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Searching the Clinical Fitness Landscape 英文参考文献.doc

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Searching the Clinical Fitness Landscape 英文参考文献

SearchingtheClinicalFitnessLandscape MargaretJ.Eppstein1*,JeffreyD.Horbar2,4,JeffreyS.Buzas3,4,StuartA.Kauffman5 1DepartmentofComputerScience,UniversityofVermont,Burlington,Vermont,UnitedStatesofAmerica,2DepartmentofPediatrics,UniversityofVermont,Burlington, Vermont,UnitedStatesofAmerica,3DepartmentofMathematicsStatistics,UniversityofVermont,Burlington,Vermont,UnitedStatesofAmerica,4VermontOxford Network,Burlington,Vermont,UnitedStatesofAmerica,5ComplexSystemsCenter,UniversityofVermont,Burlington,Vermont,UnitedStatesofAmerica Abstract Widespreadunexplainedvariationsinclinicalpracticesandpatientoutcomessuggestmajoropportunitiesforimproving thequalityandsafetyofmedicalcare.However,thereislittleconsensusregardinghowtobestidentifyanddisseminate healthcareimprovementsandadearthoftheorytoguidethedebate.Manyconsidermulticenterrandomizedcontrolled trialstobethegoldstandardofevidence-basedmedicine,althoughresultsareofteninconclusiveormaynotbegenerally applicableduetodifferencesinthecontextswithinwhichcareisprovided.Increasingly,othersadvocatetheuse‘‘quality improvement collaboratives’’, in which multi-institutional teams share information toidentify potentiallybetter practices thataresubsequentlyevaluatedinthelocalcontextsofspecificinstitutions,butthereisconcernthatsuchcollaborative learningapproacheslackthestatisticalrigorofrandomizedtrials.Usinganagent-basedmodel,weshowhowandwhya collaborativelearningapproachalmostinvariablyleadstogreaterimprovementsinexpectedpatientoutcomesthanmore traditionalapproachesinsearchingsimulatedclinicalfitnesslandscapes.Thisisduetoacombinationofgreaterstatistical powerandmorecontext-dependentevaluationoftreatments,especiallyincomplexterrainswheresomecombinationsof practices may interact in affecting outcomes. The results of our simulations are consistent with observed limitations of randomizedcontrolledtrialsandprovideimportantinsightsintoprobablereasonsforeffectivenessofqualityimprovement collaboratives in the complex socio-technical environ