Evidence-Based Healthcare in Context

Critical Social Science Perspectives

Jon Adams, Alex Broom

• Publisher: Routledge
• Year: 2016
• eBook ISBN: 9781351938051
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

With new methods of treatment standardisation resulting in various benefits for patient outcomes, evidence-based medicine and evidence-based practice have emerged as defining features of western healthcare provision in recent years. Most health professions are now adopting some form of 'evidence-based' framework for clinical training and practice. However, the rise of evidence-based healthcare has drawn sustained criticism regarding the limits of trial based evidence, the reductive character of epidemiological study designs, and the potential for an erosion of the importance of lay perspectives and clinical judgement. Evidence-Based Healthcare in Context introduces readers to the social, cultural and historical underpinnings of 'evidence' in healthcare, critically examining questions about what constitutes 'evidence' and 'effectiveness' from perspectives outside medicine, including those of patients, complementary medicine and midwifery. It focuses on the application of contemporary theoretical debates around the nature of medical and health knowledge, providing readers with a series of critical analyses of the production, application and translation of 'evidence' in a range of healthcare contexts. Featuring cutting edge work from leading social scientists in the UK, US, Canada, Norway, Australia and New Zealand, this volume draws on the latest empirical research to provide a thorough critical overview of this important field of health research.

Chapter 1
A Critical Social Science of Evidence-Based Healthcare

Alex Broom and Jon Adams

Introduction

In many respects evidence-based healthcare is neither new nor are its philosophical underpinnings unique. Getting the best knowledge to the right people in a timely fashion is commonsense. Yet, this basic principle reflects a broader social movement in knowledge production and dissemination that has been emerging for centuries. Scientific inquiry, as it were, has become more systematic, globally connected and protocol driven over the course of the twentieth century. While scientific discoveries in the nineteenth and early twentieth centuries still often occurred in the context of a sole or renegade researcher/practitioner, the latter part of the twentieth century witnessed the global streamlining, enhanced connectivity and dramatic institutionalisation of scientific knowledge production. This fundamentally changed the way both science and medicine were practiced in terms of research priorities and practice guidelines. While changes were occurring within the scientific community more broadly, 'modern' medicine, given its prominence in the community, became centre stage in this broader social movement and philosophical shift toward regulation, abstraction and systematisation in research and clinical practice. As the systematisation of healthcare developed and matured over the last few decades of the twentieth century we saw the institutional emergence of 'evidence-based medicine' (EBM), followed by 'evidence-based practice' (EBP), and then many other evidence-based models in the health and social care professions. This book is about these movements – which we put under the umbrella of 'evidence-based healthcare' (EBHC) – and setting a broad sociological platform from which to understand how these new knowledge technologies impact upon the practice of health care.

While there has been a significant shift in the definitions of, and rhetoric surrounding, the evidence-based social movements, the broad principles have remained relatively stable over time. In a well known maxim, EBM was articulated from an early stage of its development as 'the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients' (Sackett et al. 1996, see also Evidence-Based Medicine Working Group 1992). Now viewed as a sensible, perhaps uncontroversial, and certainly commonsense, statement, within the sociohistoric context that it was first articulated, it served as a timely warning that, despite the dramatic expansion of medical knowledge making in the twentieth century, methods of disseminating and utilising such knowledge internationally were limited if not non-existent for many areas of medicine. At the time, large numbers of clinicians did not follow the latest and most rigorous evidence, either due to lack of time, lack of expectation to be up-to-date, or lack of access to relevant evidence among other factors. Cochrane (1972) in particular highlighted the problem of a lack of up-to-date and high quality data for practicing clinicians, particularly in maternity care. Change was urgently needed and epidemiology began its rather dramatic ascendancy in the race to shape the form, representation and delivery of 'good medicine' in the twentieth and twenty-first centuries. Sackett's statement, as suggested, is quite simple, and understood within its socio-historic context, quite reasonable. Moreover, it conveys a seemingly benign concept. That is, until one considers the question of what constitutes 'evidence' and how the technologies of capture, synthesis and dissemination imbue and exclude certain ideas about the importance of certain types of knowledge (Holmes et al. 2006b).

Such historical calls for action from Cochrane, Guyatt and Sackett among others, have prompted action, evolved and even mutated into a wider complex system of global regulation of medical and health knowledge (Timmermans and Kolker 2004). Initial philosophical positions implicit in the 'first wave' EBM movement (Holmes et al. 2006a, Holmes et al. 2006b) were made explicit with the rapid formalisation and institutionalisation of the technologies and practices of knowledge synthesis (Borenstein and Hedges 2009, Higgins and Green 2011). That is, a sophisticated and powerful set of techniques around the production, assessment, and thus representation of medical knowledge – a process based largely on a hierarchy prioritising epidemiological/experimental designs (and often the synthesis of their outputs). Moreover, first wave EBM advocated the development of tools that are epistemologically consistent with the principles of epidemiology; tools that clinicians and clinicians-in-training could use to 'judge' the quality of evidence for themselves.

Central to the EBHC social movement has been the development and transcendence of meta-analysis (Borenstein and Hedges 2009, Moreira 2007) and different forms of critical evaluation of study design and trial quality including the Jadad and Pedro scales (see Bhogal et al. 2005, see also Jadad and Enkin 2007). It is worth noting that there was no meaningful debate around whether the development of a global system to collate and disseminate the rapidly expanding mass of health and medical knowledge was needed. It was needed, and urgently. Consider that between five and ten percent of all clinical trials published each year deal with cancer or cancer-related conditions, presenting oncology clinicians with well over 10,000 clinical trials annually (Ioannidis, Schmid and Lau 2000). Filtering even a small proportion of this information – not to mention assessing quality for use in everyday clinical work – is clearly implausible and unreasonable for oncology clinicians. The production of medical knowledge was (and in many respects still is) outdoing clinicians' capacity to use or make sense of it. Such conditions ensured the enthusiastic uptake amongst many stakeholders of an EBM-type strategy for knowledge filtering and treatment prioritisation. The fact that such 'filtering' and 'layering' was to be based on a very distinct and problematic epistemology (De Vries and Lemmens 2006, Goldenberg 2006, Gordon 2006, Holmes, Peron and O'Bryne 2006, Webb 2001) would present many stakeholders, including patients and clinicians, with a series of difficult questions in day-to-day care settings such as 'what is legitimate knowledge?', 'how important are population studies?' and 'how relevant is my or my patient's subjective experience?' (Broom and Tovey 2007b).

In many respects it is inevitable that the move to systematise expanding medical and health knowledge would lead to a crisis in 'what constitutes knowledge' (Mykhalovskiy and Weir 2004); a question far from clear in an increasingly pluralistic medical landscape (Broom and Tovey 2007a) particularly given the various patient movements supporting non-biomedical and non-evidence-based forms of care (Bakx 1991). Moreover, while there existed collective energy within the medical community focused on containing the growing corpus of research and controlling for quality, resistance and uncertainty persisted within medicine itself (Armstrong 2002, Pope 2003). Evidence-based – from whose perspective? – emerged as a key question that has persisted from the beginnings of the social movement to today (Greenhalgh 1999, Sullivan 2003). Evidence, according to what measures, also dominated discontents around EBHC. Yet, despite ongoing disputes within and outside medicine, the original EBM model quickly extended beyond the governance of practices within the medical profession and healthcare services.

Evidence-based paradigms now fundamentally shape the way health service providers, health funding bodies, governments and policy makers view 'effectiveness', and their willingness to fund and support interventions, practices, models of care and practitioner groups (Jackson and Scambler 2007, Webb 2001). EBHC and the various permutations thereof (EB practice, EB nursing practice, EB social work, EB decision making, EB physiotherapy, EB occupational therapy –the list goes on) are now shaping how we are treated, which treatments are funded, the character of illness experiences, quality of life, and ultimately, our survival chances. It is for this reason that it is vital that we explore and reveal the benefits and limitations of EBHC models in clinical context. Here we do not to dismiss the principles of the various forms of EBHC, denigrate key stakeholders, nor pursue an overly constructivist perspective common in the social sciences. Such a perspective would provide little room for acknowledgement of the legitimacy of objectivist or predictive techniques, and thus restrict constructive dialogue. Rather, we seek to examine how the principles, technologies and practices of 'evidence-based approaches' may allow certain things and promote certain understandings of health and illness while silencing others.

The Technologies of Knowledge and Consolidation of a Social Movement

As we shall see in the following chapters, the EBHC social movement has been successful largely due to the development of a sophisticated array of technologies and encoded practices that imbue particular values around the nature and production of knowledge (Broom, Adams and Tovey 2009, Timmermans and Berg 1997). That is, since the lexicon of EBM and EBP began to develop in the 1980s and 1990s we have seen the successful deployment and widespread uptake of formalised EBM technologies, design hierarchies and organisation structures that perpetuate their core principles and values. Meta-analysis, in particular, is one very effective facet of the multi-pronged program of 'knowledge contextualisation' promoted by key entities such as the Cochrane Collaboration, the Campbell Collaboration and the RAND Corporation. The construction of ideologically-infused technologies responsible for sorting the wheat from the chaff, so to speak, consolidated EBM-type models as central to judgements about the worthiness of studies and legitimacy of interventions (Moreira 2007). Various quality scales and systems of delineation emerged concurrently to the development of the aforementioned organisational entities to objectify and validate assessments. These scales – which have in turn been mimicked more recently for interpretive designs (The Joanna Briggs Institute 2011) – rate studies according to various features including randomisation, blinding, power and dropout among other things.

The trajectory towards evidence synthesis was swift in the 1990s with emphasis placed on consolidating an objective basis for synthesis, for example, effect sizes, within meta-analysis (Higgins and Green 2011, Jadad and Enkin 2007). This effectively created an enhanced a culture of polarisation in knowledge legitimacy – an evidence apartheid that many argue is politically driven and epistemologically reductive (Goldenberg 2006, Holmes et al. 2006a, Holmes et al. 2006b, Lambert 2006, Mykhalovskiy and Weir 2004). This positioned analytical/epidemiological design strategies as producing the most legitimate and accurate forms of medical knowledge (Broom, Barnes and Tovey 2004, Jackson and Scambler 2007). While the design priorities inherent in EBHC technologies do not explicitly marginalise interpretive designs, and thus qualitative insights and/or data, they do exclude interpretive designs from being part of the crux of a systematic review. By default, interpretive designs are reduced in their perceived significance for clinical work. In many established reviews of interventions interpretive data is not considered in the data meta-analysis. Descriptive/interpretive design strategies may be present (often in background sections or as 'context') but do not inform the actual outcome. This has been a critical part of the epistemological dominance of analytical design strategies that still dominate medical research and the development of clinical guidelines.

There is no doubt that the original intention of the EBM entrepreneurs was to reduce the influence of bias, poor design and poorly run or analysed studies, so as to improve healthcare delivery (Cochrane 1972, Sackett et al. 1996). Moreover, the institutions that developed were aimed at improving cost-effectiveness by reducing the use of 'ineffective treatments'. In other words, these evidenced-based approaches were designed to protect patients and communities from being treated or receiving healthcare on the basis of poorly designed studies that may be harmful rather than beneficial. Of course, the problem that emerged was in what constituted 'poor design' and the philosophical conception of validity. Ultimately, a positivist epistemology dominated early EBM models and most EBHC models today, directing funding, governance and practice toward principles around population effects and distanced meta-analysis (Holmes et at 2006a, Holmes et al. 2006b). Moves to systematise quality assessments and synthesise knowledge were represented as removing politics, poor techniques and human influence from the production and application of medical knowledge. Yet, such objectivities were illusory rather than reflected in the reality of knowledge work in medicine. Systems that rationalise quality and sort through the mass of healthcare information available are understandably appealing for many stakeholders, including managers and policy makers seeking to rationalise the delivery of certain interventions or services over others. As suggested, in the second half of the twentieth century, knowledge production (particularly publication in academic journals) was expanding dramatically and yet methods of information delivery, above and beyond individual clinicians reading studies and informing junior doctors, were lagging behind. The speed of knowledge production greatly outweighed the capacity of clinicians to understand, absorb and utilise knowledge. Moreover, most clinical programs did not, and still do not, provide rigorous training in study design and research methods. As such, a usable system of assessment, delivery and suitably institutionalised 'production houses', was met with significant enthusiasm from many quarters of the medical and healthcare establishment.

Professional Governance, Legitimacy and the Proliferation of EBHC

Politically and socially, the mid to late twentieth century was becoming increasingly risk adverse and market orientated, and there was increasing pressure for 'governance' in health service delivery and within the health and social care professions (Halligan and Donaldson 2001). Such agendas were complex and multifaceted, incorporating wider concerns over localised idiosyncrasies in health practice, cost blowouts, state-driven pressure for enhanced accountability, private sector drives for profit maximisation and a genuine concern for the widespread variations in care. Within 'other' health and social care professions – that is those other than medicine – considerable changes were taking place concurrent to the development and proliferation of EBM. Whilst medicine was the first professional and clinical body to explicitly push for rigorous across-the-board practice guidelines, hierarchies of evidence and a top-down model of managerial control over clinical practice, there have become a wide range of incentives from other health and social care professions to develop their own version of EBM. Being an 'evidence-based' profession has become critical for receiving funding, bolstering state legitimacy, achieving rhetorical legitimacy, gaining proximal credentialing and so on (Kessenich, Guyatt and DiCenso 1997, Richardson 2002, Webb 2001). Whether evidence-based nursing practice (Kessenich, Guyatt and DiCenso 1997) or evidence-based occupational therapy (Egan et al. 1998), health and social care professionals have come under pressure to replicate and transform EBM to fit their practices and shape processes of enhanced professionalisation and systematisation (Holmes, Perron and O'Byrne 2006). Moreover, such models have spread beyond state-supported and biomedically-credentialised practices to areas such as CAM, with the advent of evidence-based complementary medicine (Richardson 2002). Over the second half of the twentieth century nursing, physiotherapy, midwifery and occupational therapy have each gradually moved towards degree-based, regulated, nationally-credentialised and 'organised' professions with the development of practice guidelines in order to achieve professional credibility. An EBHC-type model has fed into each of these 'health professions' trajectories towards professionalisation and cultural legitimacy. Thus, the technologies developed initially for EBM have been drawn on, co-opted, and at times transformed, within the context of other professional groups. This has ultimately caused significant difficulties due to different ideological positions of the different health professions. Such developments are illustrative of the fact that advocates a...

Table of contents

• Cover
• Half Title
• Dedication
• Title
• Copyright
• Contents
• List of Contributors
• List of Abbreviations
• 1 A Critical Social Science of Evidence-Based Healthcare
• PART I EVIDENCE IN CULTURAL AND THEORETICAL CONTEXT
• PART II EVIDENCE IN THE CLINIC
• PART III EVIDENCE ON THE MARGINS
• Index