Evidence-Based Healthcare: a quick and dirty guide

Evidence-Based Healthcare
by E. A. Phillips, BSc, MBBS, MPH e.arthurphillps@gmail.com

What is Evidence- based Healthcare, Evidence-based Primary Care, Evidence-based Medicine, Evidence-Based...?

The process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions. It's about integrating individual clinical expertise and the best external evidence. Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Despite differing definitions, its central tenet remains the appropriate integration of relevant best practice (usually based on published research findings when available) into clinical practice. Obviously this is not a new process — we have always tried to combine ir clinical expertise, patients' values and the best available evidence.History of evidence based… in four lines. A group of doctors who wanted to improve patient care, and base their practices on the best evidence. (Wanting to base practice on best evidence sounds strange- isn’t practice based on the best evidence? Estimates of what is evidence based range from 10% to 80%). Interest in the subject has certainly increased as we have gone from one Medline citation in 1992 to more than 13 000 in 2004.

Does it work?

Since we are talking about evidence we must ask if Evidence-based... results in better health outcomes. Um Ah. Hmm. This is a little embarassing. The reality is that it seems reasonable that it should but we really don't know.•An intensive 3 day course on evidence based medicine for doctors from various backgrounds and training level led to a clinically meaningful improvement of knowledge and skills (Fritsche et al 2002)•Evidence-based medicine makes good sense in theory and while there is no good evidence that it improves patient outcomes (very difficult to arrange a good study of this- ethics contamination ect) it is clear that patients that receive effective interventions do better than those that do not. (Straus 2000)•The context- Why do we need?.. Do we need evidence based healthcare?•daily need for information to answer clinically important questions•traditional information sources are no longer adequate•clinicians’ up-to-date knowledge decreases over time as increasing amounts of new knowledge is published in increasing numbers of journals•time demands of clinical work and sifting through the volume of published information make it difficult to find and assimilate new knowledge.

What do I need to practice EBM?

Right. So supposing you were interested in practicing evidence based.. in a formal way- what would you need to do?(The following is from Phillips and Sladek 2004) Attitudes. Consider alternatives to your practice. Be willing to challenge existing practices. Contemplete unanswered questions as they arise. Commit to life-long learning acknowledging that new research knowledge may change current understandings. Knowledge. Know what the "best-evidence" would look like to answer your question (research methodologies, strengths, weaknesses, potential biases. Know where to search for answers (databases). Know how to assess the quality of published information for its validity and relevance (critical appraisal) Skills. Be able to decide which question(s) you need to pursue in the published literature. Be able to frame a question so that is answerable. Be able to search databases effectively (searching skills). The original definition of Evidence-based Healthcare (Sackett et al) (1) is distinctly process-orientated, and has probably been the most commonly expressed in the literature. They identified five essential steps: (i) asking an answerable question; (ii) finding the best evidence to answer that question; (iii) critically appraising that evidence; (iv) integrating it with expertise and the patient’s individual requirements; and then (v) evaluating effectiveness of the search for the evidence as well as the outcomes of the application of the evidence.

Doing versus Using

Should you attempt to do the formal Evidence-based thing yourself? All those skills. Formulating a question. Looking for an answer. Assessing the answer. Applying the answer. Assessing the process. Is there an alternative? Are the skills of searching for, assessing research necessary? Time, effort, understanding….
"it is difficult to picture the general practitioner, medical registrar, or even less the tyro casualty officer, asking the patient to wait while he or she boots the computer and searches the medical literature, starting with a couple of systematic reviews and delving into an article published in Revista Médica Española, for example, only to do the same during the next consultation and, possibly, repeating the process next week, as an important new contribution may have appeared.” Ivan Moseley 2001
Alternative: to access and use secondary sources of pre-assessed evidence Finding the best evidence Advantages and disadvantages of the following: colleagues, experts, textbooks, journals, internet. Question – problem- how would you describe a group of patients similar to yours? Intervention which main intervention am I considering? Comparison- what is the main alternative?. Outcome- what do I hope to accomplish? Is there an up to date systematic review?

Criticism of Evidence-based...

Criticism has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom.The difficulty with which the approach can be applied by busy doctors, especially those in primary care. Shortage of coherent, consistent scientific evidence. Difficulties in applying evidence to the care of individual patients. Barriers to the practice of high-quality medicine (funds and other resources). The need to develop new skills (epidemiology, economics, qualitative research)Limited time and resources (time, access to information resources ect)

References

Evidence based medicine: what it is and what it isn't BMJ 1996;312:71-72 (13 January)

Editorial•What is evidence-based practice? Progress in Palliative Care, 1 February 2004, vol. 12, no. 1, pp. 6-9(4)

Ruth M. Sladek and Paddy A. Phillips•Seven Alternatives to Evidence-Based Medicine. The Oncologist, Vol. 6, No. 4, 390-391, August 2001.

David Isaacs, Dominic Fitzgerald•Effect of an Evidence-based Medicine Seminar on Participants' Interpretations of Clinical Trials A Pilot Study Academic Medicine (2000) 75: 1212-1214.

Philip Schoenfeld, David Cruess and Walter Peterson•Evidence-based medicine: a commentary on common criticisms CMAJ • October 3, 2000; 163 (7) Sharon E. Straus and Finlay A. McAlister

Further Reading

Arri Coomarasamy, Khalid S Khan, What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review, BMJ 2004;329:1017 (30 October), doi:10.1136/bmj.329.7473.1017

Trisha Greenhalgh How to read a paper: Assessing the methodological quality of published papers BMJ, Aug 1997; 315: 305 - 308. Trisha Greenhalgh How to read a paper : getting your bearings (deciding what the paper is about) BMJ, Jul 1997; 315: 243 - 246. Trisha Greenhalgh How to read a paper: Papers that summarise other papers (systematic reviews and meta-analyses) BMJ, Sep 1997; 315: 672 - 675.(actually the entire greenhalgh series- diagnostic tests, cost studies, statistics intro I+II, drug trials ect)

EBM Resources

Databases: Best Evidence Clinical Evidence, Cochrane Library, DARE, OVID EBMRJournals: ACP Journal Club, Bandolier, Evidence Based Cardiovascular Medicine /Dentistry /Eye Care /Healthcare/ Medicine/ Mental Health/ NursingEBM Online. Evidence-Based Medicine (http://ebm.bmjjournals.com/) The same editorial team produces both EBM and ACP Journal Club using the same procedures, but the intended audience of each journal is different. The first is intended for use in Europe by generalists while the second one is intended for use in North America by internists.Florida State University (medical informatics programme) has a web page called Evidence-Based Medicine Resources http://med.fsu.edu/informatics/EBM.asp

Books

How to Read a Paper by Trisha Greenhalgh is based on her BMJ articles has received excellent reviews. It costs about $20 USD

Evidence Based Medicine--How to Practice and Teach EBM David L Sackett et al