Preface to the Special Issue on “The Role of Best Practices in Health Care Decision Making”

Abstract

cussing the Role of Best Practices in Health Care Decision Making. The discussion began with a provocative article published in April 2016 in which Devorah Klein, David Woods, Gary Klein, and Shawna Perry raised the question, “Can we trust best practices?” (Klein, Woods, Klein, & Perry, 2016). Klein and her colleagues highlighted some of the challenges associated with using evidence-based medicine (EBM) to support clinical care and suggested naturalistic decision making (NDM) as an important perspective for addressing these challenges. Soon thereafter, Paul Falzer (2018) submitted a manuscript deepening and extending the discussion, pointing out that these challenges are well known in the health care community, and noting that effective solutions remain elusive. In this issue, Falzer’s article provides an in-depth discussion of the concept of decision making in this context and the unintended negative consequences of evidence-based recommendations. This article became the centerpiece for this special issue; commentators were asked to react to Falzer’s article. Because the topic of EBM and its impact on decision making and the quality of health care falls at the intersection of at least two important scientific disciplines (EBM and NDM), perspectives of experts who have been thinking about these issues in various contexts and from various traditions are important. We have been fortunate to obtain commentaries from a range of thought leaders representing both EBM and NDM for this special issue. As we reviewed the commentaries, it became clear that there is sometimes disagreement about what EBM really is and what it implies for health care. “Critics” tend to view EBM narrowly, whereas “proponents” have a broader and more multidimensional view of EBM. It is also worth noting that many commentators draw strong links between EBM and the “best practices regimen” (i.e., initiatives and interventions that define the quality of decision making by conformance to evidence-based practices). Other contributors note that these are distinct concepts, suggesting that while managed care, health services research, implementation research, and the best practices regimen are directly influenced by classical decision theory, EBM might be characterized as restoring decision making to its “rightful place.” In some ways, this confusion rooted in the language can be seen as encouraging: There might not be as much disagreement as it appears on the surface, if one begins to discuss concepts and approaches rather than relying on labels. Nonetheless, important points of divergence are found in the commentaries. Although many would agree that EBM was never intended to constrain clinician discretion and discount expertise, there is little agreement about how EBM should be implemented. We invite you to enjoy the following commentaries. Haynes, a member of the working group that articulated a vision for evidence-based medicine in 1992 (Evidence-Based Medicine Working Group, 1992), clarifies that the “conformist principle,” “best practices regimens,” and “transductive models” are not part of EBM. Furthermore, EBM has, from its origins, been considered one of many inputs to decision making by clinicians and patients. He cautions, however, against adopting NDM practices and applications without empirical validation that this approach positively influences outcomes in real practice settings. He encourages collaboration among advocates of the sciences of NDM, knowledge translation, dissemination, and implementation. In the context of today’s discussions, Schneider reminds us of much earlier related discussions, 790084 EDMXXX10.1177/1555343418790084Journal of Cognitive Engineering and Decision MakingPreface to “The Role of Best Practices in Health Care Decision Making” 2018