Fulfilling the promise of evidence-based medicine
Fulfilling the promise of evidence-based medicine. Physician Executive, Silverstein Steve. 2007 Nov. 1
How can we fulfill the promise of evidence-based medicine?
Purpose and Background
There have been a lot of discussions about the promises of evidence based medicine(More effective, safer medical intervention resulting in better health outcomes for patients, Greater uniformity in the quality of care).
This paper Take concrete steps toward greater adherence to best medical practices by learning the ins and outs of evidence-based medicine.
EBM origins date back to the 1970s, when academics first began questioning the lack of evidence behind many common medical practices. Today, EBM is an undisputed linchpin of clinical practice.
Health care stakeholders--payers, providers, consumers, employers--often interpret the value and application of EBM in different ways.
- Poor and/or inconclusive science Despite the explosion of medical studies--nearly 40,000 published every month--not many actually generate valid and useful clinical data. It may be due to: Study design, the mindset of medical researchers who are seeking to prove something that they "know” or Increasing amount of research is sponsored by pharmaceutical companies seeking to prove one drug works better than another.
- Time constraints
Busy clinicians are very unlikely to have the time and resources to critically assess the quality and validity of evidence in their specialties.
- Medical culture Another factor is the inherent nature of medical culture, which historically has been somewhat cautious and slow to change.
- Unrealistic expectations
In the real world there are many areas of medicine for which evidence simply does not exist--and never will. For EBM to have a wider impact, accepting its limits is just as important as applying its lessons.
- The essence of EBM
EBM agreed on by experts--form the foundation of guidelines, which then become established best medical practices.
Guidelines in and of themselves are not evidence; they grow out of evidence and physician experience. So, in the real world, "best medical practices" can be seen as a synthesis of five major elements:
1. EBM (where available) 2. Expert consensus 3. Physician training and experience 4. Patient variables (e.g., preferences, clinical presentation) 5. Community standards of care--what is usual and customary in a given city, region, or country Together, these form the foundation of sound medical decision making.
- Integrating EBM
First step is asking the right question. In general, this entails identifying which clinical issues and challenges are most important within an organization or practice. Once you determine what you need to know, other important questions arise like: Can EBM give you the answers?
Second step, assuming that published evidence exists; lining up appropriate resources to evaluate it is our second step.
Third step is to resolve inherent conflicts between clinical arbiters (health plans. P & T committees, practice medical directors) and individual practitioners and provider institutions.
Fourth, and perhaps final, step is to acknowledge that incentives are a key factor in achieving EBM's full potential.
- Looking ahead: Whether EBM eventually delivers on its promise also depends on:
- Ensuring the validity of the scientific methods used to generate evidence.
- Improving study design and research quality.
- Developing and encouraging use of more accurate clinical decision tools to assist busy practitioners and medical decision makers.
- Finally, improving communications among all health care stakeholders.
To support consistent, appropriate clinical and reimbursement decision making, stakeholders must come to a common understanding about what EBM is and what it isn't, as well as the ways in which it is best integrated into clinical practice.