective ‘clock time’, for example, through appointment scheduling. No less important, however, is how patients experience time duration. Time is experienced as having passed slowly (time prolongation), quickly (time compression) or in rough synchronization with clock time. Duration has been theorized to be positively associated with information processing. This paper builds on that theory to suggest how practices can influence patients’ subjective experience of duration in the practice environment, for example, by making waiting times appear to quicken and consultations appear to slow. [ABSTRACT FROM AUTHOR]

Evidence‐based medicine (EBM), one of the most important movements in health care, has been a lightning rod for controversy. Conflicts about the meaning and value of EBM are owing in part to lack of clarity about basic questions regarding its development, the importance of expertise and intuition, and the role of evidence in clinical decision making. These issues have persisted in part because of unclarity at the outset, but also because of how EBM evolved, why it was introduced when it was, and how it was modified following its introduction. This paper traces the evolution of EBM from clinical epidemiology (CE) and the internal dispute that precipitated the developers to establish EBM as a distinct approach to clinical practice. The paper proposes that health care industrialization also had a significant role in EBM's emergence and that industrialization influenced the decision to merge EBM with the method of normative decision making known as decision analysis (DA). The paper discusses the impact of this merger, in particular how it led to EBM's identification with managed care and has added momentum to the effort at forging a connection between a normative decision model and clinical judgement. This effort would turn clinical decision making into a conduit for bringing administrative rules and regulations into the consulting room and would result in expertise becoming a surplus skill. The paper closes by discussing a challenge yet unmet by EBM's advocates and critics—to chronicle the dangers that EBM in the framework of DA during the current era of industrialization poses to health and health care, and discover ways of unhinging the relationship between model and judgement. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Complex and chronic disease is placing significant pressure on hospital outpatient departments. Novel ways of delivering care have been developed recently and are often described as 'triage' services. This paper reviews the literature pertaining to definitions and descriptions of orthopaedic/musculoskeletal triage processes, in order to provide information on 'best practice' to assist health care facilities. Method A comprehensive open-ended search was conducted using electronic databases to identify studies describing models of triage clinics for patients with a musculoskeletal/orthopaedic complaint, who have been referred to hospital outpatient clinics for a surgical consultation. Studies were critically appraised using the McMaster quality appraisal tool and ranked using the National Health and Medical Research Council hierarchy of evidence. A thematic analysis of the definitions, processes and procedures of triage described within the literature was undertaken. Results 1930 studies were identified and 45 were included in the review (including diagnostic and evaluative research). The hierarchy of evidence ranged from I to IV; however, the majority were at low levels of evidence and scored poorly on the critical appraisal tool. Three broad themes of triage were identified: presence of a referral, configuration of the triage (who, how and where) and the aim of triage. However, there were significant inconsistencies across these themes. Conclusions This systematic review highlighted the need for standardization of the definition of triage, the procedures of assessment and management and measures of outcome used in orthopaedic/musculoskeletal triage to ensure best-practice processes, procedures and outcomes for triage clinics. [ABSTRACT FROM AUTHOR]

Many organisations struggle to achieve their true potential. In part it is a problem of organisational design, which is an outcome of a particularly common—command and control—leadership philosophy. The traditional linear hierarchical structure of organisations suggests that all knowledge and power concentrates at the top organisational layer, and that people in the lower layers need to be told what to do and when. These arrangements disempower people at the lower level, preventing them from providing the necessary feedback to pre‐emptively address emerging concerns. Systems and complexity thinking provide different ways of understanding organisations and their complex adaptive behaviours. In this paper, we first describe the key characteristics of complex adaptive organisations—their structure and dynamic behaviours—and then propose a three‐dimensional visualisation of a complex adaptive organisation that allows its members to clearly see and appreciate its interdependencies. [ABSTRACT FROM AUTHOR]

Abstract Rationale, aims and objectives Clinical governance has been advanced as a mechanism for continuous quality improvement within the UK National Health Service (NHS). This study aimed to assess whether evidence exists to support this claim. Methods A Medline search for evidence to link the introduction of clinical governance to improvements in the quality of health care was conducted. Results Of the 335 papers retrieved initially, 114 were potentially relevant to the question, but only 10 attributed changes in quality to clinical governance directly. Of these, only three attempted to provide data to support the assertion. Conclusion No sound evidence currently exists to support the claim that clinical governance will increase service quality and moves towards its implementation must therefore be questioned. [ABSTRACT FROM AUTHOR]

Background: Implementation science (IS) should contribute to maintaining high standards of care across healthcare systems and enhancing care practices. However, despite the evident need for greater and more rapid uptake and integration of evidence in practice, IS design and methodology fall short of the needs of effective translation. Aim: In this paper we examine what it is about IS that makes it so appealing for effective uptake of interventions in routine practice, and yet so difficult to achieve. We propose a number of ways that implementation scientists could build mutual relationships with healthcare practitioners and other stakeholders including public members to ensure greater shared care practices, and highlight the value of IS training, collaborative educational events, and co‐designed research. Discussion: More consideration should be given to IS applications in healthcare contexts. Implementation scientists can make a valuable contribution by mobilizing theory and improving practice. However, goals for an evidence‐based system may be more appropriately achieved through greater outreach and collaboration, with methods that are flexible to support rapid implementation in complex adaptive systems. Collective learning and mutual trust can be cultivated by embedding researchers into healthcare services while offering greater opportunities for practitioners to learn about, and engage in, implementation research. Conclusion: To bridge the worlds of healthcare practice and IS, researchers could be more consistent in the relationships they build with professionals and the public, communicating through a shared language and co‐joining practical approaches to effective implementation. This will build capacity for improved collaboration and foster respectful, interdisciplinary relationships. [ABSTRACT FROM AUTHOR]

This special forum on resilience explores particular worldviews of resilience—clinical, psychosocial, sociological, complexity science, organizational, and political economy through eight papers. This forum aims to open up the wealth of understandings and implications in health care by taking a transdisciplinary overview. [ABSTRACT FROM AUTHOR]

Stigma has been associated with delays in seeking treatment, avoiding clinical encounters, prolonged risk of transmission, poor adherence to treatment, mental distress, mental ill health and an increased risk of the recurrence of health problems, among many other factors that negatively impact on health outcomes. While the burdens and consequences of stigma have long been recognized in the health literature, there remains some ambiguity about how stigma is experienced by individuals who live with it. The aim of this paper is to elucidate the phenomenology of stigma, or to describe how it is that stigma shows up in the first‐person experience of individuals who live with stigma and its burdens. Exploring the relationship between shame and stigma, I argue that shame anxiety, or the chronic anticipation of shame, best characterises the experience of living with a health‐related, or health‐relevant, stigma. Understanding the experiential features, or phenomenology, of shame anxiety will give healthcare professionals a greater sensitivity to stigma and its impacts in clinical settings and encounters. I will conclude by suggesting that 'shame‐sensitive' practice would be beneficial in healthcare. [ABSTRACT FROM AUTHOR]

Evidence‐based healthcare is the prevailing model for healthcare services. In Cochrane's seminal thinking, political context was included with the purpose of promoting healthcare equity. However, the subsequent evidence‐based healthcare models marginalized political context. In this paper, we argue that current models of evidence‐based healthcare fail to respond to emerging healthcare challenges. We claim that reintegration of political context is crucial to make healthcare sustainable. Global communities are anticipating ecological crises with immense repercussions for healthcare. This prospect illustrates that healthcare models failing to integrate political context also risk neglecting some of the most relevant healthcare issues of our time. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Expanded financial coverage is critical to fight against poverty through public health reforms in developing countries. This study explores inequity in public health financing reforms in Turkey between 2003 and 2015. Methods: This paper has two parts. The first part examines inequity in health care financing in Turkey between 2003 and 2015. Gini, entropy (Theil and mean logarithmic deviation), and Atkinson indexes were calculated. In the second part of the paper, we investigated the degree of progressivity by using Kakwani index and Lorenz and concentration curves. Results: We found a decreasing trend in terms of inequity. After major public health reforms and unification of the health financing system, it is seen that the distribution of out‐of‐pocket expenditure on health stands on the shoulders of vulnerable groups. Conclusions: Study results provide a deep understanding of the effects of poverty on public health financing reforms on households in Turkey. To reduce out‐of‐pocket health spending inequities and to protect vulnerable groups from increasing the level of health expenditures, we suggest that the government enlarges health insurance coverage for the poor. [ABSTRACT FROM AUTHOR]

Abstract: Rationale: Regardless of health issue, health sector, patient condition, or treatment modality, the chances are that provision is supported by “a guideline” making professionally endorsed recommendations on best practice. Against this background, research has proliferated seeking to evaluate how effectively such guidance is followed. These investigations paint a gloomy picture with many a guideline prompting lip service, inattention, and even opposition. This predicament has prompted a further literature on how to improve the uptake of guidelines, and this paper considers how to draw together lessons from these inquiries. Methods: This huge body of material presents a considerable challenge for research synthesis, and this paper produces a critical, methodological comparison of 2 types of review attempting to meet that task. Firstly, it provides an overview of the current orthodoxy, namely, “thematic reviews,” which aggregate and enumerate the “barriers and facilitators” to guideline implementation. It then outlines a “realist synthesis,” focussing on testing the “programme theories” that practitioners have devised to improve guideline uptake. Results: Thematic reviews aim to provide a definitive, comprehensive catalogue of the facilitators and barriers to guideline implementation. As such, they present a restatement of the underlying problems rather than an improvement strategy. The realist approach assumes that the incorporation of any guideline into current practice will produce unintended system strains as different stakeholders wrestle over responsibilities. These distortions will prompt supplementary revisions to guidelines, which in turn beget further strains. Realist reviews follow this dynamic understanding of organisational change. Conclusions: Health care decision makers operate in systems that are awash with guidelines. But guidelines only have paper authority. Managers do not need a checklist of their pros and cons, because the fate of guidelines depends on their reception rather than their production. They do need decision support on how to engineer and reengineer guidelines so they dovetail with evolving systems of health care delivery. [ABSTRACT FROM AUTHOR]

Aims and objectives: The aim of this paper is to present the Venus model for workforce transformation, demonstrating its research origins, theoretical foundations, and practical application for enabling individuals, teams, and services to sustain transformation in the workplace. Methods: The paper provides a brief synopsis of how the Venus model was generated from four large‐scale mixed‐method studies embracing workforce transformation, safety culture, integrated facilitation, and continuous professional development. Results: The Venus model has five stems and identifies key integrated skill sets pivotal to successful transformation, which are interdependent:Being able to facilitate an integrated approach to learning, development, improvement, knowledge translation, inquiry, and innovation—drawing on the workplace itself as an influential resource;Being a transformational and collective leader building relationships that encourage curiosity, creativity, and harnessing the talents of all not just a few;Being a skilled practice developer focused on achieving the key values of being person‐centred, and the ways of working that are collaborative, inclusive, and participative;Applying improvement skills that enable small step change using measurement wisely to focus on measuring what is valued as well as evaluating positive progress; and, finallyFacilitating culture change at the micro‐systems level while being attuned to the organizational and systems enablers required to support this. Conclusion: The paper concludes with consideration of implications for implementation of the model and its relevance for practice, policy, education, and future research as well as outlining potential limitations and conclusions. [ABSTRACT FROM AUTHOR]

The article comments on Mark Tonelli's paper on the integration of evidence-based approaches to clinical practice. The average patient needs to be compared with the actual patient because general findings cannot be applied to a particular patient. Casuistic decision making takes into account clinical experience, pathophysiological considerations, expert opinion, values and goals of the patient, along with the evidence from clinical research.

Abstract: Aim: This paper reports on the findings from 6 focus groups conducted with Australian medical students. The focus groups sought students' perspectives on how the influence of commercial interests on medical practice and education could be managed. Method: We conducted 6 focus groups with medical students in New South Wales, Australia. Participants were recruited via student‐run medical society and faculty e‐mail lists. Forty‐nine students from 6 medical schools in New South Wales participated. The research team reflected on the extent to which students uncritically appealed to science in the abstract as a management solution for conflicts of interest. Data analysis was largely inductive, looking for uses of scientific terminology, EBM, and appeals to “science” in the management of COI and applied theoretical analyses of scientism. Results: The students in our study suggested that science and evidence‐based medicine, rather than ethics or professionalism, were the best tools to deal with undue influence and bias. This paper uses philosophy of science literature to critically examine these scientistic appeals to science and EBM as a means of managing the influence of pharmaceutical reps and commercial interests. We argue that a scientistic style of reasoning is reinforced through medical curricula and that students need to be made aware of the epistemological assumptions that underpin science, medicine, and EBM to address the ethical challenges associated with commercialised health care. Conclusion: More work is needed to structure medical curricula to reflect the complexities of practice and realities of science. However, curricula change alone will not sufficiently address issues associated with commercial interests in medicine. For real change to occur, there needs to be a broader social and professional debate about the ways in which medicine and industry interact, and structural changes that restrict or mitigate commercial influences in educational, research, and policy settings. [ABSTRACT FROM AUTHOR]

Abstract: Systems thinking and reference to complexity science have gained currency in health sector practice and research. The extent to which such ideas might represent a mere passing fad or might more usefully be mobilized to tackle wicked problems in health systems is a concern underpinning this paper. Developing the usefulness of the systems idea requires appreciating how systems ideas are used essentially as constructs conceptually bounded by practitioners. Systems are used for purposes of understanding and engaging the reality of health issues, with the intent of transforming the reality into one that is more manageable, equitable, and sustainable. We examine some manifestations of the systems idea in health practice and the traditions of systems practice that variously make use of them. This provides a platform for proposing a systems thinking in (health) practice heuristic: a learning device supporting how different tools and methods can address “wicked problems” in health praxis. The device is built on the use of “conversation” as a metaphor to help practitioners use systems ideas in tandem with existing disciplinary and professional skills and methods. We consider how the application of the heuristic requires, and helps to develop, human characteristics of humility, empathy, and recognition of fallibility. [ABSTRACT FROM AUTHOR]

In recent years there has been an explosion of interest in Artificial Intelligence (AI) both in health care and academic philosophy. This has been due mainly to the rise of effective machine learning and deep learning algorithms, together with increases in data collection and processing power, which have made rapid progress in many areas. However, use of this technology has brought with it philosophical issues and practical problems, in particular, epistemic and ethical. In this paper the authors, with backgrounds in philosophy, maternity care practice and clinical research, draw upon and extend a recent framework for shared decision‐making (SDM) that identified a duty of care to the client's knowledge as a necessary condition for SDM. This duty entails the responsibility to acknowledge and overcome epistemic defeaters. This framework is applied to the use of AI in maternity care, in particular, the use of machine learning and deep learning technology to attempt to enhance electronic fetal monitoring (EFM). In doing so, various sub‐kinds of epistemic defeater, namely, transparent, opaque, underdetermined, and inherited defeaters are taxonomized and discussed. The authors argue that, although effective current or future AI‐enhanced EFM may impose an epistemic obligation on the part of clinicians to rely on such systems' predictions or diagnoses as input to SDM, such obligations may be overridden by inherited defeaters, caused by a form of algorithmic bias. The existence of inherited defeaters implies that the duty of care to the client's knowledge extends to any situation in which a clinician (or anyone else) is involved in producing training data for a system that will be used in SDM. Any future AI must be capable of assessing women individually, taking into account a wide range of factors including women's preferences, to provide a holistic range of evidence for clinical decision‐making. [ABSTRACT FROM AUTHOR]

The goals of learning health systems (LHS) and of AI in medicine overlap in many respects. Both require significant improvements in data sharing and IT infrastructure, aim to provide more personalized care for patients, and strive to break down traditional barriers between research and care. However, the defining features of LHS and AI diverge when it comes to the people involved in medicine, both patients and providers. LHS aim to enhance physician‐patient relationships while developments in AI emphasize a physicianless experience. LHS also encourage better coordination of specialists across the health system, but AI aims to replace many specialists with technology and algorithms. This paper argues that these points of conflict may require a reconsideration of the role of humans in medical decision making. Although it is currently unclear to what extent machines will replace humans in healthcare, the parallel development of LHS and AI raises important questions about the exact role for humans within AI‐enabled healthcare. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Transitions of care between healthcare facilities are associated with increased risk of adverse events and hospital readmissions. Previous studies employing pharmacists in transitions of care showed reduced 30‐day readmissions, however, many were without an active comparator. There is no standardized approach to pharmacist involvement in transitions of care services, making it difficult to ascertain where pharmacist expertise is most meaningful. This paper aims to compare the 30‐day hospital readmissions between an interprofessional hospital discharge visit (iHDV) with physician and pharmacist involvement to a non‐interprofessional HDV (PHDV) without pharmacist involvement. Method: This was a retrospective quality improvement initiative examining patients of two outpatient clinical practices within a large, academic medical centre. The primary analysis compared 30‐day hospital readmission rates for patients with a scheduled PHDV or iHDV within 30‐days of index hospital discharge date, regardless of attendance at the HDV. The secondary outcome compared 30‐day hospital readmission rates for patients who completed a PHDV or iHDV. Primary and secondary outcomes were evaluated using bivariate analysis and multivariate analysis by stepwise logistic regression, for both intention‐to‐treat (ITT) and per protocol (PP). Results: This study found significantly lower 30‐day hospital readmissions for patients scheduled for a PHDV compared to an iHDV (16.7% vs 21.5%, P =.0230) in an unadjusted analysis, but no significant difference in adjusted analyses (P =.4856). Per‐protocol analysis found no significant difference in 30‐day hospital readmission rates between groups in unadjusted and adjusted analyses. Visit completion rates were significantly different between groups, with approximately twice as many PHDV group patients completing visits as compared to the iHDV group (74.1% vs 61.5%, P <.0001). Conclusion: This study demonstrates an interprofessional clinic visit employing a clinical pharmacist in the post‐hospital discharge visit did not significantly reduce 30‐day hospital readmission rates compared to a post‐hospital discharge visit without pharmacist involvement. [ABSTRACT FROM AUTHOR]

Whilst medicine is now an immense global industry clinicians often appear unclear as to its goals. This paper uses two philosophical steps to clarify our conceptualization of health and thus our goals for healthcare. Firstly, clinicians need to understand the significance of Hume's fact / value distinction in medicine, for medicine relies on both facts and values. Secondly clinicians need a better specified definition of 'health' to use as a goal for healthcare. Aristotle's model of human flourishing is used as the starting point for a new conceptualization of health. [ABSTRACT FROM AUTHOR]

Objective Substitution of skills has been introduced to increase health service efficiency, but little evidence is available about its cost-effectiveness. This systematic review aims to identify economic evaluations of substitution between professionals, to assess the quality of the study methods applied and to value the results for decision making. Methods Publications between January 1996 and November 2006 were searched in Medline, Cochrane, Cinahl, database of Health Technology Assessments, EPOC and Embase. Randomized controlled trials (RCTs), cost–benefit analysis, interrupted time series design and systematic reviews were selected. The methodological quality of the papers was reviewed, using the critical appraisal of Drummond and the EPOC list. Results Eleven studies were finally included of 7605 studies: three cost-effectiveness studies, three cost-minimization studies and five studies related to partial economic evaluations. Small numbers of participating professionals and several limitations in the cost valuation and the measurement of costs were identified. Conclusions Several potential limitations influence the validity and generalizability. Full economic evaluations per se are of limited value for making decisions about substitution of skills. The tenuous relationship between structural, process and outcome variables is not sufficient investigated. For meaningfully placing the costs and consequences of substitution of skills in the context of health care and generating relevant data for decision making, it is strongly recommended to combine an economic evaluation (RCT) with an observational longitudinal study. [ABSTRACT FROM AUTHOR]

Rationale In the evolution of the team concept, clear distinctions between ‘groups’ and ‘teams’ were made. In this paper we argue that these distinctions were not made explicit in the translation of team structures to health care. Even though teams are appropriate for many health care settings, this paper explores the notion that when teams may not be working, it is the concept of team that may not be appropriate, not the functioning of the team itself. Methods This paper reviews the differences between teams and groups, and identifies how these differences are expressed in health care settings using urban and rural examples from the UK and Australia. Results Some suggestions about matching structures to suit the unique nature of health care provision, particularly in community health settings, are made. Discussion Instead of concentrating on improving the process of teams, the focus could be better directed to ensure that whatever structure is utilized best facilitates the necessary outcomes in the most effective way. The team approach may not always be the best approach, and sometimes referring to a number of people working together as a group is sufficient. [ABSTRACT FROM AUTHOR]

The article comments on the paper of Pascal Borry and colleagues on evidence-based medicine and its role in ethical decision making. They raised questions regarding the value of medical evidence, which questions the assumption that evidence-based medicine will necessarily improve medical care for the patient. They sometimes equate evidence with what K. Goodman means by information and treating it as a purely empirical/factual concept. They are also influenced by Goodman, and this influence would explain their intuition that evidence is also an evaluative concept.

This paper is the second of three related papers exploring the ways in which the principles of Learning Organizations (LOs) could be applied in Primary Care settings at the point of service delivery. Based on a theoretical and empirical review of available evidence, here we introduce the process by which a Practice can start to become a Learning Practice (LP). Steps taken to enhance both individual and organizational learning begin the process of moving towards a learning culture. Attention is given to the routines that can be established within the practice to make learning systematically an integral part of what the practice does. This involves focusing on all three of single-, double- and triple-loop learning. Within the paper, a distinction is made between individual, collective and organizational learning. We argue that individual and collective learning may be easier to achieve than organizational learning as processes and systems already exist within the Health Service to facilitate personal learning and development with some opportunities for collective and integrated learning and working. However, although organizational learning needs to spread beyond the LP to the wider Health Service to inform future training courses, policy and decision-making, there currently seem to be few processes by which this might be achieved. This paper contributes to the wider quality improvement debate in three main ways. First, by reviewing existing theoretical and empirical material on LOs in health care settings it provides both an informed vision and a set of practical guidelines on the ways in which a Practice could start to effect its own regime of learning, innovation and change. Second, it highlights the paucity of opportunities individual general practitioner practices have to share their learning more widely. Thirdly, it adds to the evidence base on how to apply LO theory and activate learning cultures in health care settings. [ABSTRACT FROM AUTHOR]

This paper is the third of three related papers exploring the ways in which the principles of Learning Organizations (LOs) could be applied in Primary Care settings at the point of service delivery. Here we provide a systematic literature review of contextual factors that either play a key role in providing a facilitative context for a Learning Practice or manifest themselves as barriers to any Practice's attempts to develop a learning culture. Core contextual conditions are identified as, first, the requirement for strong and visionary leadership. Leaders who support and develop others, ask challenging questions, are willing to be learners themselves, see possibilities and make things happen, facilitate learning environments. The second core condition is the involvement and empowerment of staff where changes grow from the willing participation of all concerned. The third prerequisite is the setting-aside of times and places for learning and reflection. This paper contributes to the wider quality improvement debate in three main ways. First, by highlighting the local contextual issues that are most likely to impact on the success or failure of a Practice's attempts to work towards a learning culture. Second, by demonstrating that the very same factors can either help or hinder depending on how they are manifest and played out in context. Third, it adds to the evidence available to support the case for LOs in health care settings. [ABSTRACT FROM AUTHOR]

This paper is the first of three related papers exploring the ways in which the principles of Learning Organizations (LOs) could be applied in Primary Care settings at the point of service delivery. Here we introduce the notion of the Learning Practice (LP) and outline the characteristics and nature of an LP, exploring cultural and structural factors in detail. Drawing upon both theoretical concepts and empirical research into LOs in health care settings, the format, focus and feasibility of an LP is explored. Characteristics of LPs include flatter team-based structures that prioritize learning and empowered change, involve staff and are open to suggestions and innovation. Potential benefits include: timely changes in service provision that are realistic, acceptable, sustainable, and owned at practitioner level; smoother interprofessional working; and fast flowing informal communication backed up by records of key decisions to facilitate permanent learning. Critical comment on potential pitfalls and practical difficulties highlights features of the present system that hinder development: tightly defined roles; political behaviours and individual-oriented support systems; plus the ongoing difficulties involved in tolerating errors (whilst people learn). This paper contributes to the wider quality improvement debate in the area in three main ways. First, by locating Government's desires to create health systems capable of learning within the theoretical and empirical evidence on LOs. Second, it suggests what an LP could be like and how its culture and structures might benefit both staff and patients in addition to meeting externally driven reforms and health priorities. Third, it extends the application of LO concepts to the health care sector locating the principles in bottom-up change. [ABSTRACT FROM AUTHOR]

Current day realities of diminishing resources, reductions in spending and organizational change within health care systems have resulted in an increased emphasis on a multidisciplinary team approach to quality patient care. The movement of nursing towards more autonomous practice combined with the current trend towards ‘evidence-based practice’ in health care demands increased accountability in clinical decision making. This paper focuses on one aspect of nurses’ clinical decision making within the demands of evidence-based practice and cardiac surgery. In this field recent advances, combined with increasing demands on health care institutions, have promoted early extubation of post-operative cardiac patients. While this remains a medical role in many institutions, an increasing number of intensive care units now consider it as a nursing role. This paper explores the realities of nurses’ clinical decision making through a discussion of current practice in the extubation of patients following cardiac surgery. In addition, it considers the implications of current practice for both nurse education and the continued development of clinical nursing practice. The findings indicate that evidence-based practice appears to be an incomplete model of the relationship between theory and professional work. [ABSTRACT FROM AUTHOR]

Summary Clinical governance was intended to ensure clinical quality in the National Health Service. Its first full description, in the British Medical Journal in 1998, seemed to some to be more rhetoric than substance. Now, 3 years on, its proponents believe it is starting to achieve its purpose. The British Medical Journal has again published a paper, this time subtitled ‘turning vision into reality’. Expectations might have been that this paper would present evidence of how clinical governance is changing practice to ensure quality, but analysis of the paper shows that it does little more than repeat the rhetoric of the earlier description. It describes how clinical governance might be organized and what it might do, but not what it has done. Its authors repeat the idea that everyone can be ‘the best’ and achieve ‘excellence’, which is not reality at all. Anyone introducing a new method of managing the National Health System has the same obligation as those who introduce new treatments to provide evidence that the method works, and that the financial and non-financial costs are not too high. The new paper fails to provide that evidence. [ABSTRACT FROM AUTHOR]

Objective: In this article, we offer an extended critical review of a new conception of bioethics, presented by Darlei Dall'Agnol, in the book Care and Respect in Bioethics. Methods: Critical philosophical analysis of background assumptions of a new approach to bioethics, enriched with critical discussion of related philosophical literature. Results: In Care and Respect in Bioethics, through an approach filled with hard cases, Dall'Agnol argues that the metaethics of respectful care has theoretical advantages over the intuitionist metaethics of principlism and the particularism of casuistry, offering an original comprehensive approach that crosses the three dimensions of ethical inquiry: metaethical, normative, and applied ethics. Conclusions: Dall'Agnol offers an insightful and persuasive account of how the single attitude of respectful care can express practical moral knowledge in healthcare. In this paper, we evaluate, criticize, and suggest refinements. One of them concerns Dall'Agnol's interpretation about Stephen Darwall's views on care and respect as two attitudes supported, respectively, by a third‐ and a second‐personal moral point‐of‐view. Other is about the Dall'Agnol's Wittgensteinian description of the moral language‐games of Clinical Bioethics, adding to the approach the "language‐game of rights." [ABSTRACT FROM AUTHOR]

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy 'at the bedside'? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions - about what we should do in any given situation - are embedded within whole understandings of the situation, inseparable from our beliefs about what is the case (metaphysics), what it is that we feel we can claim to know (epistemology), as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition. [ABSTRACT FROM AUTHOR]

Abstract: Clinical practice guidelines (CPGs) and clinical pathways have become important tools for improving the uptake of evidence‐based care. Where CPGs are good, adherence to the recommendations within is thought to result in improved patient outcomes. However, the usefulness of such tools for improving patient important outcomes depends both on adherence to the guideline and whether or not the CPG in question is good. This begs the question of what it is that makes a CPG good? In this issue of the Journal, Djulbegovic and colleagues offer a theory to help guide the development of CPGs. The “fast‐and‐frugal tree” (FFT) heuristic theory is purported to provide the theoretical structure needed to quantitatively assess clinical guidelines in practice, something that the lack of theory to guide CPG development has precluded. In this paper, I examine the role of FFTs in providing an adequate theoretical framework for developing CPGs. In my view, positioning guideline development within the FFT framework may help with problems related to adherence. However, I believe that FTTs fall short in providing panel members with the theoretical basis needed to justify which factors should be considered when developing a CPG, how information on those factors derived from research studies should be interpreted, and how those factors should be integrated into the recommendation. [ABSTRACT FROM AUTHOR]

Abstract: Rationale, aims, and objectives: Patients with somatoform disorders are frequent attenders in primary and secondary care. While co‐morbid mental disorders, especially depression and anxiety, are frequently present, there is controversy on whether mental co‐morbidity leads to higher health care utilization (HCU). The present paper investigates the influence of co‐morbid depressive and anxiety disorders on primary, specialized somatic and mental HCU in primary care patients with somatoform disorders. Additionally, we investigated the predictive value of self‐rated health and illness perception on HCU. Methods: Patients in 19 primary care practices were screened with the Patient Health Questionnaire, and patients at high risk for somatoform disorders were assessed using the Composite International Diagnostic Interview. N = 71 patients with somatoform disorders were analysed. We analysed whether having one vs two co‐morbidities (depression and/or anxiety), self‐rated health, and illness perception were predictors for primary, specialized somatic and mental HCU using binominal and hierarchical regression analyses. Results: Having both co‐morbid depressive and anxiety disorder predicted higher primary HCU (IRR = 1.96, 95% CI, 1.30‐2.93), and increased the odds of being in mental health care (OR = 5.16, 95% CI, 1.10‐24.20), while only one co‐morbidity did not. No differences were found for specialized somatic HCU. Illness perception and self‐rated health did not predict HCU. Conclusion: Not a single but only the presence of multiple co‐morbidities predicts primary and mental HCU in patients with somatoform disorder. Health care utilization might be essentially influenced by the associated psychological distress, which should be considered in treatment. [ABSTRACT FROM AUTHOR]

Abstract: In spite of substantial spending and resource utilization, today's health care remains characterized by poor outcomes, largely due to overuse (overtesting/overtreatment) or underuse (undertesting/undertreatment) of health services. To a significant extent, this is a consequence of low‐quality decision making that appears to violate various rationality criteria. Such suboptimal decision making is considered a leading cause of death and is responsible for more than 80% of health expenses. In this paper, we address the issue of overuse or underuse of health care interventions from the perspective of rational choice theory. We show that what is considered rational under one decision theory may not be considered rational under a different theory. We posit that the questions and concerns regarding both underuse and overuse have to be addressed within a specific theoretical framework. The applicable rationality criterion, and thus the “appropriateness” of health care delivery choices, depends on theory selection that is appropriate to specific clinical situations. We provide a number of illustrations showing how the choice of theoretical framework influences both our policy and individual decision making. We also highlight the practical implications of our analysis for the current efforts to measure the quality of care and link such measurements to the financing of health care services. [ABSTRACT FROM AUTHOR]

Evidence-based health care (EBHC), previously evidence-based medicine (EBM), is considered by many to have modernized health care and brought it from an authority-based past to a more rationalist, scientific grounding. But recent concerns and criticisms pose serious challenges and urge us to look at the fundamentals of a changing EBHC. In this paper, we present French philosopher Bruno Latour's vision on modernity as a framework to discuss current changes in the discourse on EBHC/EBM. Drawing on Latour's work, we argue that the early EBM movement had a strong modernist agenda with an aim to 'purify' clinical reality into a dichotomy of objective 'evidence' from nature and subjective 'preferences' from human society and culture. However, we argue that this shift has proved impossible to achieve in reality. Several recent developments appear to point to a demise of purified evidence in the EBHC discourse and a growing recognition-albeit implicit and undertheorized-that evidence in clinical decision making is relentlessly situated and contextual. The unique, individual patient, not abstracted truths from distant research studies, must be the starting point for clinical practice. It follows that the EBHC community needs to reconsider the assumption that science should be abstracted from culture and acknowledge that knowledge from human culture and nature both need translation and interpretation. The implications for clinical reasoning are far reaching. We offer some preliminary principles for conceptualizing EBHC as a 'situated practice' rather than as a sequence of research-driven abstract decisions. [ABSTRACT FROM AUTHOR]

Rationale People working in the health sector have been looking to complexity science to help them deal with the complex phenomena they encounter in their everyday working practice. While complexity science has assisted many in the field to look at the complex issues from a different viewpoint and explained the emergence of complex phenomena, however, practicable, pragmatic approaches and techniques have not been provided. Aims and objectives In this article, actual issues and challenges that these practitioners face and the needs they expressed during a workshop called 'Putting Complexity to Work - Supporting the Practitioners' are discussed. Conclusion As the nature of complexity offers no one single ultimate solution, the paper concludes that, for operationalizing the insights received from complexity science into their day-to-day work, practitioners in health care and other domains need to address a range of challenges that are outlined in the paper. [ABSTRACT FROM AUTHOR]

Uncertainty is unavoidable in health care, yet frequently tacit. When uncertainty is acknowledged, it tends to be defined in terms of the unpredictable nature of the care, and limits to human knowledge. It is cast as a problem that evidence-based health care can minimize. Challenging that simplistic perspective, this paper reconstructs uncertainty as a property whose meaning derives from how people are relationally disposed to perceive it in the social context in which they are embedded. Five conditions are suggested to define a need to protect and cultivate uncertainty as a virtue or positive disposition. These conditions are that uncertainty is natural, promotes creativity and a critical attitude, can signify wisdom, nurtures safety, sustains hope and protects against excess. In contrast, certainty is a delusion. Believing in certainty is unscientific and antiscientific because it can obscure and devalue critique in scientific practice. [ABSTRACT FROM AUTHOR]

The concept of complexity is a popular and contentious topic. Just what is complexity? What does it mean to ‘think complexly’? This paper addresses both of these issues. Complexity thinking is impossible to define with any precision as it deals not only with change, dynamic change, evergoing, but with transformative change. Definitions require stability, the very element complexity neither has nor aspires to have. Instead complexity asks us to see, to deal with a world in continual flux; but a world that does have patterns to it, patterns that bind and structure through their interplay. In short, complexity seeing/thinking asks us to envision our world and events within that world in terms, not of ‘things’ but of process. In so doing, we are moving from a science that studies particles to the new sciences of chaos and complexity that study the interactive relations between and among particles, events, happenings. After distinguishing the similarities and contrasts between chaos and complexity, and showing the characteristics of each, along with looking at systems closed and open, frames modern and post-modern, this paper enumerates practical aspects of thinking complexly: accepting ambiguity, allowing humility to permeate one's being, and seeking out and utilizing difference and diversity. The health care profession by its very nature of dealing with that which is dynamically living deals with the complex daily. Its routines and rules, though, are too often caught in a modernist trap. This paper challenges all health care professionals to break free from that trap, and suggests ways to do so. [ABSTRACT FROM AUTHOR]

In this paper we argue that policy calls for personalization or ‘tailored’ services derive a large part of their appeal from the way they ‘fudge together’ different things. Using the recent policy discourses surrounding personalization in the UK NHS as a case study we illustrate the policy ‘work’ that is accomplished by this vagueness and focus in on one important fudge – that between a health service tailored to people's medically defined needs and one tailored to people's wants. Our analysis highlights some of the fundamental philosophical and political questions that need to be addressed before personalization can take shape as a coherent policy option. We also highlight the potential scale of the implications personalization has for the welfare state and argue that such implications warrant greater discussion than is currently being afforded to them. We conclude that philosophical analysis is crucial for guiding the redirection of services implied by personalization discourses. The process of selecting and justifying the way in which the personalization agenda is advanced requires both an analysis of the relationships between needs and wants in human flourishing and an explicit reconsideration of the purpose of the welfare state. [ABSTRACT FROM AUTHOR]

Objective To evaluate the impact of protocol-based care on nursing roles, practice and service delivery. Design Case study evaluation informed by realistic evaluation methodology. Qualitative data collection methods were used including non-participant observation, post-observation interviews with nurses and patients, key informant interviews, tracking patient journeys and document review. Participants 141 participants took part including 73 nurses, midwives and health visitors, 4 allied health professionals, 20 doctors, 5 support staff and 39 patients. Settings Five sites were purposively sampled and included acute and primary care service provision. Findings As a mechanism for standardization, the use of protocol-based care approaches such as guidelines, care pathways, protocols and algorithms was patchy and dependent on contextual, professional and individual factors. Protocol-based care approaches were commonly used as checklists and for reference; nurses and doctors expressed concern that such use could lead to a ‘tick box mentality’ and restricted judgement. By using standardized care approaches nurses were taking on new tasks and developing skills beyond the traditional scope of practice including prescribing, diagnosing, ordering tests and sometimes deciding on treatments. The ability to perform these roles meant that they were able to run clinics or services independently. The extension of roles to incorporate prescribing, for example, meant that nurses were able to provide a more streamlined service for patients because they did not have to refer to doctors. In turn, it was reported that this reduced doctors' workload. Protocol-based care was viewed as a ‘nurses' thing’; however, some General Practitioners and junior doctors were using available standardized care approaches. Conclusions The potential of standardization was mediated by the patchy use of protocol-based care approaches and negative perceptions about standardization. Use of protocol-based care has the potential to impact on nurses' roles, increasing their autonomy and subsequently impacting on service delivery. [ABSTRACT FROM AUTHOR]

Background and setting This paper outlines the development of a diagnostic tool to help Primary Care general practitioner (GP) Practices diagnose the extent to which they are developing effective techniques for collective learning and if their Practice culture supports innovation. This project is undertaken by the University of St Andrews and NHS Education for Scotland. Methods Based on Learning Organization and Organizational Learning theory, and using a modified Behaviourally Anchored Rating Scale, the Learning Practice Inventory (LPI) identifies attitudes, behaviours, processes, systems and organizational arrangements associated with being a Learning Practice. The LPI is a self-assessment, fixed-choice, survey-feedback tool that surveys all Practice members. Results The survey-feedback tool empowers Practice members to view, assess and prioritize the developments they wish to make collectively to Practice life. The LPI assumes complexity and non-linearity in change processes, used longitudinally it tracks the impact of change on Practice life through time. Practitioners and Practices involved in its development give favourable feedback on the tool, and its potential usefulness. Discussion This contributes to our wider understanding in three main ways: first, it applies the ideas of Learning Organizations and Organizational Learning to health care settings. Second, as a practical advance, the tool assumes complexity, non-linearity and systemic knock-on effects during change in Primary Care. Third, it offers practitioners who work together the opportunity to share knowledge and learning in practical ways helping them to change by themselves and for themselves and their patients. [ABSTRACT FROM AUTHOR]

Aims and objectives The aim of this paper is to analyse the protocols used in German hospitals and nursing homes for the prevention of pressure ulcers with regard to their contents and accordance with the national standard of the Deutsches Netzwerk für Qualitätsentwicklung in der Pflege (DNQP) and the European Pressure Ulcer Advisory Panel (EPUAP) and Royal College of Nursing (RCN) guidelines. Additionally, it is to show the relation between the existence and contents of the protocols of pressure ulcer prevention and pressure ulcer prevalence in the institutions. Methods On a fixed date trained nursing staff gathers data regarding the frequency of pressure ulcers during a prevalence survey. The existence of a pressure ulcer is established by physical examination after the risk assessment with the Braden-Scale. The patient’s or resident’s informed consent is a precondition for his or her participation in the survey. The protocols are available as hard copies on paper or electronic files. Results Only two out of the 21 protocols developed in-house are completely concurrent with the expert standard. The EPUAP and RCN guidelines include the aspect of training and further education that is missing in the in-house protocols and the DNQP expert standard. Evaluation of the data reveals that there is no relation between the availability of protocols and pressure ulcer prevalence. Neither is there any relation between the contents and pressure ulcer prevalence. The institutions currently developing protocols have the lowest prevalence rates. Conclusion It is obvious that, while developing in-house protocols, the discussion about pressure ulcer prevention has led to a higher problem awareness in nurses and thus to an increased attentiveness in daily nursing practice which then results in improved outcomes. Two years after its publication, the expert standard is still not very well known, therefore this concentrated form of the most up-to-date knowledge is not available to all nursing staff as a basis for evidence-based practice. In addition, the sometimes outdated knowledge of nursing staff impedes the implementation of evidence-based practice guidelines. A systematic implementation strategy that assists guidelines being applied in practice is therefore required. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The development of rehabilitation and intermediate care services, and roles therein, is part of current UK health policy to meet the demands of the ever-growing older population. One new role is the rehabilitation assistant (RA). This is a generic support worker trained at a basic level in nursing, physiotherapy, occupational therapy and social work who works under the supervision of the referring professionals, to deliver integrated rehabilitation programmes. RAs were introduced in one region in the north-west of England to increase the rehabilitation activity for patients. An empirical qualitative study was recently undertaken to evaluate the impact of the RAs from the perspectives of patients and associated nurses, therapists, managers and the RAs. Methods Fifty-five semi-structured interviews were used to collect data, which was then inductively analysed into categories and then themes. The categories included variations in role, benefits of role, acceptance and integration of role, difficulties with role, training and retention. This paper focuses on the benefits and difficulties of the role. Results It was found that patients, professionals and the RAs expressed great satisfaction with the new role. However, barriers to effective rehabilitation were reported owing to ward routines and organizational systems that interrupted and caused inconsistencies with the rehabilitation care programmes for patients. Conclusions If it is agreed that the majority of patients (unless end stage terminally ill, unwilling or unable) could benefit from some degree of rehabilitation, then there is an issue around how such skills could be widely implemented. This paper discusses the barriers to effective rehabilitation, the benefits and drawbacks of looking at new ways of working and the need for a unified approach by all care workers in rehabilitative care. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives To assess the criterion validity of paper-and-pencil vignettes to assess guideline adherence by physiotherapists in the Netherlands. The evidence-based physiotherapy practice guideline for low back pain was used as an example. Methods Four vignettes were constructed and pre-tested. Three vignettes were found to represent an adequate case-mix. They described one patient with specific low back pain, one with non-specific low back pain and a normal recovery process and one with non-specific low back pain and a delay in the recovery process. Invited to participate were 113 primary care physiotherapists who had joined an randomized controlled trial study 8 months before, in which guideline adherence had been measured by means of semi-structured treatment recording forms. The criterion validity was determined with Spearman’s r s, using Cohen’s classification for the behavioural sciences to categorize its effect size. Results Of the 72 physiotherapists who agreed to participate, 39 completed the questions on the vignettes. In the end, both adherence measures were available for 34 participants, providing 102 vignettes and 268 recording forms. Mean guideline adherence scores were 57% (SD = 17) when measured by vignettes and 74% (SD = 15) when measured by recording forms. Spearman’s r s was 0.31 ( P = 0.036), which, according to Cohen’s classification, is a medium effect size. Conclusion Vignettes are of acceptable validity, and are an inexpensive and manageable instrument to measure guideline adherence among large groups of physiotherapists. Further validation studies could benefit from the use of standardized patients as a gold standard, a more diverse case mix to better reflect real physiotherapy practice, and the inclusion of longitudinal vignettes that cover the patients’ course of treatment. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Longstanding debate on evidence-based medicine (EBM) may have reached a critical saturation point. I briefly report on systematic reviews on the recurring themes in the critical literature. In this context, some criticisms to EBM are substantial and enduring, although convincing arguments to contrast unresolved issues have yet to be produced. Nonetheless, few changes have been adopted and conservative attitudes persist in EBM. Despite its ‘success’, implementation in practice has been inexorably overshadowed leading to paradoxical shortcomings. This controversial scenario offers a formidable occasion to gain needed insight. The aim of this paper is to attempt a comprehensive analysis by reframing a number of key concerns, while furnishing pragmatic, interdisciplinary solutions for these deep-rooted dilemmas. In the interests of all stakeholders, I seek to promote a concerted effort to resolve conflict and build consensus. Methods This paper explores a strategically unifying vision of primary care, based on current understanding of practice patterns, having a research-friendly ‘common ground’ where practitioners’ information needs may be met. In addition, an analysis of existing problems identifies underlying ‘root causes’. Moreover, I expediently reframe crucial matters by focusing on EBM, more than as a paradigm, as an organisation, hence amenable to a variety of cross-disciplinary analyses and solutions. Finally, recent state-of-the-art reviews on implementation and dissemination research are cited for the pertinent implications for study design and practice. Results Present policies and influential testimonials on behalf of EBM encounter the pitfalls of hindering learning and progress through defensive attitudes and mechanisms. Current study designs and evaluation criteria must strive to adapt to real-world settings, rather than vice versa. Conclusions The arguments exposed herein alter the terms of the debate on EBM and may outline a basis for initiatives with conflict-resolution and consensus-building scopes. [ABSTRACT FROM AUTHOR]

The article comments on Mark Tonelli's paper on the integration of evidence-based approaches to clinical practice. Tonelli proposes the adoption of a casuistic approach to clinical practice. He divided possible sources of medical evidence into five categories that are recognized as different in kind rather than in degree. The author thinks that Tonelli's proposed casuistic approach is realistic and easy to teach to medical students and residents.

The article comments on Mark Tonelli's paper on the integration of evidence-based approaches to clinical practice. Tonelli correctly pointed out important shortcomings of evidence-based medicine particularly in his claim that evidence-based medicine focuses on an attempt to treat differential potential warrants for medical decision making. His proposed casuistic model is a fruitful one, and his issues he raised are as much epistemic as they are existential and moral.

As is the case with most health care program evaluations, disease management (DM) programs typically follow an observational study design, indicating that randomization to treatment or control was not performed. The foremost limitation of observational studies, compared to randomized studies, is that the only biases that can be controlled for are those associated with observed variables. Hidden bias refers to all those unobserved covariates that may distort the conclusions of the study. This paper introduces a sensitivity analysis that is used to determine the magnitude of hidden bias necessary to alter the conclusion that a DM program intervention was indeed effective. [ABSTRACT FROM AUTHOR]

Abstract Rationale, aims, and objectives Evidence-based medicine (EBM) has given rise to evidence-based practice (EBP) in the field of mental health. EBP too is predicated on an evidence hierarchy and has the goal of using the “best evidence” (usually randomized controlled trials) to improve practice. EBP is increasingly influential in mental health care in the U.S. Growing numbers of researchers and public officials endorse its claims and pursue its benefits. The rationale for this paper is to examine the potential of EBP for the field of mental health—and public mental health care specifically. Is it likely to contribute to improved lives for mentally ill people? If so, how? Methods This qualitative study relies on archival, and to a much lesser extent, informant interview data. Informants were mostly public mental health officials because they are in a position to implement EBP on a large scale and their policies are a matter of public record. Interviews were semi-structured, held in person and on the telephone, and lasted one to two hours. Archival research included the substantial literature on EBM and EBP plus studies and articles on the practice and policy of U.S. public mental health care. Results The results of this study were that there exists an extensive, coherent literature critical of EBM and of EBP specifically. Attempts to implement EBP will falter on epistemological and organizational barriers. Still, as a public idea—that more science will bring about better mental health practice—EBP may well serve political purposes, especially in the U.S. public mental health system, where more overtly ideological policies have been inadequate in the past. EBP, as a public idea, has the advantage of ambiguity, accountability, quantifiability, etc. Conclusions This paper concludes that EBP is growing more influential in public mental health care in the U.S. Its practical strengths, i.e., its improvement of mental health... [ABSTRACT FROM AUTHOR]

AbstractPatient decision support (PDS) tools or decision aids have been developed as adjuncts to the clinical encounter. Their aim is to support evidence-based patient choice. Clinical trials of PDS tools have used an array of outcome measures to determine efficacy, including knowledge, satisfaction, health status and consistency between patient choice and values. This paper proposes that the correlation between ‘subjective expected utility’ (SEU) and decision may be the best primary endpoint for trials. SEU is a measure usually used in behavioural decision theory. The paper first describes how decision support tools may use decision analysis to structure the presentation of evidence and guide patient decision-making. Uses of expected utility (EU) are suggested for evaluating PDS tools when improving population health status is the objective. SEU is the theoretically better measure when internal consistency of patient choices is the objective. [ABSTRACT FROM AUTHOR]