Evidence based medicine what does it really mean
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Evidence-Based Medicine: What does it really mean?. Sports Medicine Rounds November 7, 2007. What is Evidence-Based Medicine?. A Philosophical Framework? An Evolving Concept? A Method of Practice? A Quality Improvement Approach? A Teaching Tool?

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Evidence-Based Medicine: What does it really mean?

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Evidence-Based Medicine:What does it really mean?

Sports Medicine Rounds

November 7, 2007

What is Evidence-Based Medicine?

  • A Philosophical Framework?

  • An Evolving Concept?

  • A Method of Practice?

  • A Quality Improvement Approach?

  • A Teaching Tool?

  • A Potentially Dangerous Thing if used Incorrectly?


A New Concept?

  • The concept of modifying clinical practice based on research results has been in place for hundreds, perhaps thousands of years

  • In the 20th century (1990’s+) it has evolved to impact almost all fields of healthcare and policy; a structured approach

Largely Developed by One Group

The specific methodologies used to determine “best evidence” were largely established by a research group led by David Sackett & Gordon Guyatt at McMaster U.

What is Evidence-Based Medicine?

“Evidence-based medicine is the conscientious, explicit, & judicious use of current best evidence in making decisions about the care of individual patients” David Sackett, 1996

What is Evidence-Based Medicine?

“The integration of best research evidence with clinical expertise & patient values”

Sackett et al, 2000

Types of Evidence-Based Medicine

  • Evidence-based guidelines (EBG): practice of EBM at the organizational, institutional, or group level (establishing guidelines, policy, regulations)

Types of Evidence-Based Medicine

  • Evidence-based individual decision making (EBID): EBM as practiced by the individual healthcare provider in determining how to treat patients

Some are suggesting we may be

too EBM focused

Evidence-Based Medicine: A Process

1. Identify a patient-oriented/practice-oriented problem that is of interest

2. Develop a specific clinical question that targets the problem

3. Review the available evidence

4. Appraise the evidence → Decision

5. Integrate the evidence into your practice

6. Assess your outcomes (if appropriate)

An Idealistic EBM Model

  • Important not to confuse Levels of Evidence with Quality of Evidence or Importance

Study Design Should Match “?”

  • RCT: Homogeneous patients randomized to intervention A or B & compare outcomes

  • Longitudinal Cohort: Compare a group of people with a risk factor over time to see who develops a disease/injury; prognosis

Study Design Should Match “?”

  • Case-Control: People with condition are compared to those without on a set of variables to assess effect(s) or associations with variables; Diagnostic or descriptive

  • Cross-sectional Survey: A sample from a population is assessed for a certain disease/finding and specific risk factors at that single point in time; descriptive

Systematic Reviews & Meta-analyses

  • Systematic Review:

    • Structured review of the literature

    • Set inclusion & exclusion criteria

    • Assess study design quality

    • Assess methodological quality (rarely)

    • Compile & summarize results

    • Goal: determine what the current evidence is on a specific topic

Systematic Reviews & Meta-analyses

  • Meta-Analysis:

    • Also a structured review of the literature

    • Set inclusion & exclusion criteria

    • Assess study design quality

    • Assess methodological quality (rarely)

    • Perform statisticson the integrated results of the grouped studies

    • Goal: draw conclusions from the results of the analysis of the grouped data

Systematic Reviews

  • Goal: Summaries of best evidence; information overload

  • Top level of evidence; everyone doing them

  • Most are fair in terms of value

  • Over 1.3 Million listed in MEDLINE alone

  • About 5000 on the knee alone

  • Need to evaluate carefully

Systematic Review Killers

  • Low level research / Lack of Research

  • Heterogeneity of subject pools

  • Heterogeneity of methodology

  • Lack of detail prohibits comparison

  • Authors are often knowledgeable on general topic & evaluating study design & sources of bias, but not intervention methods

Must be Savvy Consumers of the Scientific Literature

  • Cannot just read abstract, conclusions, & look at figures

  • Hypotheses, methods, & results are most important

  • Design appropriate?

  • Bias?

  • Conclusion based on results & consistent with methods?

Things to Consider

  • EBM is only as good as the data available

  • A quality case-control study is more meaningful than a flawed RCT

  • Thus, systematic reviews of RCTs are not necessarily best evidence

Final Thoughts

  • Payers have also adopted this

  • Lack of evidence is being equated with lack of benefit; this is not true (call for evidence)

  • There are other clinical decision-making approaches

  • There are highly reputed health care experts who are stark opponents to the EBM approach accepted by most

Patient-Based Outcomes Measures

  • What do they tell us?

  • Does the KOOS QOL tell us someone’s knee is healthy?

  • Can it tell us how well someone is doing or does it simply tell us if there is noteworthy disability or not?

  • Is the difference between an 80 & 88 on the score the same as 88 to 96?

  • What is a good score? In a young athlete?

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