Practical example of critical realism: Heart failure, decompensation and readmissions

My colleague (Konrad Dias) and I have a new paper out this September that is a working practical example of the implications of a critical realist approach to epistemology (theory of knowledge). Though, the words critical realist, critical realism or stratification of reality will not be found in the paper itself. Rather, these words are representations of the philosophical foundation, perhaps even a worldview for scientific exploration and understanding. The paper is not about the philosophical foundation - the paper is about heart failure, particularly the concept of stability in patient’s with heart failure, and the notion of decompensation as a cause of readmission and how reality, across stratifications, provide insights into possible causal connections.

The paper’s abstract can be found here. And since the abstract is open - it is reproduced here.

Chronic heart failure (HF) is a common diagnosis seen by physical therapists in many settings. This Year in Review article specifically focuses on current empirical evidence regarding escalating readmissions for HF and the potential role physical therapists can play in reducing these events. We examine the current HF readmission prediction models using the International Classifications of Function, Disability, and Health framework to highlight the need to consider reduced exercise capacity, ability to perform activities of daily living, and quality of life as integrated, inherent, and integral components of chronic HF itself. Consideration of stability at the levels of body structure and function, activity, and participation is proposed, and related literature is reviewed and integrated. [Collins, S., & Dias, K. (2015). Year in Review — Heart Failure : Stability , Decompensation , and Readmission, 1–15. ](http://journals.lww.com/cptj/Abstract/2015/09000/Year_in_Review_Heart_Failure___Stability,.3.aspx)

Here I am interested in sharing a bit about how the philosophical foundation is related to the concepts of the paper as presented in the abstract. For more on the paper itself you will have to get a copy of the paper.

Critical realism (CR) provides an epistemology that connects with reality and in doing so engages with empirical (observable) facts that when combined provide evidence: ”current empirical evidence regarding escalating readmissions for HF”.

While CR engages with reality, it realizes that the evidence derived from empirical evidence is put together with a rationale process of model building. And once the rationale models are built, if they are causal models, we can consider the implications for experimentation and intervention: “the potential role physical therapists can play in reducing these events”  Such as how to manipulate the variables in the causal model - if experimentation and intervention lead to model predicted responses when we observe again, we consider that a confirmation of the underlying model. When they do not confirm we consider why they do not confirm. Over time we balance examples of confirmation and disconfirmation in revisiting out models.

CR recognizes the stratification of reality (ontology) and the implications of this for knowledge (epistemology), in a sense, ontology determines epistemology: “We examine the current HF readmission prediction models using the International Classifications of Function, Disability, and Health framework…” The ICF is an excellent - indeed an already utilized - example of ontology determine epistemology and the stratification of reality. Prediction models (and predictive analytics) rely on an underlying causal model whether explicitly or implicitly. These approaches should make their underlying causal models and therefore assumptions explicit. Care should be taken to consider the stratification of reality engaged with during the modeling process.

CR does not take a reductionist or a holist approach. It recognizes the need for both approaches, we must dig deep to understand causal models as well as we can, but we must look broadly to see the interactions within and between strata: “to highlight the need to consider reduced exercise capacity, ability to perform activities of daily living, and quality of life as integrated, inherent, and integral components of chronic HF itself.” In other words, the causal model of HF and readmissions needs to keep in mind that the disease, exercise capacity, ADLs and quality of life are integrated (connected and complex), inherent (essential attributes) and integral (necessary to make our understanding whole or complete).

YiR - Figure

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