Use of evidence in acute stroke decision‐making: Implications for evidence‐based medicine

Abstract

Rationale, aims and objectives Evidence‐Based Medicine proposes a prescriptive model of physician decision‐making in which ‘best evidence’ is used to guide best practice. And yet, proponents of EBM acknowledge that EBM fails to offer a systematic theory of physician decision‐making. Methods In this paper, we explore how physicians from the neurology and emergency medicine communities have responded to an evolving body of evidence surrounding the acute treatment of patients with ischemic stroke. Through analysis of this case study, we argue that EBM's vision of evidence‐based medical decision‐making fails to appreciate a process that we have termed epistemic evaluation. Results and Conclusions Physicians are required to interpret and apply any knowledge—even what EBM would term ‘best evidence’—in light of their own knowledge, background and experience. This is consequential for EBM as understanding what physicians do and why they do it would appear to be essential to achieving optimal practice in accordance with best evidence.

Stroke physicians’ and staff perspectives on machine learning to optimise thrombolysis decision making in stroke: a qualitative study

“…First, given reservations expressed by some of our participants and healthcare professionals elsewhere about the underpinning SSNAP data 66 it seems important to ensure that intended adopters are reassured about the integrity of modelling based on this data. Second, evidence from this research and elsewhere indicates that the ED physicians' may have less confidence in the evidence base for, and safety of thrombolysis 75,79 . It is therefore likely that more work will need to be done with the ED physician community to build trust in the SAMuel-2 technology:…”

“…Given the shortfall of consultant stroke specialist provision in the UK 73 non-stroke specialists are likely to continue to be involved in thrombolysis decision-making and delivery. Evidence shows the wider ED physician community of practice has some reservations about the efficacy and safety of thrombolysis for acute stroke [74][75][76][77][78][79][80][81][82][83][84] The College supports robust governance procedures, but does not support the translation of elements of these into arbitrary performance targets or commissioning targets (for example, regarding the number of patients actually thrombolysed). This is a concern that this may create perverse incentives within stroke care, or be prey to the Goodhart principle.…”

“…Dewar et al, noted75 (p 8) , 'Emergency physicians appear to feel uncomfortable diagnosing stroke and so fret about causing unnecessary hemorrhage in patients who should never have received tPA in the first place'. Similarly, Langlois-Thérien et al79 argue that emergency physicians' different 'epistemic evaluation' process means they do not accept the evidence base for thrombolysis in stroke in the way the neurology community of practice does. The Royal College of Emergency Medicine position statement from 2015 about acute ischaemic stroke and intravenous thrombolysis 85 stated:…”