More on CEUs & grading evidence

Here are some articles on the Strength of Recommendation Taxonomy (SORT). I like this  idea that the American College of Family Practice (ACFP) adopted for grading articles or patient oriented evidence that matters (POEMs).  I suggest considering a similar taxonomy for grading courses endorsed by the APTA, from I (highest) to III (lowest) grade of evidence. This is about 'sorting' courses by their strength of evidence; it is not about offering only EBP courses. 

Realistically, most true innovations in treatment & Diagnosis are going to be Grade III courses, if it is at the earliest level of development. However, like John C stated, the slow, but steady pressure should be on the innovator to demonstrate true evidence of effectiveness or accuracy (Dx Tests) over time. This taxonomy would be a motivator for exploration of the true value of a intervention and it would not allow the innovator to just 'rest on their laurels' after the initial 'Eureka' of discovery. Brian Mulligan, or those around him, is a good example of moving his technique regime from Grade III to Grade II, with Vincenzino et al working on validation and demonstration of the technique effectiveness with specific groups of patients (e.g. lateral epicondyalgia).

More importantly, the taxonomy would tell the consumer of education (i.e. the PTs taking the courses) what the grade is I-III (e.g. G, PG-13, R, X...same function for sex and violence in movies).  A grade III should imply the 'surgeon generals' statement: Caution: This course may (or may not) improve your patient care outcomes. A grade I means something like: Grade A inspected Techniques: Safe and effective in the management of a selected subgroup of patients [Don't mix with alcohol and caution using with pharmaceuticals as the outcomes are unknown!]

The APTA should be promoting Level I evidence all over the country (e.g. the manipulation courses for LBP) at this time in our development. The Philedelphia Panel served the function of 'whacking the weeds' away for modalities and other interventions (non-manual therapy). We should take these types of highly critical reviews as a tonic for our ailment, a purging of the system (or in alimentary terms: suppository served the same function for 'getting the crap out'). The good healthy diet of the proven 'rich & healthy' courses and slow introduction of novel favors and varieties (i.e. innovation) should help with creating the EBP Profession we envision for the future.

Any thoughts?
Britt

Download weiss.SORT. fam. med. 04.pdf

Download SORT.jfp.04.pdf

Download sort.amj.fp. 04.pdf

Comments

[Jon Newman]

A labeling system seems to be reasonable to me. However,I've been to a number of APTA's ACP courses and there is a healthy amount of speculation in those course also. I can foresee headaches from those who assign the label (like deciding if someone is disabled) but that's what they'll get paid the big bucks for I guess.
I would hope also that I wouldn't be made to only attend certain types of courses for reasons I tried to make clear in previous posts.
It seems like a good start.

jon

[John Childs]

Britt:

Dead on as usual, and an enjoyable read to boot. I like the system (actually, it's perfect as far as I'm concerned). However, getting behavior change from state professional associations - the majority of which (I recognize there are exceptions) hide behind their CEU approval committess as a means to rubber stamp approvals and collect fees - will be as formidable a task as achieving EBP behavior change among clinicians. Regardless of the difficulty, it is a reform initiative worth pursuing with vigor and due diligence.

John

[Britt Smith]

Jon,
I don't see the system as a way to make PTs attend types of courses, but it could be construed that way. I envision the system as a guide, again, like the rating of movies to help parents, perverts or people-in-love to decide the levels of sex and violence in the movies.
Biological plausibility is at the bottom rung, also, even though it is based on excellent science (e.g. pathology, physiology, histology, biomechanics)....necessary but not sufficient. The ACFP has adopted the pneumonics of DOEs (Disease oriented Evidence) and POEMs (Patient oriented evidence that matters). DOEs are papers (good science) based on cadaveric studies, physiology, etc. POEMs, however, are a different bred. These are about patient(s) and populations and how care changes, or improves their lives. I like the distinction in literature.
Back to the biological plausibility issue being necessary (actually not) and insufficient. Guyatt and Sackett (can't recall the evidence: JAMA 1992) cite studies of lidocaine in suppression of arhythmias after an MI. The originators of the regime of administering the drug noted that patients post-MI had arhythmias, which were assumed to be dangerous or associated with sudden death. Lidocaine suppresses these arhythmias nicely....however, RCTs demonstrated the mortality rate of patients given lidocaine was significantly worse than patients not given lidocaine. [Indeed, this is case demonstrating a 'lag' of several years between substantial evidence showing worse outcomes with an RX, but experts and Textbooks continued to endorse the Rx regime!!!). Much of the drug problems today are from this putting the cart before the horse in marketing a drug based on physiology and a few studies before good outcomes (benefit and harm studies) are available.
Long winded, but I would support a tiering of DOEs courses from POEMs courses to clear up some of the confusion of good vs. less good evidence.
Britt

[Jon Newman]

Hi Brit,

I think the basic sciences are essential in order to make any sense of an RCT. Scott Sehon and Donald Stanley capture my beliefs best when they stated

"Statistical information from an RCT is virtually uninterpretable and meaningless if stripped away from the backdrop of our basic understanding of physiology and biochemistry"

in the following article

http://www.biomedcentral.com/1472-6963/3/14

The lidocaine study likely answered one set of questions, including does lidocaine decrease hearth arrhythmias? They found their answer to be yes but presumed, as you noted, that an absence of heart rate variability was a good thing, which we now know to be wron--at least over the long haul. Perhaps lidocaine is currently being used acutely instead of as a chronic therapy but that's way outside of my field of understanding.

Here's Jules Rothstein's take on this

http://www.ptjournal.org/april96/apred.cfm

jon

[Britt Smith]

Jon,
I agree, we absolutely need the basic sciences and every operates from some theoretical construct. Jules Rothstein was who gave me a great example that demonstrates the biological plausibility or understanding of mechanism of action was not necessary: Aspirin. The drug has been on the 'market' for 6,000 years. It is very effective for a wide range of action: anti-inflammatory, anti-coagulant and anti-pyrectic. The mechanism of action was not understood until prostaglandin studies in the 1970's. The point Rothstein was making was that Aspirin worked and worked well (maybe without RCTs and such), without the basic science to demonstrate the underlying effect...
I agree basic science is essential. I'm just suggesting that courses of basic sciences could be 'labeled' (like DOEs) to separate them before grading the evidence on courses for interventions(POEMs). Sound reasonable?
Britt

[Jon Newman]

Hi Brit,

It sounds very reasonable. Also, as you noted, everyone operates from some theoretical construct. I think this is a large source of practice variation-- perhaps even more so than the lack of applying info gained through RCT's. Of course the danger is that if our construct is wrong and cannot change the way we practice we run the risk of looking foolish like some of the chiropractic profession still aligning people or reducing subluxations. I'm not sure I see a theory with good explanatory power driving PT practice in terms of pain management. Do you?

jon

[Britt Smith]

Probably not any unifying theory, that I know of. A few years ago at the Academy meeting in St. Louis, a colleague presented a morning on the neurophysiology of pain... I have to admit, despite loving neurophys. in School, I was overwhelmed with neuro-transmitters & networks of neurons! Pain and neurophysiology are the great frontiers of science & potentials for interventions.
The chronic pain patient poses the most humbling experience for all of us in the clinic. The chronic pain patient is where the largest variance in theory and treatment lies. I don't have an answer to the wide variety of interventions.
It is healthy to have different world views in the profession and in science. I will be concerned if we continue to propagate a new intervention every few months....I bought a textbook on chiropractic techniques and there must be 25 or 30 listed, minimally. Some resemble PNF, some are variances of manipulation theory and technique, some are fascia techniques, some have gadgets (activators), some don't....but very little or no outcomes studies, case studies let alone RCTs. Let's not go down that path.
Psychology and psychotherapy has followed the same long road of many, many schools of thought. It seems that Problem-based approaches and more pragmatic approaches have saved psychology from the brink of obscurity and, worse yet for their profession, non-reimbursement! Some great thinker have laid claim to the terrain in psychology, but demonstration of effectiveness has saved the profession. No one can argue that chronic pain patients should be engaged in a multi-disciplinary approach with a strong behavioral component....
neurophysiology bubbles up int he behavior of we human beings. Now, I am rambling on...big topics, lots of terra obscura & incognita.
Thanks, Jon
Britt

[Rob Wainner]

Britt,

You are spot-on; refreshing perspective that meets both the evidence test as well as reality check.

Rob

[Jason Silvernail]

I think this sort of non-exclusionary system addresses many concerns, some of which I brought up in the previous discussion of CEU system problems.
For what it's worth, it seems to me a very good start.
J