Practicing outcome-based medical care using pragmatic care trials

Abstract

The current separation between medical research and care is an obstacle to essential aspects of good medical practice: the verification that care interventions actually deliver the good outcomes they promise, and the use of scientific methods to optimize care under uncertainty. Pragmatic care trials have been designed to address these problems. Care trials are all-inclusive randomized trials integrated into care. Every item of trial design is selected in the best medical interest of participating patients. Care trials can eventually show what constitutes good medical practice based on patient outcomes. In the meantime, care trials give clinicians and patients the scientific methods necessary for optimization of medical care when no one really knows what to do. We report the progress of 9 randomized care trials that were used to guide the endovascular or surgical management of 1212 patients with acute stroke, intracranial aneurysms, and arteriovenous malformations in a single center in an elective or acute care context. Care trials were used to address long-standing dilemmas regarding rival medical, surgical, or endovascular management options or to offer innovative instead of standard treatments. The trial methodology, by replacing unrepeatable treatment decisions by 1:1 randomized allocation whenever reliable knowledge was not available, had an immediate impact, transforming unverifiable dogmatic medical practice into verifiable outcome-based medical care. We believe the approach is applicable to all medical or surgical domains, but widespread adoption may require the revision of many currently prevalent views regarding the role of research in clinical practice.

Most Promising Approaches to Improve Brain AVM Management: ARISE I Consensus Recommendations

“…54 This care trial, aims at replacing singular treatment choices with a systematic 1:1 randomized assignment when established knowledge is insufficient, thereby converting unconfirmed traditional medical practices into evidence-based health care. 55 Other efforts such as multicenter registries with prospectively acquired data and long-term follow-up are underway. The MARS (Multicenter Arteriovenous Malformation Research Study) is a collaborative multicenter study with a target enrollment of 4500 unruptured bAVMs.…”

“…54 This care trial, aims at replacing singular treatment choices with a systematic 1:1 randomized assignment when established knowledge is insufficient, thereby converting unconfirmed traditional medical practices into evidence-based health care. 55…”

Ethical care requires pragmatic care research to guide medical practice under uncertainty

“…Nine care trials are currently being used to guide the care of neurovascular patients in the presence of serious uncertainty. A progress report has been published to explain how the methodology can be used in practice [7]. The integration of trial methods into medical practice requires adjustments on both the research and care fronts.…”

“…supporting the necessity of using pragmatic care trial methods to guide good medical practice in the presence of uncertainty [2]. The care trial methodology and examples of its use in practice are detailed elsewhere [2,7].…”

Application of Medical-Nursing Integration Multidisciplinary-Assisted Surgical Wound Nursing Mode in Improving the Quality of Wound Treatment

“…Debridement, suture, and other methods can effectively promote wound healing at the local injury site. However, in some patients, postoperative pain and poor nursing lead to slow wound recovery and even cause wound infection in severe cases, which increases the difficulty of clinical treatment and medical expenses of patients [ 3 , 4 ]. Therefore, it is extremely important to choose effective nursing intervention methods to improve the quality of wound management.…”