To evaluate the quality of evidence and strength of various recommendations, the ACP guide employs the Grade Working Group system. (The Grading of Recommendations Assessment, Development and Evaluation Working Group began as an informal collaboration of people with an interest in addressing the shortcomings of present grading systems in health care. They have "developed a common, sensible and transparent approach".)

Common language is crucial. The Alternative Medicine guide uses Grade to enforce the use of consistent language in describing the quality of evidence about the effectiveness of various treatments (see below). This is an important step in truly collaborating or developing a set of standards in any field.

An admirable effort. This is a significant undertaking, and I like what they're doing with this guide -- the right intent is there, and they seem to have gathered together people who can make it happen. (Contributors include lots of people with "MD" after their names, and they are using a nice publishing tool, ipublishcentral.net, to create a reader-friendly experience.) Complementary and alternative medicine (CAM) has gained substantial recognition over the past 15 years, and it deserves an evidence-based analysis.

Needs supplements? This guide probably needs more time to fully evolve -- and I'm guessing it's probably suffering from a lack of solid CAM-related evidence to chew on. For example, consider Chapter 3 on Allergic Disorders. It's only one page long.

Along those lines, there's now an accreditation program for evidence-based design in the healthcare field, which means using evidence to protect patient safety, improve the level of care, and provide good working environments for caregivers. Brought to you by the Center for Health Design, "Evidence-based design (EBD) is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes." The Center is a non-profit organization, so it should be able to function effectively as a clearinghouse for evidence on healthcare building design.

The Evidence-Based Design Accreditation & Certification (EDAC) program "educates and assesses individuals on their understanding of how to base design decisions on available, credible evidence." These professionals "will demonstrate a clear understanding of these components and use an evidence-based design process to meet and/or exceed the recommended minimum requirements. The program's goal is to test on the proper process to identify, hypothesize, implement, gather, and report the data associated with their project. Once an individual is EDAC accredited, he or she will have an ethical obligation to employ an evidence-based design process in his or her work."

Covering the gamut. This had me wondering if they are emphasizing the how of finding and interpreting evidence, or the what contained in the body of evidence (or both). I took a look at their study guides and the content outline describing what's on the certification exam (8-page pdf here). The examination has five sections: evidence-based design for healthcare, research, predesign, design, and construction and occupancy. Here's what the study guides cover:

• Study Guide 1:  An Introduction to Evidence-Based Design: Exploring Healthcare and Design. It "explores the history and evolution of evidence-based design through its present defintion and defines the key steps of the EBD process. Once the context is set, the guide will explore the components of the healthcare delivery system, the trends affecting it and the various settings in which delivery occurs."
• Study Guide 2: Building the Evidence Base: Understanding Research in Healthcare Design. "Guide two explores the role of research in evidence-based design. The types of research and evidence will be discussed as well as methodologies for doing that research. The guide covers the value of using credible evidence in healthcare projects, and how through research design solutions are empirically evaluated and scientific evidence is generated."
• Study Guide 3: Integrating Evidence-Based Design: Practicing the Healthcare Design Process. "Guide three pulls together the EBD process to walk you through the key steps of the design process in detail from pre-design, design, construction and occupancy. Practical examples demonstrate key areas and show how EBD is practically applied."

The content outline covers a wide range of stuff: There's everything from "how evidence-based design can contribute to attributes of a therapeutic environment" to "describe the role of the Board of Directors in understanding and championing evidence-based design processes" -- and lots in-between. Overall, I'd say this definitely demonstrates an understanding of the importance of following the evidence.

Teaching them how to fish? There's no one way to design a medical facility, and the body of evidence will always be changing -- so testing on specific design elements would be tricky. EDAC seems to be focused on the process stuff, so that's good: Their study materials include a section on critical evaluation, saying "Determine the relevance of evidence to the project based on one or a variety of
factors (e.g., sources, author qualifications and / or experience, appropriateness of research methodology, replication, composition of sample, reliability, validity, generalizability)". Excellent.

ECAD is discussed in Evidence-Based Design, a nice article appearing in a publication called NEXT (Spring 2009). (Alas, it's viewable in a particularly un-reader-friendly online magazine format.) The author, C. Richard Hall, says "As awareness increases and the body of evidence grows, more and more people are seeking to build hospitals with the guidance of those skilled in the practice. But up until now, there was no standard definition of evidence-based design." He explains that the EBD discipline has emerged over the past 15 years.

EDAC's stated mission is to "develop a community of accredited industry professionals through education and assessment of an evidence-based design process." And the vision statement says they want to see "a world where all healthcare environments are created using an evidence-based design process."

Getting the word out. Besides this certification process, the Center does a nice job of explaining to healthcare providers why they should pay attention to evidence-based design. Their web site has a section for healthcare leadership, presenting "evidence-based design resources for healthcare executives." This includes a white paper on the role of the CEO in evidence-based design, and guidance on establishing the business case for EBD.

"1. The person who dreamed up the BMI said explicitly that it could not and should not be used to indicate the level of fatness in an individual. The BMI was introduced in the early 19th century by a Belgian named Lambert Adolphe Jacques Quetelet. He was a mathematician, not a physician. He produced the formula to give a quick and easy way to measure the degree of obesity of the general population to assist the government in allocating resources. In other words, it is a 200-year-old hack.

2. It is scientifically nonsensical. There is no physiological reason to square a person's height (Quetelet had to square the height to get a formula that matched the overall data. If you can't fix the data, rig the formula!). Moreover, it ignores waist size, which is a clear indicator of obesity level.

3. It is physiologically wrong." And the story goes on. OK, so this doesn't mean we should be snarfing extra beer and brats over the holiday. But it is a great example of the tyranny of faulty evidence.

It's not just about PR, it's an ethical obligation. The document opens by saying "Often a neglected afterthought in busy research schedules, the dissemination of key findings upon project completion is a crucial step in community-based research. In fact, we believe that researchers have an ethical obligation to ensure that research findings are disseminated to research participants, as well as other individuals and institutions in the communities in which we work. In an effort to increase ease and efficiency, this document provides key strategies for dissemination, including practical advice and specific templates you can adapt for your use. Through this strategic dissemination approach, CARE intends to distribute salient findings to affected communities, participant agencies, health departments, researchers, policy makers, and health advocacy groups." Topics include media coverage, press releases, research summaries & briefs, posters, newsletters, community publications, web sites, list-serves, events, and conferences.

Writing tips. I've done *lots* of writing that translated research into plain English. The Yale document offers some good tips to researchers, which is good, although I'm convinced many will need more guidance and hands-on help than this -- often they need a seasoned presenter to help them package up their findings. Recommendations include producing content that is:

• "Responsive: Consider your target audiences when deciding on document type.
• Concise: Make it short and to the point; be sure that information is easy to find.
• Interesting: Sort through all findings, and present just those that are new and/or compelling.
• Highlight key points: Use bulleted lists, with one finding or conclusion per bullet.
• Logical: Make sure the points progress in a logical order.
• Useful: Write clear conclusions and recommendations; if readers know what to do with the information, they will be more likely to apply it."

The document also helps authors categorize and summarize their findings so journalists, physicians, and other audiences know how it applies. All this would be even more valuable with better publishing tools (explicit metadata, etc.), but it's a good start. Here's an example of the provided templates:

The National Center for Catastrophic Injury Research at the University of North Carolina has released its 26th annual report (58-page pdf here). For the period fall 1982 - spring 2008, LiveScience says "the numbers tell us:

• High school sports were associated with 152 fatalities, 379 non-fatal injuries and 374 serious injuries. College sports accounted for 22 fatalities, 63 non-fatal injuries and 126 serious injuries.

• Cheerleading accounted for 65.2 percent of high school and 70.5 percent of college catastrophic injuries among all female sports."

A lesson in how *not* to disseminate research findings. I'm grateful to LiveScience for sorting through these stats. The National Center for Catastrophic Injury Research site presents none of this evidence on web pages, which would speed dissemination of their findings and make them available to web search engines. Here's all they say: "In order to view the reports, just click on the report you wish to view on the left sidebar. You will need Adobe Acrobat or Reader to view the reports. This can be downloaded for free at www.adobe.com. The data tables referenced in the reports can be found using the link Data Tables on the left side-bar of the website. The majority of the tables can also be found within the reports as well." Sheesh. They're not doing themselves any favors.

Their information is available only in the formal report. And although the findings are interesting, the reports are particularly difficult to digest. First, there's no Executive Summary to present key results and offer quotable sound bites -- there's not even a table of contents. Instead, the authors begin with an introduction, and then go right into a discussion of data collection methods. They give us lengthy prose discussing the findings for each sport, referring to tables in an appendix (example below). If they want their evidence to have maximum impact, they need to package it much differently.

Brand Week's Todd Wasserman has a new article, Scientist: Influencer Theory is Bogus, covering an interview with Watts, who "first came to the marketing world's attention in 2003, when a New York Times article positioned the Columbia University professor as the anti-Malcolm Gladwell. While Gladwell's 2000 book The Tipping Point laid out an entertaining theory that fads like Hush Puppy shoes ...spread because of groups of people called influencers, Watts has argued that that model is deeply flawed. Watts, now a research scientist with Yahoo, charges that influencers have been poorly defined and that scientific data show you're just as likely to spread a message or product by targeting a random group of consumers as you would by going after so-called influencers. Mostly, Watts says marketers should be much more scientific in their approach, especially as social media grows in importance."

"Brandweek: What's wrong with the influencer model? Duncan Watts: ...when you scrutinize [the claims] carefully, they turn out to not really be very meaningful. Or to put it another way, everyone thinks they know what an influencer is and everyone thinks they know why they matter, but everybody thinks something different. Is an influencer the hipsters in the East Village or Oprah Winfrey? What makes Oprah influential is very different from what makes the hipster in the East Village influential. And so by failing to differentiate carefully between all these different types of influencers you really undermine the ability of the theory to say anything predictive.... Somebody asked the publisher of the surprise bestseller Eats, Shoots & Leaves why that book was so successful and he said it was successful because lots of people bought it. ...Hits are highly unpredictable. It's very difficult to even retrospectively go back and show that there are certain kinds of consistent attributes that result in being popular.

"[Brandweek]: So what would your advice be to a marketer trying to learn from things like that? [Watts]: My first advice would be stop fooling yourself.... Marketers have been chasing influencers for a decade and they haven't found them. And the reason is not that influence doesn't matter. It may very well matter.... The reason is that history is a very poor guide to the future.

"...[T]he whole influencer theory is actually more of a rhetorical device than a theory. It's not like people actually have an explicit theory of who is influential and they go out there and they use that theory to decide who to target. It's more that they do whatever they do. They throw parties or they give away free samples or they advertise in particular publications that brand themselves as reaching an influential audience and run some campaign in their normal manner. And if it works, they say, 'We reached the influencers.' ...In that sense, it's just a rhetorical device to help you explain the randomness that you actually experience in the world.... So it's one of these impossible-to-falsify theories because who you identify as an influencer is always after the fact."

(Photo courtesy of Oceana.) Gerry Hadden with The World quoted Sergi Tudela, who runs the Fisheries Program for the World Wildlife Fund in Barcelona: "Our estimate is that unless something very strong is done the breathing population will completely disappear in three, four years time. And then fishery gets ecologically extinct." Hadden said "The WWF and other environmental groups say the main problem is that there are simply too many boats throughout the Mediterranean. Maria Jose Cornax, a marine scientist with the ocean’s advocacy group Oceana, said 'At the current levels of exploitation that we have and taking also into account the illegal fishing, we have amounts of around 61,000 tons caught each year from this stock when scientists are recommending a maximum amount of 15,000 tons. So it’s four times the amount recommended by scientists.' The scientists ...work for the International Commission for the Conservation of Atlantic Tunas or ICCAT. The group is comprised of dozens of countries that fish and consume tuna from Europe to Asia. Each year it sets limits on tuna catches. This year it ignored its own researchers...."

Blame it on Europe? People in Japan are enthusiastic consumers of bluefin tuna, driving price levels up to $25US per pound. But Japanese officials apparently recognize the seriousness of the situation: Sergi Tudela of WWF says" ...at the latest ICCAT meeting it was the Europeans who pushed for higher catches, sidelining the science. And they succeeded against the advice of US, Canada, Norway, and even Japan. I have to say that last year Japan was rightly aligned in terms of conservation of the species."

Sigh.

I've written about hail cannons several times before. Some claim they prevent hail from damaging food crops and other property, but others aren't convinced. According to Eggers Hail Cannons, a vendor, "Hail cannons ignite a charge of acetylene gas in a specially designed blast chamber releasing an explosive pressure wave creating a cavitation effect which disrupts the formation process of the hail stone embryo." Among others, USA Today has covered them. (Photo from HailCannon.com.)

Today Boing Boing picked up on a good post by Nacken, who said "This weekend we went to the [Piedmont] Roero wine area and after a loooong lunch we sat with friends outside and looked fearfully at the looming, darker growing clouds. When suddenly we heard a loud boom in the distance. Followed by more booms closer by … and within minutes it sounded like we were in the middle of a WW1 battlefield....Totally baffled about what was going on, the locals explained to us that this is the noise of air cannons, which shoot hot, compressed air against the clouds in order to prevent hail." Nacken includes a video, recommended for those who want to hear the sound of the cannons.

Is this an example of the triumph of hope over evidence? The Wikipedia page on hail cannons reviews the scientific evidence (not favorably, I might add): "There is very little empirical evidence in favor of the effectiveness of these devices. A 2006 review by Jon Wieringa and Iwan Holleman in the journal Meteorologische Zeitschrift summarized a variety of negative and inconclusive scientific measurements, concluding that "the use of cannons or explosive rockets is waste of money and effort. From a theoretical perspective there is reason to doubt that hail cannons are effective. For example, thunder is a much more powerful sonic wave, and is usually found in the same storm that generates hail, yet doesn't seem to disturb the growth of hailstones." You can see the research for yourself in If cannons cannot fight hail, what else? [17-page pdf here]. Here's how the authors explain it in their abstract: "Hail suppression is an uncertain meteorological subject in premature agricultural servitude. Commonly known is the method of seeding menacing cumulonimbus clouds with silver iodide by means of rockets or aircraft flares. Less discussed but widely practised alternatives are also reviewed here, in particular the useless but still quite popular practice to attempt destroying hailstones with explosives or with sound blasts from so-called hail cannons."

Those who don't know the history of hail cannons are condemned to repeat it. A 1981 Bulletin American Meteorological Society article, History Repeated: The Forgotten Hail Cannons of Europe, reminded readers that this attempt at weather modification had been tried at the turn of the century... as in 1900, the turn of the *20th* century [8-page pdf here]. But it "went unnoticed by the 'pioneers' of 1950-1970."

Wherever hail cannons go, cranky neighbors can't be far behind. Unwelcome noise has become a key component of the hail cannon experience. Fox News has reported on disagreements in Vermont over hail cannon noise: "Scientists snicker at such devices. But farmers swear by 'em. As for the neighbors, they just swear." In 2004, WLBT reported that a Jackson, Mississippi Nissan automobile dealership was using hail cannons to protect the cars on its sales lot. "The sound at ground zero is about 120 decibels, or about the same as a tornado warning siren. Workers are installing fences around two of the machines in the 140-acre parking lot at Nissan and filling the fences with hay in an effort to reduce the sound level."

Emerging trend? Anti-bird cannons. Absurd Intellectual is wondering if hail cannons work on crows. And other flavors of cannons are also causing controversy: In some areas, people are using propane cannons to keep birds away from berry crops -- which has prompted creation of the anti-anti-bird-cannon site called Ban the Cannons.

"Lawyers think that the mere disclosure of risks and conflicts of interest provides the information that investors or consumers need. That is a fantasy. Faced with 47 pages' worth of 'Risk Factors,' investors come away with a warm glow of safety; risks that seem hard to understand appear unlikely to happen, and people who provide you with lots of detail seem likely to be honest. To inform anyone, information has to be accessible." Amen to that.

Zweig is a big fan of the book Nudge by Richard Thaler and Cass Sunstein. "The central idea in 'Nudge' is what Profs. Thaler and Sunstein call 'choice architecture' -- the context, format and framing of how decisions are presented to consumers. You will eat more nuts from a big bowl than from a small bowl. You will choose surgery if you are told it offers a 90% chance of survival; you will reject it if you are told there is a 10% chance it will kill you. The same people who would skip investing in a 401(k) if they had to 'opt in' to the plan will participate if they have to 'opt out' in order to skip it."

Thaler and Sunstein elaborate in an interview on amazon.com, "Amazon.com: What do you mean by 'nudge' and why do people sometimes need to be nudged? Thaler and Sunstein: By a nudge we mean anything that influences our choices. A school cafeteria might try to nudge kids toward good diets by putting the healthiest foods at front. We think that it's time for institutions, including government, to become much more user-friendly by enlisting the science of choice to make life easier for people and by gentling nudging them in directions that will make their lives better.

"Amazon.com: What are some of the situations where nudges can make a difference? Thaler and Sunstein: Well, to name just a few: better investments for everyone, more savings for retirement, less obesity, more charitable giving, a cleaner planet, and an improved educational system. We could easily make people both wealthier and healthier by devising friendlier choice environments, or architectures.

"Amazon.com: Can you describe a nudge that is now being used successfully? Thaler and Sunstein: One example is the Save More Tomorrow program. Firms offer employees who are not saving very much the option of joining a program in which their saving rates are automatically increased whenever the employee gets a raise. This plan has more than tripled saving rates in some firms, and is now offered by thousands of employers.

"Amazon.com: What is 'choice architecture' and how does it affect the average person's daily life? Thaler and Sunstein: ...The architecture includes rules deciding what happens if you do nothing; what's said and what isn't said; what you see and what you don't. Doctors, employers, credit card companies, banks, and even parents are choice architects. We show that by carefully designing the choice architecture, we can make dramatic improvements in the decisions people make, without forcing anyone to do anything. For example, we can help people save more and invest better in their retirement plans, make better choices when picking a mortgage, save on their utility bills, and improve the environment simultaneously." 

In his WSJ piece, Zweig may be a bit overenthusiastic in saying that the Obama "proposal is an outgrowth of 'Nudge'". It's not as if the coverage is all about "choice architecture" -- see Factbox or FindLaw, for example. However, Sunstein has been nominated to head the Office of Information and Regulatory Affairs, a role sometimes described as "the regulation czar." In reading the coverage of the proposal for a Consumer Financial Protection Agency, But the debate over how to regulate financial institutions ain't over yet; it's complicated and stakeholders will fight hard to protect their turf. The one thing I know for sure is that we desperately need to use evidence more creatively, transparently, and comprehensively. For that, I am grateful to folks like Thaler and Sunstein.

"His claim will probably intensify the debate over the George W. Bush administration's use of harsh techniques to gain information from terrorism suspects....'I make up stories,' Mohammed said, describing in broken English an interrogation probably administered by the CIA that concerned the location of Al Qaeda leader Osama bin Laden.... Monday's disclosure, representing a rare allegation by a detainee that he lied while subjected to harsh practices, also could raise new questions about whether the techniques worked. A lawyer for the American Civil Liberties Union, which obtained the documents through a Freedom of Information Act lawsuit, said the statements raised questions about the effectiveness of the CIA's interrogation program. 'It underscores the unreliability of statements obtained by torture,' said Jameel Jaffer, director of the ACLU's National Security Project.

But the CIA took issue with the description of the techniques as methods of torture that were not useful. 'The CIA plainly has a very different take on its past interrogation practices -- what they were and what they weren't -- and on the need to protect properly classified national security information,' said Paul Gimigliano, an agency spokesman. "

Obama isn't exactly the poster child for transparency, either. ACLU's Ben Wizner, part of the National Security Project, appeared tonight (Monday) on Rachel Maddow's MSNBC show. He showed statements that had previously been released by the Bush Administration, consisting of a page with the entire text blacked out -- um, "redacted" -- and then showed the same page as released by the Obama administration, with just a few words made visible (un-redacted?). Wizner said it made him feel like the Obama team was just saying "keep the change". According to the Public Record, "'The documents released today provide further evidence of brutal torture and abuse in the CIA's interrogation program and demonstrate beyond doubt that this information has been suppressed solely to avoid embarrassment and growing demands for accountability,' said Ben Wizner, a staff attorney with the ACLU National Security Project and lead attorney on the FOIA lawsuit. 'There is no legitimate basis for the Obama administration's continued refusal to disclose allegations of detainee abuse, and we will return to court to seek the full release of these documents.'"