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GRADE ("Grading of Recommendations Assessment, Development and Evaluation") provides a transparent framework to evaluate scientific evidence and to develop healthcare recommendations. The GRADE method has been further developed, its application has been significantly broadened and over 100 organizations have endorsed GRADE. In this article, we give an overview of the most important methodological developments and discuss the basic principles. The transparent approach to make it easier for users of evidence to assess the judgments behind recommendations is not only applicable to the EBM domains but also to other disciplines. The methods developments show that GRADE is still evolving, and is constantly being further developed based on the latest methodological insights and users perspective. GRADE is not an instrument to determine the "true" certainty of the evidence. The value of applying GRADE is that judgments about the quality of evidence and the considerations behind recommendations are structured, transparent and explicit.

The guideline-informed treatment for personality disorders (GIT-PD) was developed as an alternative to the specific treatments for personality disorders. Even though this form of treatment is widely used in health care and has been included in the Health Care Standard for Personality Disorders, its scientific evidence remains unclear.To review the indirect evidence for GIT-PD and compare it with the evidence for specific treatments.Literature review including reviews and meta-analyses in the field of personality disorders.Although there is increasing evidence for specific treatments, the amount of studies remains limited and the quality of the evidence is rather low. There are indications that specific treatments are poorly implemented in clinical practice, which may detract from their efficacy. There is no clear evidence that specific treatments are on average no more effective than well-designed generic treatments that are similar to GIT-PD. There is considerable evidence for the role of the common factors on which GIT-PD is based.There is indirect evidence for the efficacy of GIT-PD. Good care on a broad scale needs both specific and generic forms of treatment, whereby the most relevant question becomes how clients can be optimally allocated to both forms of treatment.

De prevalentie van multimorbiditeit stijgt met de leeftijd: ruim 70% van de 75-plussers heeft drie of meer chronische aandoeningen, veelal gecombineerd met kwetsbaarheid. In de huidige medische praktijk vormt evidence-based medicine met evidence-based richtlijnen de basis voor de behandeling. Het doel van deze studie is nagaan hoe toepasbaar de huidige medisch specialistische richtlijnen in de praktijk zijn bij de heterogene groep ouderen.Alle richtlijnen uit de Nederlandse Richtlijnendatabase werden onderzocht. De twaalf ouderen-specifieke richtlijnen werden vergeleken met de aanbevelingen uit de ‘methodiek’.In 117 richtlijnen (54%) werden algemene termen, zoals “oudere(n)” gevonden. Een leeftijdsgrens werd vermeld in 26 richtlijnen (12%). De term “kwetsbaarheid” werd genoemd in 38 richtlijnen (18%), de term “comorbiditeit” in 107 (50%) en “cognitieve problemen” in acht (4%). Vijf ouderen-specifieke richtlijnen maakten een onderscheid tussen wel en niet kwetsbare ouderen. Drie richtlijnen bespraken relevante uitkomstmaten voor ouderen.De resultaten laten zien dat de huidige richtlijnen in de praktijk niet optimaal toepasbaar zijn bij de diverse groepen ouderen. Ons inziens is aanpassing van de richtlijnen bij voorkeur door middel van implementatie van de ontwikkelde richtlijnmethodiek een noodzakelijke eerste stap in het bruikbaar maken van de huidige evidence-based richtlijnen uit de tweede lijn in Nederland voor de groeiende groep kwetsbare en multimorbide ouderen., The prevalence of multimorbidity increases with age, with over 70% of people aged 75 years and over having three or more chronic conditions, often combined with frailty. In current medical practice, evidence-based medicine with evidence-based guidelines forms the basis for treatment.The aim of this study is to determine the practical applicability of the current medical specialist guidelines for the treatment of the heterogeneous group of older patients.All guidelines from the Dutch guidelines database were examined. Twelve guidelines identified as elderly-specific were compared with the recommendations from the ‘methodology for the development of guidelines tailored to the elderly’.In 117 guidelines (54%) general terms such as ‘older’ or ‘elderly’ were found. An age limit was mentioned in 26 guidelines (12%). The term ‘frailty’ was mentioned in 38 guidelines (18%), the term ‘comorbidity’ in 107 (50%) and cognitive problems in eight (4%). Five age-specific guidelines distinguished frail from non-frail older people. Three guidelines discussed relevant outcome measures for the elderly.The results show that the practical applicability of current guidelines is not optimal for the various groups of older people. In our opinion, the improvement of the guidelines preferably by implementation of the Dutch methodology for senior-proof guidelines is a necessary first step in making the current second-line evidence-based guidelines in the Netherlands usable for the growing group of frail and multimorbid elderly.

Behavioural interventions, such as developing positive sleep-related associations and gradual extinction, are common and proven methods to treat behavioural childhood sleep problems. Although behavioural interventions are safe and effective, controversy has arisen because of the impression that they are incompatible with sensitive parenting (i.e. cued care). The practice of extinction, however, does not preclude a sensitive parenting style. It stimulates autonomy and self-regulation in the child. Instead of counterposing behavioural interventions and cued care, we suggest it is more productive to start from their similarities, such as optimizing sleep hygiene and developing a fixed sleep-wake rhythm. Such measures could be the first steps in a stepped-care model that may be supplemented with additional treatment aimed at the underlying causes of insomnia. For this comprehensive approach it is necessary to have a diverse array of evidence-based treatment options that suits the needs of both children and parents.

BACKGROUND: New approaches are needed in the treatment of characteristic symptoms of schizophrenia such as hallucinations and negative symptoms. Non-invasive brain stimulation can make a useful contribution. AIM: To discuss the published evidence regarding efficacy and safety of repetitive transcranial magnetic stimulation (rtms) and transcranial direct current stimulation (tdcs) when used in the treatment of auditory verbal hallucinations and negative symptoms. METHOD: We review and discuss recent meta-analyses and we analyse relevant factors. RESULTS: On average, when compared to sham-stimulation, rtms was found to have a significant effect on hallucinations and negative symptoms. Nevertheless, the results of some studies were variable and some studies did not report any improvement. There are indications that some factors such as age and distance between scalp and cortex may influence efficiency. There were only a few studies relating to the use of tdcs and none of these reported a clear effect. CONCLUSION: There is reasonable evidence that rtms is an efficient treatment for hallucinations and negative symptoms, although some variable results have been reported. There is insufficient evidence for conclusions to be drawn about the efficacy of tdcs for the treatment of hallucinations and negative symptoms. However, both simulation methods are safe and largely without side-effects.

Antidepressants remain controversial, partly due to allegations that disappointing results were buried and because of their modest average efficacy.br/AIM: To investigate bias in the antidepressant literature and the possibilities for predicting which patients with depression or anxiety do receive significant benefits from antidepressants.br/METHOD: We investigated bias by comparing information from the US Food and Drug Administration with the published literature. To predict response, we used patient data from randomized trials.br/RESULTS: Of all studies on depression or anxiety, 50% and 72% were positive, compared to 95% and 96% of all published studies. Safety outcomes were poorly reported in published articles and unpublished studies were often 'bundled' into pooled-trials publications with positive conclusions. We found an association between severity and antidepressant efficacy for some, but not all, anxiety disorders; previous research has found inconsistent evidence for this association for depression. Furthermore, patients with depression that showed early improvement were more likely to attain a good response, irrespective of which symptoms improved.br/CONCLUSION: These results demonstrate the severe impact of bias on the antidepressant literature. Severity and early improvement predicted a good response, but more information is needed to improve predictions. The increased accessibility of individual patient data will hopefully soon enable further progress in this area.

The new Dutch guideline on cardiovascular risk management has lowered the target value for LDL cholesterol from 2.5 to 1.8 mmol/L. The authors claim transparency, yet there is no hard scientific evidence that supports this new target value. There is only a theoretical model developed by theCholesterol Treatment Trialists' (CTT) Collaboration Group. This group has the raw data of the cholesterol trials and they have signed confidentiality agreements with manufacturers stating that they will not share this data with others. This group also produced the Cochrane review on primary cardiovascular prevention with statins. If the real effect of cholesterol-lowering drugs is not disclosed to the population in a transparent manner, this will be done through independent channels with the message 'leave those PCSK9 inhibitors alone until there is hard scientific evidence for their efficacy.' And if patients suffer greatly from, for example,muscle pain, diabetes or amnesia due to taking statins, in accordance with the guideline they will decide for themselves whether or not to continue taking it.

Mahtani et al. review the evidence for sodium restriction in heart failure. The paucity of solid studies is striking, but deplorably in line with the paucity of high-quality studies on lifestyle management in general. One hard endpoint study (Sodium-HF) is underway. Promising results were obtained in the GOURMET study, which integrated sodium restriction into a broader nutritional approach that simultaneously targeted malnutrition, a major problem in heart failure. Targeting overall nutritional status - rather than single nutrients - matches current trends in nutrition guidelines, and deserves further exploration. Using fresh products and avoiding processed foods is the main step towards an overall healthier diet with less sodium. Dietary improvement, with its clinical benefit, is feasible in most patients by means of adequate support and feedback. Hopefully, the emergence of 'lifestyle medicine' will, with clinical and scientific effort, allow for the health potential of nutrition to be translated into clinical benefit for patients.

A doctor with good critical thinking skills will intervene when required, but abstain from intervening wherever possible. He or she has the ability to apply resource stewardship, acknowledges the limitations of guidelines and is able to deviate from protocols when appropriate, with sound arguments for why this is in the patient's best interest. We believe that critical thinking is an important skill for any doctor, and that it will contribute to better patient-centred outcomes at lower societal costs and with greater job satisfaction among healthcare professionals. The current medical curriculum for medical students and doctors in specialty training in the Netherlands highlights several aspects (e.g. evidence-based medicine, shared decision making, cost awareness) that are required if the student is to become a critically thinking doctor. This focus should, however, be further emphasized, and should include knowledge of cognitive bias and the skills required for the critical thinking process. On the basis of three patient vignettes several forms of cognitive bias are described, along with bias-mitigation strategies.

ACHTERGROND Verzekeraars vragen in toenemende mate een getalsmatige onderbouwing van de behandelresultaten in de ggz. Daarbij baseren zij zich op de door de Stichting Benchmark ggz (sbg) aangeleverde data en procedures. sbg heeft een beperkt aantal (generieke) vragenlijsten geaccepteerd om te kunnen benchmarken. Binnen de klinische praktijk voldoen die instrumenten niet om daarmee routine outcome monitoring (rom) mee te kunnen verrichten. De behoefte bestaat om daar een veelgebruikte depressievragenlijst, de Inventory of Depressive Symptomatology (ids), voor te gebruiken. DOEL Argumenten aandragen waarom de ids een uitstekend en bruikbaar instrument is om door sbg als meetinstrument te worden geaccepteerd. METHODE Door middel van een literatuuroverzicht de kwaliteit van de ids bespreken. RESULTATEN De ids is een kwalitatief goed instrument om de ernst van depressies te meten en is tevens gevoelig om verbetering in de stemming te meten. CONCLUSIE De ids is een uitstekend instrument om rom-metingen mee te verrichten en is zonder kosten verkrijgbaar. Er wordt voor gepleit dat sbg deze vragenlijst accepteert als een van de instrumenten om te kunnen benchmarken.

When formulating recommendations, guideline developers have opportunities to use systematic reviews (SRs), which are widely considered to be the best available evidence. However, in practice the use of SRs by guideline developers is limited. Recent research has shown that only 22% (60/279) of the recommendations on screening of newborns for rare diseases were based on SRs. Moreover, the non-use of SRs was correlated with positive recommendations. This commentary discusses the reasons for limited SR use and the influence of wishful thinking on decision making. Although standards for guideline development are evolving, differing methods can still be used without compromising quality. Expert opinion is always needed to weigh the benefits and harms of the available management options. As long as potential conflicts of interest and considerations as well as choices made during the process are explicitly described, guidelines and policy decisions can be considered to be trustworthy.

Reading the literature of recent years could give one the impression that many treatments fall short when they are submitted to high-quality scrutiny. This perspective discusses sensible and senseless care in orthopaedics and traumatology, using concepts such as evidence-based medicine, managing expectations and shared decision-making.

Evidence based medicine (EBM) is the integration of the best research evidence, clinical expertise and patient values in the decision making process for patient care. However, elderly people are often excluded from participating in scientific studies and they often have multiple morbidities, which complicates the application of EBM. Shared decision making (SDM), a process where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve appropriate treatment can help to shape EBM for this group of patients.In this article, we provide tools for finding relevant literature for the geriatric patient population and for shaping the SDM process to achieve personalized care.

Muris JWM, Damoiseaux RAMJ, Van Dijk N. Bijwerkingen en valkuilen van EBM: trap er niet in! Huisarts Wet 2017;60(11):548-50. Huisartsen zijn echte evidence-based zorgverleners. Systematische reviews en richtlijnen helpen ons bij het nemen van beslissingen – evidence-based medicine (EBM) heeft ons veel opgeleverd. Door de sterke nadruk op de wetenschappelijk onderbouwing is de kans echter groot dat de wensen en situatie van de specifieke patiënt die tegenover ons zit en onze eigen klinische ervaring te weinig aandacht krijgen. Uitkomsten uit onderzoek kunnen daarnaast een te grote invloed krijgen op ons handelen en de afrekening door zorgverzekeraars te sterk bepalen. Ook kan de industrie klinisch irrelevant onderzoek gebruiken voor financieel gewin. Deze ontwikkelingen hebben weerstand tegen EBM opgeroepen. Het is daarom van groot belang om tijdens de opleiding het eigenlijke perspectief van EBM centraal te stellen: het gebruik van evidence met inachtneming van de wens en situatie van de patiënt, en de klinische expertise van de arts. Behalve bevragen, zoeken en wegen van evidence moeten we de vertaalslag naar de praktijk benadrukken. Hoe kunnen we de valkuilen en bijwerkingen van een te beperkte toepassing van EBM ontwijken?

New approaches are needed in the treatment of characteristic symptoms of schizophrenia such as hallucinations and negative symptoms. Non-invasive brain stimulation can make a useful contribution.br/AIM: To discuss the published evidence regarding efficacy and safety of repetitive transcranial magnetic stimulation (rtms) and transcranial direct current stimulation (tdcs) when used in the treatment of auditory verbal hallucinations and negative symptoms.br/METHOD: We review and discuss recent meta-analyses and we analyse relevant factors.br/RESULTS: On average, when compared to sham-stimulation, rtms was found to have a significant effect on hallucinations and negative symptoms. Nevertheless, the results of some studies were variable and some studies did not report any improvement. There are indications that some factors such as age and distance between scalp and cortex may influence efficiency. There were only a few studies relating to the use of tdcs and none of these reported a clear effect.br/CONCLUSION: There is reasonable evidence that rtms is an efficient treatment for hallucinations and negative symptoms, although some variable results have been reported. There is insufficient evidence for conclusions to be drawn about the efficacy of tdcs for the treatment of hallucinations and negative symptoms. However, both simulation methods are safe and largely without side-effects.

Repetitive transcranial magnetic stimulation (rTMS) has been found to be an effective technique in the treatment of unipolar depression. However, it is not yet clear whether rTMS is also useful in the treatment of bipolar depression.To evaluate the available evidence that rTMS is effective in the treatment of bipolar depression.Review of available literature (RCTs and open-label studies).We looked closely at four RCTs and four open-label studies. In three of the four RCTs the results for patients who had received rTMS were no better than those for patients who had received a placebo. Patients in all four open-label studies showed significant improvement. One individual developed hypomanic symptoms. The studies used many different parameters; some studies included diagnoses, some referred to the type of medication used.So far, there is a lack of high quality studies on which we can base our conclusions about the effectiveness of rTMS for the treatment of bipolar depression. The use of rTMS to treat patients with bipolar depression does not seem to increase the risk that a patient will develop (hypo)mania.

A recently released report by the Dutch Council for Public Health and Society ('Raad voor Volksgezondheid en Samenleving') is subtitled "About the illusion of evidence-based practice in healthcare". The author argues that this report is a sign of the times, a period of "post-truth medicine" and "alternative facts", in which "science offers nothing but a reduction". Although the report rightly - but superfluously - argues that having an evidence base is insufficient for delivering quality care (no decisions without considering context), its depiction of the illusory nature of evidence-based practice represents a brutal slap in the face of all those who turn to sound clinical and biomedical research to back up or refute claims about the effectiveness of healthcare interventions.

The randomised placebo-controlled trial (RCT) is the gold standard for the evaluation of medical interventions. Observational studies, on the other hand, usually do not get much credit. For studies investigating surgical interventions this does not always seem entirely justified. A more refined approach might be needed for the often-used hierarchical structure of research designs. Instead of a strict separation of results from RCTs and other designs, results of the different designs should rather be regarded as complementary to each other when evaluating surgical interventions in traumatology.

In Flemish emergency psychiatry, clotiapine is still one of the options available for the treatment of agitation. However, there is a lack of evidence concerning the efficacy of this practice.br/AIM: To find out whether there is sufficient evidence to justify the continued use of clotiapine in the treatment of agitation.br/METHOD: On searching the literature systematically, we identified controlled trials of clotiapine.br/RESULTS: The efficacy and safety of clotiapine were studied in two randomised controlled trials. Clotiapine (administered intramuscularly) was compared with zuclopenthixol acetate and lorazepam. Clotiapine was found to be just as efficient as the control treatments, causing fewer anticholinergic side-effects than zuclopenthixol but more extrapyramidal side-effects than lorazepam. The study population comprised only 102 patients, 51 of whom were treated with clotiapine. Because the quality of the reported data was low, straightforward conclusions were difficult to draw.br/CONCLUSION: Scientific evidence to support the use of clotiapine in the treatment of agitation ranges from meagre to practically non-existent. Since alternative treatment options are available, the contained use of clotiapine should be questioned.

Treatment guidelines are widely used nowadays but it is not really clear whether or to what extent patients in routine care benefit from these guidelines.br/AIM: To achieve a twofold objective: to measure in a routine clinical setting, the overall level of adherence to clinical guidelines by using a set of process indicators that are independent of the disorder under study, and to measure the clinical and psychosocial correlates of adherence among outpatients suffering from mood, anxiety and somatoform disorders.br/METHOD: We developed a set of quality indicators and tested the set over a period of three years in a randomly selected sample of 300 outpatients who were about to receive treatment for a mood, anxiety and somatoform disorder. We used routine outcome monitoring (ROM) data to determine risk factors for non-adherence and to identify patients whose treatment outcomes were likely poor.br/RESULTS: A high percentage of indicators were positive, indicating that many elements of treatment in this routine clinical practice had been carried out according to the guidelines. We observed that the combined treatment group showed significantly lower adherence than the two other treatment groups. Low-adherence was predicted independently by a low score on the vitality subscale of the SF-36. No significant differences relating to the degree of adherence were found in socio-demographic variables, comorbidity and the scores on the BSI subscales. Predictor indicators for poor treatment outcome included higher age, a comorbid axis I diagnosis, a number of dysfunctional personality traits and a (reported) poor general health status.br/CONCLUSION: It is possible to assess guideline adherence by means of our set of process indicators that were independent of all type of disorder involved. Most factors hampering adherence could be identified. An understanding of the factors that affect treatment adherence to treatment guidelines may help to prevent non-adherence and can contribute to both the quality and the cost-effectiveness of care.

Multimorbidity, functional impairment and frailty among community-dwelling older people are causing increasing complexity in primary care. A proactive integrated primary care approach is therefore essential. Between October 2014-2015, an evidence-based proactive care program for frail older people was implemented in the region Noord-West Veluwe en Zeewolde, the Netherlands. This study evaluated the feasibility of the implementation, having a strong focus on the collaboration between the medical and social domain.Using a mixed-methods design we evaluated several process indicators. Data were obtained from electronic routine medical record data within primary care, questionnaires, and interviews with older adults. The questionnaires provided information regarding the expectations and experiences towards the program and were sent to health care professionals at baseline and six months follow-up. Stakeholders from various domains were asked to fill in the questionnaire at baseline and twelve months follow-up. Interviews were conducted to explore the experiences of older adults with the program. Regional work groups were set up in each municipality to enhance the interdisciplinary and domain transcending collaboration.The proactive primary care program was implemented in 42 general practices who provided care to 7904 older adults aged 75 years or older. A total of 101 health care professionals and 44 stakeholders filled in the questionnaires. The need for better structure and interdisciplinary cooperation seemed widespread among the participants. The implementation resulted in a positive significant change in the demand for a better regional healthcare-framework (34% p ≤ .001) among health care professionals, and the needs for transparency regarding the possibilities for referral improved (27% , p = .009). Half of the participants reported that the regional collaboration has been improved after the implementation. Health care professionals and stakeholders gained increased attention and awareness of frail elderly in their area compared to before the implementation. Older people and their caregivers were positive about the proactive approach. The nurses reported that the screenings questionnaire was too lengthy and therefore time consuming.The implementation of the proactive primary care approach in daily practice was feasible. A strong interdisciplinary collaboration was realized. The program was easily adapted to the local context.

The suggestion that schizophrenia does not exist has let to a discussion in Dutch national newspapers. According to several contributors, the diagnosis schizophrenia can wrongly lead to stigmatisation and defeatism with regard to treatment and should therefore be replaced by the broader concept, psychosis. This view strengthens the argument that 'schizophrenia does not exist'. In reaction to this view it has been suggested that in some articles that schizophrenia is now believed to have a definite biological basis.To clarify the various arguments and concepts that are used.The arguments for and against are reviewed from an ontological perspective. Ethical/political arguments and scientific arguments are handled separately and are set against each other.The ontological status of psychiatric disorders, including schizophrenia, are problematic, as has been shown in a recent study by Kendler. From the perspective of the medical scientific programme - namely, try to go from syndromes to anatomically defined diseases - it would appear that one party wants to abandon this programme, whereas the other party wants to continue it.Research over the last few decades has been unable to clarify the ontological status of schizophrenia.

A patient's values and preferences are one of the three 'pillars' of evidence-based medicine (EBM). How can we explain that this one pillar has hardly been elaborated in the EBM-literature?? Were the EBM pioneers really committed to the patient's preferences, were they not ready yet, or were they not committed at all? In key international EBM publications dated between 1985 and 2000, we only found sympathetic, yet vague, statements lacking concrete content. In the Netherlands, a Health Council report set the tone with a sense of fear for 'consumer medicine'. In addition to an overly optimistic view of the past, in 2014 Greenhalgh sketched a vision of the future of EBM in which the sympathetic comments about patient preferences are finally made concrete. The EBM movement has already successfully adapted to social developments in the past; therefore, there is reason for optimism.

To determine the effect of an evidence-based classification list on use of total hip prostheses of proven quality in the Netherlands.Observational study.The Netherlands Orthopaedic Association (NOV) drew up a classification list for total hip prostheses in 2013. This classification list considered total hip prostheses to be of proven quality when the average percent of revision was ≤ 10% after 10 years of follow-up (category 1A) or ≤ 5% after 5 years of follow-up (category 1B). Data from the Dutch National Orthopaedic Implant Registry Register (LROI) were used to determine the effect of the classification list on the use of hip prostheses of proven quality in the Netherlands. All patients, operations and prosthesis characteristics of the hip prostheses used in the Netherlands were registered in the LROI. We selected details of all interventions in which a hip prosthesis was implanted in patients with 'osteoarthritis' as primary diagnosis between 2012 and 2014 from the LROI. The prostheses could be classified as 1A, 1B or 'not 1A or 1B' by means of the implant code of the acetabular and femoral components. We took 2012 as the reference year.In the reference year, 84% of the acetabular components and 94% of the femoral components were category 1A or 1B. In 2013 these percentages had increased to 89% and 95%, respectively; in 2014 the percentages had increased to 92% and 97%.After implementation of the NOV classification list there was an increase in the percentage of total hip prostheses of proven quality, which means that patient care has become better and safer.

Increasingly, health insurance companies are asking for treatment results in mental health care to be expressed in actual numbers. They base their request on the data supplied by sbg (Stichting Benchmark ggz) and the procedures that sbg has followed. For the purpose of benchmarking, the sbg has accepted a limited number of questionnaires. These tools are not suitable for performing routine outcome monitoring (rom) in clinical practice. There is a urgent need for these questionnaires to be replaced by a widely-used depression questionnaire, namely the ids.To present arguments supporting the view that the ids is an excellent and useful instrument that the sbg should accept as a measuring tool.We discuss the quality of the ids by reviewing the literature.The ids is a high quality instrument well suited for measuring the severity of depressions and also is sufficiently sensitive for measuring mood improvements.br/The ids is an excellent tool for performing rom measurements and is available free of charge. The authors argue that the sbg should accept this questionnaire as a suitable instrument for benchmarking.

ACHTERGROND Verzekeraars vragen in toenemende mate een getalsmatige onderbouwing van de behandelresultaten in de ggz. Daarbij baseren zij zich op de door de Stichting Benchmark ggz (sbg) aangeleverde data en procedures. sbg heeft een beperkt aantal (generieke) vragenlijsten geaccepteerd om te kunnen benchmarken. Binnen de klinische praktijk voldoen die instrumenten niet om daarmee routine outcome monitoring (rom) mee te kunnen verrichten. De behoefte bestaat om daar een veelgebruikte depressievragenlijst, de Inventory of Depressive Symptomatology (ids), voor te gebruiken. DOEL Argumenten aandragen waarom de ids een uitstekend en bruikbaar instrument is om door sbg als meetinstrument te worden geaccepteerd. METHODE Door middel van een literatuuroverzicht de kwaliteit van de ids bespreken. RESULTATEN De ids is een kwalitatief goed instrument om de ernst van depressies te meten en is tevens gevoelig om verbetering in de stemming te meten. CONCLUSIE De ids is een uitstekend instrument om rom-metingen mee te verrichten en is zonder kosten verkrijgbaar. Er wordt voor gepleit dat sbg deze vragenlijst accepteert als een van de instrumenten om te kunnen benchmarken.

BACKGROUND: In the March edition of this journal a group of professors criticised the methods adopted by the SBG (Benchmark foundation of the Dutch Mental Health Services). The critical comments relate to the alleged objectives ('pay-for-performance' in the Dutch Mental Health Services) and the methods involving confounding, bias and the use of insufficiently sensitive instruments.AIM: To provide more detailed information about the SBG and the role of the scientific council (WR) and about the social context within which rom and benchmarking are developing, and to give our views on the methodological criticisms.METHOD: We elucidate the methods of the SBG and the role of the WR and we clarify the ways in which ROM and benchmarking are currently being used.RESULTS: We recognise that there are methodological problems. The wr too warns against jumping to conclusions on the basis of data whose validity is still under discussion. The Dutch Mental Health Services have practically no experience of rom and benchmarking. The Dutch Mental Health Services need to gain more experience in this field. On the other hand, it is true that rom data and comparisons between institutions can lead to improvements in the standard of care, provided these procedures are carried out carefully. In the SGB methods the aforementioned problems have been removed, at least partially. The SBG is concerned not only with symptom reduction but also with the functioning of the individual and with his or her quality of life.CONCLUSION: The WR believes that the Dutch Mental Health Services should operate a scientifically validated benchmark system. Sofar, there has been hardly any research into whether benchmark data really say anything about quality and/or whether comparisons between institutions are valid. A national ROM-system is needed. Current initiatives are creating ways in which these matters can be investigated, preferably in conjunction with scientists and professionals.

The end of the year is always a perfect moment to look back. However, looking back over the past year alone is not enough if you want a complete picture of developments in medical science, which is why the Dutch Journal of Medicine (NTvG) has posted a timeline on its website charting medical milestones over the past 45 years. Some of these milestones are illustrated in the infographic in this number, and some interesting patterns can be observed. In this article we discuss various trends, from the increasing tendency to quantify to the rise of evidence-based medicine.

Music therapy is a predominantly non-verbal psychotherapy based on music improvisation, embedded in a therapeutic relationship. This is the reason why music therapy is also used to treat depression.To examine the efficacy of music therapy and to report on the results of recent research into the value of music therapy as a treatment for depression.We reviewed the literature on recent research into music therapy and depression, reporting on the methods used and the results achieved, and we assessed the current position of music therapy for depression in the context of evidence-based scientific research.A wide variety of research methods was used to investigate the effects of using music therapy as a psychotherapy. Most studies focused usually on the added value that music therapy brings to the standard form of psychiatric treatment, when administered with or without psychopharmacological support. Music therapy produced particularly significant and favourable results when used to treat patients with depression.Current research into music therapy and depression points to a significant and persistent reduction in patients' symptoms and to improvements in their quality of life. However, further research is needed with regard to the best methods of illustrating the effects of music therapy.

Guidelines contain evidence-based recommendations for clinical practice. Physicians and other healthcare providers are expected to follow these guidelines to provide proper care to their patients. Deviation from guidelines is possible, but should be undertaken for a reason. New evidence and insights involve guidelines having to be revised periodically. What are the implications of such revisions for doctors and patients? And what can be done about patients who have been lost to care but who are eligible for treatment according to the new guideline? Difficult dilemmas lie in waiting. It is a joint responsibility of both drafters and users of guidelines to implement changes in guidelines appropriately for the individual patient.

The evidence for an association between systemic diseases and periodontitis is strongest with diabetes mellitus type 2 and cardiovascular disease. There is a moderate association of periodontitis with adverse pregnancy outcomes and rheumatoid arthritis. Periodontal treatment has, on average, a positive effect on reducing systemic infection and improving the condition of the vascular system. For diabetes patients, periodontal treatment can also have a positive effect on metabolic regulation. There is insufficient evidence that periodontal treatment prevents adverse pregnancy outcomes and rheumatoid arthritis.De aanwijzingen voor een verband tussen systemische ziekten en parodontitis zijn het sterkst bij diabetes mellitus type 2 en hart- en vaatziekten. Er is sprake van een matig verband van parodontitis met zwangerschapscomplicaties en reumatoïde artritis. Parodontale behandeling draagt gemiddeld genomen bij aan een verlaging van de systemische ontsteking en een verbetering van de conditie van het bloedvatenstelsel. Bij diabetespatiënten kan parodontale behandeling ook een positief effect hebben op de metabole regulatie. Er is onvoldoende bewijs dat parodontale behandeling een positief effect kan hebben op afgeleide parameters van zwangerschapscomplicaties en reumatoïde artritis.

Evidence-based therapies for major depression, as described in the clinical guidelines, are based on results from randomised controlled trials (RCTs). So far, it is not known to what extent results of RCTs on major depression can be generalised to 'real life' clinical practice.To compare treatment results for major depression from RCTs (efficacy) and results from daily practice (effectiveness); furthermore, to assess to what extent eligibility criteria and (un)intended selection by recruitment procedures influences treatment outcomes in daily practice.In a 'real life' patient population (n=1653) suffering from major depression (established by the MINIplus) and assessed in routine outcome monitoring at baseline, we explored how many patients met the eligibility criteria for antidepressant and psychotherapy efficacy trials. Furthermore we explored to what extent RCT participants differed in socio-demographic and socio-economic status from 'daily practice' patients. 626 of the ROM patients had at least one follow-up assessment. In this follow-up group we compared the treatment outcome (assessed by the MADRS and BDI-II) to the results of 15 meta-analyses of RCTs. We also explored to what extent patient selection based on eligibility criteria and socio-demographic/socio-economic status influenced treatment outcome.Remission percentages (21-27% in ROM versus 34-58% in RCTs) and effect sizes (0.85 in ROM versus 1.71 in RCTs, within-group data) were lower in daily practice than in RCTs. ROM patients differed from RCT participants in many disease-specific and socio-economic features. These differences are due to patient selection in RCTs. However, the influence of patient selection based on eligibility criteria and socio-demographic differences in treatment outcome were very modest (explained variances 1-11%).Treatment success for major depression is lower in daily practice than in RCTs and 'real life' patients differ in many features from RCT participants. However, these differences cannot explain the difference between efficacy and effectiveness. The generalisability of the results of depression trials to daily practice might not be jeopardised by the use of eligibility criteria and recruitment procedures to the extent suggested in earlier research.

David Sackett, the father of evidence-based medicine (EBM), died recently - exactly 25 years after the term EBM was coined. This coincidence calls for reflection on the historical significance of EBM and on Sackett's role. The rise of EBM appears to be part of a much broader development: a shift from 'trust in the experts' to 'trust in numbers' that occurred under the pressures of the socio-political conditions of the late twentieth century. Insight into this historical context contributes to a better understanding of the emergence, merits and weaknesses of EBM and of the current tensions between medical professionals and insurers. However, context alone does not explain everything; the course of history - and the history of EBM - is partly determined by special men and women, individual reformers who manage to set things and people in motion. David Sackett is an excellent example of this.

In 1992, the Canadian physician Gordon Guyatt wrote an article that is generally regarded as the starting point of evidence-based medicine (EBM). He described the ideas behind the McMaster residency programme for 'evidence-based practitioners', founded by David Sackett. Eight years later, in 2000, Guyatt concluded that this programme was too ambitious. In a new publication he described most doctors as 'evidence-users'. This editorial marks the transition from an individual to a collective form of EBM, emphasizing the use of evidence-based guidelines. The starting point of this collective form of EBM is not the well-known 1992 paper, but the forgotten editorial in 2000, which was described by Guyatt's colleagues as the capitulation of EBM.

With regard to the treatment of patients who have been traumatised in childhood by interpersonal trauma and have been diagnosed as having symptoms of complex ptsd, it is advisable that exposure of such patients to traumatic memories should be preceded by a stabilisation phase: during this phase patients can be taught various techniques including particularly those that enable them to regulate their emotions.To find out whether there is strong empirical evidence for the introduction of a phase-based treatment approach for this patient group.We performed a critical evaluation of the available scientific literature and guidelines. We took as our starting point the studies that formed the basis of the Expert Consensus Guidelines for Complex ptsd.Our research shows that trauma-focused treatment, be it with or without a preparatory stabilisation phase, is also effective for patients with complex ptsd symptoms. However, there is certainly no compelling evidence to support the assumption that well-organised and carefully administered evidence-based treatment has to be preceded by a stabilisation phase.Among the experts there is uncertainty about the best form of treatment for patients with complex ptsd that has resulted from interpersonal trauma in childhood. For the time being, the severity and complexity of trauma-related problems are not valid reasons for denying patients a period of stabilisation as recommended in national treatment guidelines, nor are they valid reasons for preferring a phase-based treatment over a trauma-focused type of treatment.

Cost-effectiveness research in elderly residents in long-term care facilities is based on general principals of cost-effectiveness research; these have been developed primarily from the perspective of relatively healthy adults in curative medicine. These principals are, however, inadequate when evaluating interventions for the fragile elderly in long-term care, both in terms of the value attached to the health of patients and to the specific decision-making context of the institution. Here we discuss the pitfalls of cost-effectiveness research in long-term care facilities, illustrated by two prevention interventions for prevalent conditions in nursing homes: pressure ulcers and urinary tract infections. These turned out to be effective, but not cost-effective.

Effect modification and interaction are terms often used in medical research. However, the analysis of effect modification and interaction has differing objectives. These two phenomena require different methods of analysing and presenting. Effect modification means that the association under study differs between certain subgroups, e.g. men and women. The aim is to identify clinically relevant subgroups, without the need to know the underlying cause of the modification. The presence and direction of effect modification may depend on the effect measure, e.g. risk difference or risk ratio. Interaction means that the combination of two determinants has more or less effect than each of the determinants separately. The aim is to estimate the causal relationship between these two determinants and the outcome as accurately as possible. Interaction can be calculated on an additive or multiplicative scale.

This article discusses recent criticism of evidence-based medicine (EBM), which has tended to place unilateral emphasis on evidence originating from randomised trials into effectiveness. The goal of the pioneers of EBM, however, was actually the application of scientific evidence to the individual patient, including the doctor's experience ('practice-based') and the patient's preference ('preference-based') in decision making. Guidelines can support this process by systematically paying attention to patients' preferences and by presenting the advantages and disadvantages of different management options. The application of guidelines should not involve pursuit of 'standard care' but, primarily, the pursuit of shared decision making. This could lead to 'real EBM', in which medical knowledge is translated to practical choice options from different perspectives.

Medicine for frail elderly patients is complex because of the omnipresent multimorbidity, multicausality, the high risk of adverse effects, lack of an evidence base for guideline-based treatment options, and the predominance of quality of life-related outcomes, rather than mortality and morbidity. This complexity puts off most medical students, while there is a requirement for physicians who like and are well trained to work with frail older persons. Luckily, there are signs of increasing interest, for example in the excellent introduction to geriatric medicine written by author/surgeon Atul Gawande in his last book "Being mortal" (2014). With this commentary, this journal is starting a series presenting new research findings, insights and case studies on frail older patients in order to spread the expanding knowledge base of geriatrics, and suggest tools for working effectively with this fast-growing, complex but rewarding patient group.

Muris JWM, Damoiseaux RAMJ, Van Dijk N. Bijwerkingen en valkuilen van EBM: trap er niet in! Huisarts Wet 2017;60(11):548-50. Huisartsen zijn echte evidence-based zorgverleners. Systematische reviews en richtlijnen helpen ons bij het nemen van beslissingen – evidence-based medicine (EBM) heeft ons veel opgeleverd. Door de sterke nadruk op de wetenschappelijk onderbouwing is de kans echter groot dat de wensen en situatie van de specifieke patiënt die tegenover ons zit en onze eigen klinische ervaring te weinig aandacht krijgen. Uitkomsten uit onderzoek kunnen daarnaast een te grote invloed krijgen op ons handelen en de afrekening door zorgverzekeraars te sterk bepalen. Ook kan de industrie klinisch irrelevant onderzoek gebruiken voor financieel gewin. Deze ontwikkelingen hebben weerstand tegen EBM opgeroepen. Het is daarom van groot belang om tijdens de opleiding het eigenlijke perspectief van EBM centraal te stellen: het gebruik van evidence met inachtneming van de wens en situatie van de patiënt, en de klinische expertise van de arts. Behalve bevragen, zoeken en wegen van evidence moeten we de vertaalslag naar de praktijk benadrukken. Hoe kunnen we de valkuilen en bijwerkingen van een te beperkte toepassing van EBM ontwijken?