Guest Editorial: Evidence-informed Practice in a Just-in-Time Format: Woundpedia and the World Union of Wound Healing Societies

  Over the last 20 years, the number of studies focusing on wound management has increased dramatically. This new knowledge fuels new transformative approaches to wound care. Thomas Kuhn¹ aptly described this epistemological revolution as a paradigm shift. Punctuating this paradigm shift is this year’s World Union of Wound Healing Societies (WUWHS) meeting in Toronto, Canada (June 4-8). The theme for the meeting, “One problem, one voice,” signifies the effort to unite almost 30 wound healing societies worldwide. The mission is to combine old and new scientific evidence utilizing the expertise of a faculty comprising more than 175 global opinion leaders. The goal is to improve the lives of persons with acute and chronic wounds worldwide.   The meeting is arranged in subject streams (10 breakouts each) and themes (sessions across streams). Streams include sessions pertaining to pressure ulcers; diabetic foot ulcers; ostomy, continence, and skin care; leg ulcers; acute wounds (postsurgical, burns, trauma); complex wounds; global perspectives; free papers; Canadian perspectives; and research. Themes incorporate information on infection, pain, and quality of life; local wound care; evidence education; healthcare systems; and research (visit www.wuwhs2008.ca/ for details). Just-in-time evidence is a resource for clinicians, researchers, policy-makers, and patients/family members that contains the most rigorous and recent evidence that also reflects patient concerns and expert knowledge. Selected streams and themes will be presented on the WoundPedia website {www.woundpedia.com) launched at the meeting.

  Evidence-based medicine was coined by David Sackett² in 1996 to describe the combination of scientific evidence with clinician experience (expert opinion or knowledge) and patient preference. Although research evidence was always important to researchers, the work by Sackett and his team marked the beginning of a major drive to support clinical practice with “evidence.” Clinicians always have valued expert opinion, sometimes in the absence of any supporting research evidence. The importance of patients’ preference should not be overlooked in the clinic or in research.

  The evidence-based imperative in the health disciplines has stimulated research to support skin and wound care practices. Although large, well-designed and conducted randomized controlled trials (RCTs) provide the best evidence that an intervention works, RCTs are not infallible as the gold standard. Potential biases are introduced by small sample sizes, flawed randomization, lack of standardized protocols, inappropriate measurement instruments, comparators not used in everyday practice, and commercial sponsorship of trials.

  In addition, meticulous inclusion and exclusion criteria may limit the ability to generalize RCT results to the usual everyday patient population. These RCTs are designed to establish the efficacy of an intervention. When we recruit subjects for these studies, 80% of chronic wound patients may not qualify for enrollment due to their age, co-existing diabetes, peripheral diseases, concomitant medications, and other patient adherence issues. Despite RCTs’ methodological rigor, their efficacy results should not be extrapolated to the general chronic wound population. As an alternative, “real-life” patients in daily practice are enrolled in effectiveness studies with more encompassing inclusion criteria. The new treatment is compared with routine or standard clinical practice. Effectiveness trials are conducted to determine if an intervention works in real-life circumstances but often requires a much larger patient number, especially if multiple treatment comparators exist. Cost or efficiency also should be addressed; often, trials are designed to provide cost information or the cost is calculated using various statistical models.

  Also, in many RCTs the primary outcome is focused on complete wound healing as opposed to other surrogate endpoints. These alternative endpoints can include the healing trajectory over time, quality of life, pain, odor, and activities of daily living. Other important clinical questions also may require different clinical endpoints, such as the correction of critical colonization or an improved healing trajectory. In these cases, the wound bed may be prepared for healing by decreasing local inflammatory bacterial damage and producing a faster healing trajectory.

  Qualitative methodologies are most suitable to promote understanding of the subjects’ perspective and the abstraction of an experience. This methodology answers completely different questions than the causality established by a RCT. There are many ways of knowing and the wound care community needs to espouse and encourage diversity in our ways of acquiring knowledge. Qualitative research answers different questions than quantitative research and the two approaches should be considered complementary.

  In healthcare, different research designs answer different questions. The hierarchical model we use for quantitative evaluation of a therapy or intervention is one small part of the entire interprofessional healthcare evidence scheme. Different categories of evidence are needed to provide proof of concept and to support physiological processes as they relate to skin and wound care. To improve patient outcomes, we also need expert knowledge and the patients’ preference.

  Valid evidence is provided by a study design that appropriately addresses the research question. Thus, the RCT may not be the best study design for interventions that cannot be randomly assigned using ethical methods, cannot be double-blinded, or cannot be measured quantitatively. Vital to these considerations is the assessment of the various forms of research evidence (systematic reviews and RCTs, clinical studies, expert knowing, animal studies, in vitro studies, and guidelines) and their potential contributions.

  We proposed six characteristics of evidence that will sustain excellence in knowledge development; the key questions for knowledge transfer bridge the gap between research studies and clinical practice (see Table 1).

  As Confucius said, “By three methods we may learn wisdom. First – Reflection which is noblest, Second – Limitation which is easiest, Third – Experience which is bittersweet.” Thus, although many healthcare professionals rank the RCT as the gold standard for evidence, it may be too limiting for a variety of research questions. Many other categories of evidence, including expert knowledge and patient preference, should be part of the healthcare decision process. The WUWHS meeting will address these vital concerns to support the clinical decision-making process.

 This article was not subject to the Ostomy Wound Management peer-review process.

1. Kuhn TS. The Structure of Scientific Revolutions. Chicago, Ill: University of Chicago Press;1962.

2. Sackett D, Rosenberg WS, Grey JAM, Haynes RB, Richardson WS. Evidence-based medicine: What it is and what it isn’t. BMJ. 1996;312:71-72.