Difference between revisions of "EBM"
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| − | The second step of the EBM process is to search the medical literature. Aside from understanding the methods, strengths, and weaknesses of various search strategies and search engines, this step also involves looking for the highest level of evidence. | + | The second step of the EBM process is to search the medical literature. Aside from understanding the methods, strengths, and weaknesses of various search strategies and search engines, this step also involves looking for the highest level of evidence. In general, Systematic Reviews (not to be confused with general Review Articles) are considered the highest level of evidence, followed by Randomized Controlled Trials (RCT), then Case-Control Studies, followed by Expert Opinion and then, lastly, anecdotal evidence. |
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More information on searching can be found [[Searching for Evidence|here]]. | More information on searching can be found [[Searching for Evidence|here]]. | ||
Revision as of 20:02, 26 October 2015
Evidence-based medicine (EBM) is a branch of medicine that emphasizes using clinical and research evidence in making decisions about patients.[1] The origin of evidence-based medicine was largely due to the work of a group of epidemiologists, such as Sir Austin Bradford Hill, Archie Cochrane, and Richard Doll. The premise of EBM is that medical knowledge grows at a faster rate than health care providers can absorb. To resolve this, EBM concentrates knowledge from published medical literature, via systematic review and meta-analyses, into a more easily accessible format for health care providers with a scarcity of time.
Contents
Introduction
The EBM Process can be summarized by four steps:
- Formulate a sensible, focused clinical question.
- Search the medical literature for evidence related to the clinical question.
- Rate the quality of the available studies.
- Apply the evidence to a particular patient or clinical situation.
Formulate a sensible, focused clinical question
In the first step, the clinician must decide explicitly what patient population he or she is interested in, what tests, treatments, and alternatives he or she is considering, what the outcome of interest is (and how is it to be measured). These questions can be remembered with the mnemonic "PICO": Patient, Intervention(s),Comparisons, and Outcomes.
The second step of the EBM process is to search the medical literature. Aside from understanding the methods, strengths, and weaknesses of various search strategies and search engines, this step also involves looking for the highest level of evidence. In general, Systematic Reviews (not to be confused with general Review Articles) are considered the highest level of evidence, followed by Randomized Controlled Trials (RCT), then Case-Control Studies, followed by Expert Opinion and then, lastly, anecdotal evidence.
More information on searching can be found here.
Rate the quality of the available studies
The third step--rating the quality of the available studies--involves a knowledge of research methodology that is important to make valid conclusions. For example (for RCTs): Was a control group used? Was assignment to an experimental vs. control group truly random? Were patients, treatment providers, and outcome assessors blinded to group assignment? What is the risk of a Type I or Type II error? What is the effect size? Or for Systematic Reviews: Was the literature review truly comprehensive (and how can you know)? Was the assessment of study quality rigorous and subjectively graded? Can numerical assessments be statistically combined (a "meta-analysis") to increase statistical power? The answer to these questions often depends on the particular parameters decided in the first step.
Apply the evidence to a particular patient or clinical situation
The last step of the EBM process is the ability to translate the ideal findings of carefully controlled studies to the less-ideal and less-carefully-controlled situation of a particular patient. What are the particular risks and benefits for this patient? What are his or her preferences? What are the costs, alternatives, and availability of particular treatments? Even for a statistically significant finding, is the effect size practically significant? Does the practitioner have the necessary skill or resources to deliver a treatment or to monitor the outcomes?
As medicine has continued to grow and become more complicated, the number of medical specialties has increased and their depth matures. At the same time, the amount and complexity of the medical literature has similarly grown. In this sense, Evidenced Based Medicine can be considered a burgeoning medical specialty, with the medical literature itself as the object of study.
Evaluation methods of EBM
The evaluation of medical evidence for EBM is primarily based upon research study design parameters (population size, types of controls, analytic methodologies, etc.). The randomized-controlled trial is considered to yield the strongest evidence within medical research. Inherent in this, is the ability to judge the quality of the medical literature, to understand what statements can rationally be made from the medical literature, to appreciate the strength of those inferences, and to realistically apply them to a particular patient or clinical situation.
Controversies
There exists a recognized delay between the time that medical research discovers a profound truth to the time this truth is actually applied within the clinical environment. The lag has been reported as up to 7 years. Even with summaries of relevant research, many providers are still unable to allocate the necessary time to acquire and implement this knowledge. Some providers discount the entire premise of EBM. It is likely that some combination of time-constraints and knowledge management primarily contribute to this lag time.
EBM is awash in opportunities for Healthcare Information Technology solutions. Pattern-recognition and algorithm management are IT tools that may dramatically improve the collection of evidence and the application of consistent, high-quality health care services. A serious evaluation of where and how HIT can be inserted into the process of medical knowledge acquisition and application is urgently needed, as of 04/19/2006.
Advantages
Limitations
HIT’s Role in EBM
The link below describes a process for building health science knowledge-bases used by evidence-based decision support tools. This gives an expanded view of the processes corresponding to the quality metrics, practice guidelines, knowledge services and tools, and CQI feedback loops.
Evidence-based HealthCare Decision Support System
Clinical Trial Registries
Searching for Evidence
Pubmed’s new evidence based searching utility
On pop up windows during drug order entry displaying the latest evidence-based medicine articles from pubmed.
Statement of the problem: there is a lack clinician’s access to contextual information at the point of drug order entry in most CPOEs.
Background information: In the mid-1990s, PubMed introduced it’s search engine. This search engine is a web-based information portal for all types of medically-related journals, which now includes a category for evidence based medicine (EBM). PubMed later introduced limits and automatic web service interfacing to view returns via a web page from a program written in java. Thus, it is possible to build a program that would return the latest evidence based medicine articles limited to those published in the last year to the clinician automatically during drug-order entry on Windows and Unix based CPOE clients. This may be useful in cases where a clinician has incomplete knowledge of a drug’s important recent studies and access to the articles is only provided through a button on the CPOE entry screen.
A description of any alternatives: Alternatives are limiting drug decision support to guidelines.
Major conclusions: With Pubmed’s new evidence based searching utility, one may ask, is it worthwhile to put up a link to PubMed articles for the most recent year during drug order entry? This would be a teaching aid as well, given that only the most recent EBM article would be returned. This would be useful in case of perhaps, when the entering clinical is a pharmacist.--Crawford 18:59, 5 November 2007 (CST)
Related Topics
Basic statistical concepts for interpreting study data.
Related articles
METEOR: An Enterprise Health Informatics Environment to Support Evidence-based Medicine
