Evidence-Based Medicine

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Evidence-Based Medicine

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WHO Criticized for Neglecting Evidence"When developing "evidence-based" guidelines, the World Health Organization routinely forgets one key ingredient: evidence. That is the verdict from a study published in The Lancet online Tuesday. The medical journal's criticism of WHO could shock many in the global health community, as one of WHO's main jobs is to produce guidelines on everything from fighting the spread of bird flu and malaria control to enacting anti-tobacco legislation. … Pang said that, while some guidelines might be suspect and based on just a few expert opinions, others were developed under rigorous study and so were more reliable."

ARTICLES:

Does "Evidence-Based Medicine" Diminish the Physician's Role? "Medicine that is based on prevailing opinion results in things, such as double mastectomies for fibrocystic breast disease because a particular surgeon believes that lumpy breasts are a risk for breast cancer, hysterectomies for all postmenopausal women because a gynecologist believes that female reproductive organs past a certain age only serve to breed cancer, or surgery on every case of sciatica because a back surgeon says that that's the best approach. I regret to say that I have seen all of these, always in a small town where one specialist's opinion sets the gold standard of care for his or her field simply because he or she is the only expert available. This is not good medicine by any measure, and yet, it was for the most part how medicine was practiced before the EBM movement became popular."

Ethics and Evidence-Based Medicine: Is There a Conflict? "When the phrase was first coined, "evidence-based medicine" (EBM) simply referred to the use of therapy that had been proved and tested in a rigorous manner to the point of its becoming "state of the art."[1] … If one strictly adheres to the terminology and resultant definition (ie, that "good" medical practice must be based on evidence that "x" is helpful in treating disease "y" for a particularly defined group "B") one can hardly oppose EBM outright. Presumably the only alternative to that definition would be "myth or rumor-based medicine" … Most things we do in medicine today are by no means strictly evidence-based; one hopes that this will change but only after the term "evidence" is strictly applied. But even then, medical treatment consists of a lot more than prescribing drugs or operating on people. Physicians themselves are by their very nature therapeutic tools -- something that cannot be weighed and measured the way EBM would suggest. … Conclusion I have discussed the advantages and disadvantages of EBM protocols. While it is my view that they may serve as guidelines, the danger of their becoming straightjackets is by no means trivial. Such a procedure threatens to separate the patient's uniqueness further from the physician and would support looking at the disease instead of at the patient who happens to have that disease. In making all treatment a routine, it may well decrease physicians' curiosity and cause them to overlook important incidental findings. "

Evidence-Based Medicine and the Cochrane Collaboration on Trial "While evidence-based medicine is absolutely essential to comprehensive healthcare reform, it has been profoundly corrupted by money. … From this single well-designed study of anticoagulants came a startling result: The anticoagulants did not prevent deaths. … Based on the complication rate of anticoagulation for DVT or PE in much larger observational studies, anticoagulants kill 1000-4000 Americans with VTE each year due to internal bleeding, mostly in the brain. … The Cochrane peer reviewers (at least 4 out of 7 of which had undisclosed financial ties to the drug companies that make anticoagulants) delayed four years over releasing this review for publication. … Since anticoagulation researchers and FDA scientists chose not to rebut any of the data or conclusions of either review, the media was not interested, few physicians read the reviews, and no debate ensued. Researchers continue receiving lucrative contracts from drug companies for more anticoagulant trials. The medical establishment (drug companies, doctors, hospitals) keeps making money from the diagnosis and treatment of DVT and PE with anticoagulants (estimated total cost in 2007 will be $13 billion-$48 billion in the United States[15]), and medical journals keep publishing more anticoagulation trials without proper controls, which are dutifully covered by a compliant media, while thousands of DVT and PE patients keep bleeding to death."

Evidence-Based Standards Should Apply to Dietary Supplements, Too

Guidelines and Rules: Friend or Foe?

Guidelines Are Never Enough: A Commentary on "When Guidelines Are Not Enough" "In clinical oncology, many management decisions are based largely on clinical judgment because of the lack of specific, high-quality evidence. It is primarily for this reason that the most widely used guidelines, those published by the National Comprehensive Cancer Network (Jenkintown, PA), are not truly evidence based, but are "a statement of consensus" of experts in the field.2"

Trials and Tribulations of Evidence-Based Medicine: The Case of Alzheimer Disease Therapeutics

JOURNAL ARTICLES:

Clinical use of evidence-based medicine--clinical questions. (WMJ. 2007) "There is currently no high quality evidence on the risk of bleeding with high-dose ASA versus low-dose ASA. The current evidence does not support using high-dose ASA therapy in patients with known coronary artery disease and a history of gastrointestinal bleeding."

[Critical reading and EBM : the LIFE trial] (Rev Med Brux. 2007)

Evaluating medicines: let's use all the evidence. (Med J Aust. 2007) "The current drug regulatory system is outdated and relies primarily on a process of premarketing evaluation, followed by periodic reviews of reported adverse events. While long-term medicine use for chronic conditions is now commonplace, current drug evaluation systems do not incorporate the comprehensive evidence accruing over time in clinical practice."

Evaluating primary care doctors' evidence-based medicine skills in a busy clinical setting. (J Eval Clin Pract. 2007) "Rationale, aims and objectives To date, primary care doctors' (PCDs) evidence-based medicine (EBM) skills have rarely been studied. We conducted a cross-sectional study to evaluate PCDs' practical EBM skills and to determine risk markers associated with these skills. … Results PCDs found it difficult to formulate clinical questions both in the written and online exam, mostly neglecting to mention the Patient and Comparison components of PICO (patient, intervention, comparison and outcome). Search strategies primarily dispensed with the use of MeSH terms, ignoring appropriate limits. Doctors final scores were low (score = 41.5/100, SD = 16.2). … Conclusions This study emphasizes the need for enhancing PCDs practical EBM skills. Future research and interventions should focus on this population emphasizing the specific needs of subpopulations (i.e. general practitioners and doctors without previous EBM training)."

Evidence based medicine methods (part 1): the basics. (Paediatr Anaesth. 2007)

Evidence-based medicine. (J Am Coll Radiol. 2007) "When practiced effectively, EBM integrates clinical expertise, patients' values, and best evidence, and promotes optimal patient care. The process of EBM has five components: (1) formulation of a clinical question based on a relevant and immediate clinical problem; (2) selection of appropriate resources and conduction of a literature search; (3) appraisal of the literature for its validity and applicability; (4) integration of the information with clinical expertise and unique patient needs; and (5) self-evaluation of one's performance with a specific patient. Each clinical problem is different, and the resources available to solve each problem vary."

How Evidence-Based Are the Recommendations in Evidence-Based Guidelines? (PLOS Medicine 2007) "There has been a rapid expansion in the number of clinical practice guidelines over the past decade and, as a result, clinicians are frequently faced with several guidelines for treatment of the same condition. Unfortunately, recommendations may differ between guidelines [1,2], leaving the clinician with a decision to make about which guideline to follow. While it is easy to say that one should follow only those guidelines that are “evidence based,” very few guideline developers declare their documents to be non–evidence based, and there is ambiguity about what “evidence based” really means in the context of guidelines. The term may be interpreted differently depending on who is referring to the guideline—the developer, who creates the guidelines, or the clinician, who uses them.. … In conclusion, our finding that less than one-third of treatment recommendations (and less than half of those citing RCTs in support of the advocated treatment) were based on high-quality evidence in national evidence-based guidelines for common conditions should sound a note of caution to consumers of clinical practice guidelines who assume that the sobriquet “evidence based” means that all recommendations contained therein are derived from high-quality evidence. In particular, we have documented that even evidence arising from internally valid RCTs may not be directly applicable to the populations, interventions, and outcomes specified in a guideline recommendation."

How Evidence-Based Are the Recommendations in Evidence-Based Guidelines? (PLOS Medicine) "Editors' Summary: … The recommendations made in different clinical practice guidelines vary, in part because they are based on evidence of varying quality. To help clinicians decide which recommendations to follow, some guidelines indicate the strength of their recommendations by grading them, based on the methods used to collect the underlying evidence. Thus, a randomized clinical trial (RCT)—one in which patients are randomly allocated to different treatments without the patient or clinician knowing the allocation—provides higher-quality evidence than a nonrandomized trial. Similarly, internally valid trials—in which the differences between patient groups are solely due to their different treatments and not to other aspects of the trial—provide high-quality evidence. … Nevertheless, the findings serve to warn clinicians that evidence-based guidelines are not necessarily based on high-quality evidence. In addition, they emphasize the need to make the evidence base underlying guideline recommendations more transparent by using an extended grading system like the CHEP scheme. If this were done, the researchers suggest, it would help clinicians apply guideline recommendations appropriately to their individual patients."

How well does "evidence-based" medicine help neurologists care for individual patients? (Rev Neurol Dis. 2007) " … evidence from therapeutic trials cannot always be applied to the care of individual patients. These studies yield information only on the likely benefit of a particular treatment strategy among a large group of often heterogeneous patients with a given condition. Some trials may show statistically significant positive results for a certain therapy, but these results may be of little or no practical benefit for most patients with the condition studied. Other studies may show that a certain treatment is beneficial to most patients, although it may have serious risks and cause harm in others with the same condition."

Improving the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting: The IMPROVE HF performance improvement registry (American Heart Journal 2007) "Evidence-based consensus treatment guidelines are available to assist physicians with the management of chronic heart failure (HF). Although it has been generally presumed that physicians incorporate these treatment guidelines into clinical practice, the actual assimilation of evidence-based strategies and guidelines has been demonstrated to be less than ideal. Studies of HF care show that treatment guidelines are slowly adopted and inconsistently applied and, thus, often fail to lead to improvements in patient care and outcomes."

Lost in Translation: Bibliotherapy and Evidence-based Medicine. (J Med Humanit. 2007)

Patient Outcomes and Evidence-Based Medicine in a Preferred Provider Organization Setting: A Six-Year Evaluation of a Physician Pay-for-Performance Program. (Health Serv Res. 2007)

Surgeons' attitudes towards and usage of evidence-based medicine in surgical practice: a pilot study. (ANZ J Surg. 2007)

The impact of an evidence-based medicine educational intervention on primary care physicians: a qualitative study. (J Gen Intern Med. 2007) "Both facilitators and participants believed EBM enhanced the quality of their practice. The intervention affected attitudes and knowledge, but had little impact on physicians’ ability to utilize pre-appraised resources at the point of care. Using EBM resources during consultation was perceived to be a complex task and impractical in a busy setting. Conversely, a positive impact on using medication databases was noted. Medication databases were perceived as easy to use during consultations in which the benefits outweighed the barriers. The intervention prompted physicians to write down clinical questions more frequently and to search for answers at home."

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