Slides Evidencemedicine

Where Healthcare Meets Policy
Evidence-Based Medicine:
What It Means for Patients
and Physicians

Evidence-Based Medicine Is a Powerful
Tool That Holds Great Promise If Used
Properly
Evidence-Based Medicine (EBM):
The conscientious, explicit, and judicious use of current best evidence
in making decisions about the care of individual patients.
Can enhance the patient-physician relationship
Can improve patient care
History:
First randomized trials (streptomycin for TB) 1940s
Focus on process (post-thalidomide tragedy) 1960s
New FDA regulations requiring controlled trials 1962
Cochranes suggestion of lack of evidence 1971
Translational gap identified 1974
Focus on systematic review/funding for guidelines 1980s90s
Adherence to guidelines was not optimal
Sources: Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isnt. BMJ. 1996;312:71-72.
Colston J. Descending the Magic Mountain: how early clinical trials transformed the treatment of tuberculosis. National Institute for Medical Research.
U.S. Food and Drug Administration. The Evolution of U.S. Drug Law. Available at: http://www.fda.gov/fdac/special/newdrug/benlaw.html. Accessed March 15, 2005.
Cochrane AL. Random reflections on health services: Effectiveness and efficiency. 1971 (reprinted by RSM Press 1999).
Chalmers TC. The impact of controlled trials on the practice of medicine. Mt Sinai J Med. 1974;41:753-759.
Perfetto EM, Morris LS. Agency for Health Care Policy and Research clinical practice guidelines. Ann Pharmacother. 1996;30:1181.
David Sackett: Evidence-Based
Medicine: What It Is and What It Isnt
When used correctly, evidence-based medicine incorporates:
Evidence Physician Patient values
expertise
Good doctors use both individual clinical expertise and the best available
external evidence, and neither alone is enough. Without clinical expertise,
practice risks becoming tyrannized by evidence, for even excellent external
evidence may be inapplicable to or inappropriate for an individual patient.
Without current best evidence, practice risks becoming rapidly out of date,
to the detriment of patients.
David Sackett
Evidence-Based Medicine: What It Is and What It Isnt 1996
EMB requires a bottom-up approach that integrates the best external

evidence with individual clinical expertise and patients choice.
Source: Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isnt. BMJ. 1996;312:71-72.
A Critical Examination of Evidence-
Based Medicine Can Flesh Out Its
Complexities
Evidence-Based Medicine Process
1. Precisely identify the problem

2. Access information necessary to
solve the problem
3. Search the literature
4. Select relevant studies
5. Apply rules of evidence to
determine validity
6. Apply knowledge to individual
patient and clinical setting
7. Continually update knowledge
Source: Evidence-Based Medicine. A new approach to teaching the practice of medicine. Evidence-based Medicine Working Group. JAMA. 1992;268:2420-2425.
Evidence Evolves Rapidly and Has
Historically Suffered in the Translation
1st Translational Gap Delay from expert to practice
Moving knowledge from trials to textbooks,
articles, recommendations
2nd Translational Gap Physicians continuous education and patients

educational empowerment
Evolution, knowledge, simultaneous delivery
of information
Inappropriate Use of EBM as a Cost-Containment Device

Some fear that evidence-based medicine will be hijacked by purchasers and
managers to cut the costs of health care. This would not only be a misuse of
evidence-based medicine but suggests a fundamental misunderstanding of its
financial consequences . . .
David Sackett
Sources: Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isnt. BMJ. 1996;312:71-72.
Soumerai SB. Benefits and risks of increasing restrictions on access to costly drugs in Medicaid. Health Affairs. 2004;23:141.
Standards for Evidence-Based Medicine
Must Be Consistent, Transparent, and
Applied to All Parties
Standards must be:
Applied equally to all health care interventions
Diagnostic and therapeutic
Used by all health care participants

Open to stakeholders and to the public
Considerate of the clinical merits of
recommendations that impact access
and independently considerate of cost
Constantly evaluated and advanced
Evidence-Based Medicine Benefits
From Clear Definitions and Principled
Grounding
Principles
1. EBM should support the decision-making function of the

patient-physician relationship
2. EBM should enable the delivery of the best available
patient care and consider the patients individual condition
and priorities
3. Financial impact studies should be decoupled and include
all costs for care and treatment
4. EBM must be reviewed regularly in light of evolving
evidence, be shared with doctors and patients
simultaneously, and evolve in a manner that preserves
personalized medicine
Evidence-Based Medicine: What
It Means for Patients and
Physicians
Release Date: 3/23/2005 www.healthpolitics.com

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Where Healthcare Meets Policy

Where Healthcare Meets Policy

EMB requires a bottom-up approach that integrates the best external

1. Precisely identify the problem

2nd Translational Gap Physicians continuous education and patients

Inappropriate Use of EBM as a Cost-Containment Device

Used by all health care participants

1. EBM should support the decision-making function of the

Release Date: 3/23/2005 www.healthpolitics.com

Where Healthcare Meets Policy

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