evidence-based medicine: what does it really mean? sports medicine rounds november 7, 2007
TRANSCRIPT
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Evidence-Based Medicine:What does it really mean?
Sports Medicine Rounds
November 7, 2007
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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?
ALL OF THE ABOVE
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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
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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.
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“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?
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“The integration of best research evidence with clinical expertise & patient values”
Sackett et al, 2000
What is Evidence-Based Medicine?
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Types of Evidence-Based Medicine
• Evidence-based guidelines (EBG): practice of EBM at the organizational, institutional, or group level (establishing guidelines, policy, regulations)
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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 betoo EBM focused
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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)
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• Important not to confuse Levels of Evidence with Quality of Evidence or Importance
An Idealistic EBM Model
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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
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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
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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
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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 statistics on the integrated results of the grouped studies
• Goal: draw conclusions from the results of the analysis of the grouped data
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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
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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
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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?
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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
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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
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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?