Showing papers by "Lee A. Green published in 2000"

Users" Guides to the Medical Literature XXV. Evidence-Based Medicine: Principles for Applying the Users' Guides to Patient Care

Abstract: This series provides clinicians with strategies and tools to interpret and integrate evidence from published research in their care of patients. The 2 key principles for applying all the articles in this series to patient care relate to the value-laden nature of clinical decisions and to the hierarchy of evidence postulated by evidence-based medicine. Clinicians need to be able to distinguish high from low quality in primary studies, systematic reviews, practice guidelines, and other integrative research focused on management recommendations. An evidence-based practitioner must also understand the patient's circumstances or predicament; identify knowledge gaps and frame questions to fill those gaps; conduct an efficient literature search; critically appraise the research evidence; and apply that evidence to patient care. However, treatment judgments often reflect clinician or societal values concerning whether intervention benefits are worth the cost. Many unanswered questions concerning how to elicit preferences and how to incorporate them in clinical encounters constitute an enormously challenging frontier for evidence-based medicine. Time limitation remains the biggest obstacle to evidence-based practice but clinicians should seek evidence from as high in the appropriate hierarchy of evidence as possible, and every clinical decision should be geared toward the particular circumstances of the patient.

Strategies for changing clinicians' practice patterns. A new perspective.

Abstract: How can we persuade clinicians to adopt proven practices? Education, incentives, feedback, social marketing, and various other change strategies have inconsistent and unpredictable effects. We propose a theoretical framework that can provide a reliable basis for selecting effective change strategies. We divide clinicians into 4 categories on the basis of their responses to new information about the effectiveness of clinical strategies. We similarly divide the universe of practice change strategies into knowledge-oriented and behavior-oriented methods. We then show why specific combinations of these strategies are likely to be consistently effective for each of the 4 categories of clinicians.

Implications of recent hypertension trials for the generalist physician: whom do we treat, and how?

Abstract: The publication of the results of the Swedish Trial in Old Patients with Hypertension-2 (STOP-2) and the termination of the doxazocin arm of the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack (ALLHAT) study again raise the question of whether all antihypertensives deliver equal cardiovascular outcome benefits. Data from research on congestive heart failure and from the Heart Outcomes Prevention Evaluation (HOPE) trial illuminate the roles and possible mechanisms of humoral mediators of vascular damage, suggesting, first, that some antihypertensives (thiazides, beta-blockers, and angiotensin-converting enzyme inhibitors) can deliver more improvement in outcomes than other agents and, second, that decisions on whom to treat are best made based on risk appraisal, not merely pressures.