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Advances in Skin & Wound Care:
doi: 10.1097/01.ASW.00004409911.32985.63
Departments: Editorial

The Gap Between Clinical Evidence and Practice: Venous Ulcer Disease

Salcido, Richard MD, EdD

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Richard “Sal” Salcido, MD, EdD, is the Editor-in-Chief of Advances in Skin & Wound Care and the Course Director for the Annual Clinical Symposium on Advances in Skin & Wound Care. He is the William Erdman Professor, Department of Rehabilitation Medicine; Senior Fellow, Institute on Aging; and Associate, Institute of Medicine and Bioengineering, at the University of Pennsylvania Health System, Philadelphia, Pennsylvania.

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This month’s continuing education activity (page 35) titled, “Chronic Venous Leg Ulcers: Is Topical Zinc the Answer? A Review of the Literature,” is demonstrable of unresolved practice and methodological issues in the specialty of wound care. That is, it validates the gap between evidence and practice. Systemic literature reviews allow us to take a clinical practice and research snapshot, in time and space, by placing before us clinical practice issues in a succinct, sequential readable format. Although we strive for evidence-based medical (EBM) decision making, when it comes to practices that have been used in wound healing for centuries, such as zinc, silver, and others, the full interpretation of the reviews and their conclusions is limited by tradition, bias, and theoretical boundaries. Some of these limitations are practitioner and patient preferences and even preexisting clinical practice guidelines, which may need to be updated. Mendelson and Carino1 state that a significant barrier to the adoption of EBM is the overwhelming support for preserving the practitioner-patient relationship. Moreover, “despite the extensive investment in developing clinical guidelines, most clinicians do not routinely integrate them into their practices.”1 In the recent past, it was anticipated that practice guidelines would indeed standardize patient care. The current trend toward EBM is also linked to a third consideration that we are now coming to grips with, policy decisions through quality-based purchasing for medical coverage or payment.2,3 From a policy perspective, payments for medical dressings and equipment may in the future be tighter linked to findings from systematic reviews, meta-analysis, health policies, and even politics.3

Ideal systemic reviews should provide an analysis of the “research gaps,” preferably found in the discussion section of the paper. However, several reasons may contribute to the lack of such explicit research gap analyses, including “insufficient or imprecise information, biased information, inconsistency or unknown consistency, and not the right information (such as not the appropriate outcome measured or population assessed).”4,5 For an interesting comparison of the systemic review method for EBM reviews in wound care and venous ulcers, I would invite the readership to review an excellent review by Brölmann et al.6

There is an inherent bias to publish papers that are peer reviewed and demonstrate positive outcomes but that are not always applicable to the real-world environment. To use a well-worn metaphor, “We can learn what not to do by observing others’ mistakes,” and we could learn about practice pitfalls by reading about trials that failed, as well.7 According to The Journal of Negative Results in Biomedicine, “It is useful and important to publish well-documented failures, such as with drugs that show no benefit or clinical improvement, as well as with the use of methods that are unreliable, but for which the shortcomings have not been publicized.”8

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Richard “Sal” Salcido, MD, EdD

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References

1. Mendelson D, Carino TV . Evidence-based medicine in the United States—de rigueur or dream deferred? Health Aff. 2005; 24: 133–6.

2. Atkins D, Siegel J, Slutsky J . Making policy when the evidence is in dispute. Health Aff. 2005; 24: 102–13.

3. Fox DM . Evidence of evidence-based health policy: the politics of systematic reviews in coverage decisions. Health Aff. 2005; 24: 114–22.

4. Carey Tim, Yon A, Beadles C, Wines R . Prioritizing Future Research Through Examination of Research Gaps in Systematic Reviews. Washington, DC: Patient-Centered Outcomes Research Institute; 2012; .

5. Robinson KA, Saldanha IJ, Mckoy NA . Frameworks for Determining Research Gaps During Systematic Reviews. Rockville, MD: Agency for Healthcare Research and Quality (US); 2011;.

Report No. 11-EHC043-EF.


6. Brölmann FE, Ubbink DT, Nelson EA, Munte K, van der Horst CM, Vermeulen H . Evidence—based decisions for local and systemic wound care. Br J Surg. 2012; 99: 1172–83.

7. Salcido R . Evidence-based medicine: inherent limitations. Adv Skin Wound Care. 2010; 23: 535–6.

8. Pfeiffer C, Olsen BR . Editorial. J Negat Results Biomed. 2002; 12: 1–2.

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