Searching the clinical fitness landscape.
Searching the clinical fitness landscape.
复制标题
搜索临床健身景观。
DOI：
10.1371/journal.pone.0049901
复制
发表时间：
2012
期刊：
影响因子：
3.7
通讯作者：
Kauffman SA
中科院分区：
文献类型：
--
作者：
Eppstein MJ;Horbar JD;Buzas JS;Kauffman SA
临床实践和患者结果中普遍存在的无法解释的变化表明，提高医疗保健质量和安全性存在重大机遇。然而，关于如何最好地识别和传播医疗保健改善以及缺乏指导辩论的理论，几乎没有共识。许多人认为多中心随机对照试验是循证医学的黄金标准，尽管结果往往是不确定的，或者由于提供护理的背景不同而可能不普遍适用。越来越多的其他人主张使用“质量改进协作”，其中多机构团队共享信息，以确定潜在的更好的做法，随后在特定机构的当地环境中进行评估，但人们担心这种协作学习方法缺乏随机试验的统计严谨性。使用基于代理的模型，我们展示了如何以及为什么协作学习的方法几乎总是导致更大的改善预期的患者结果比更传统的方法在搜索模拟的临床健身景观。这是由于更大的统计能力和更依赖于背景的治疗评价相结合，特别是在复杂的地形中，一些做法的组合可能会相互作用，影响结果。我们的模拟结果与随机对照试验的局限性相一致，并为医疗机构复杂的社会技术环境中质量改进协作的有效性提供了重要的见解。我们的方法说明了如何将医疗实践的演变建模为对临床健康状况的搜索，可以帮助识别和理解提高医疗质量和安全性的策略。
Widespread unexplained variations in clinical practices and patient outcomes suggest major opportunities for improving the quality and safety of medical care. However, there is little consensus regarding how to best identify and disseminate healthcare improvements and a dearth of theory to guide the debate. Many consider multicenter randomized controlled trials to be the gold standard of evidence-based medicine, although results are often inconclusive or may not be generally applicable due to differences in the contexts within which care is provided. Increasingly, others advocate the use “quality improvement collaboratives”, in which multi-institutional teams share information to identify potentially better practices that are subsequently evaluated in the local contexts of specific institutions, but there is concern that such collaborative learning approaches lack the statistical rigor of randomized trials. Using an agent-based model, we show how and why a collaborative learning approach almost invariably leads to greater improvements in expected patient outcomes than more traditional approaches in searching simulated clinical fitness landscapes. This is due to a combination of greater statistical power and more context-dependent evaluation of treatments, especially in complex terrains where some combinations of practices may interact in affecting outcomes. The results of our simulations are consistent with observed limitations of randomized controlled trials and provide important insights into probable reasons for effectiveness of quality improvement collaboratives in the complex socio-technical environments of healthcare institutions. Our approach illustrates how modeling the evolution of medical practice as search on a clinical fitness landscape can aid in identifying and understanding strategies for improving the quality and safety of medical care.
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DOI：
10.1136/bmj.e813
发表时间：
2012-02-14
期刊：
BMJ (Clinical research ed.)
影响因子：
--
作者：
Bafeta A;Dechartres A;Trinquart L;Yavchitz A;Boutron I;Ravaud P
通讯作者：
Ravaud P
影响因子：
8
作者：
Horbar, JD;Rogowski, J;Carpenter, JH
通讯作者：
Carpenter, JH
影响因子：
4.5
作者：
Briggs, Andrew
通讯作者：
Briggs, Andrew
影响因子：
39.2
作者：
Dechartres, Agnes;Boutron, Isabelle;Ravaud, Philippe
通讯作者：
Ravaud, Philippe
影响因子：
15.8
作者：
Ioannidis, JPA
通讯作者：
Ioannidis, JPA