Evidence-based - Process and Progress

Process and Progress

The five steps of EBM in practice were first described in 1992 and the experience of delegates attending the 2003 Conference of Evidence-Based Health Care Teachers and Developers was summarized into five steps and published in 2005. This five step process can broadly be categorized as:

1. Translation of uncertainty to an answerable question and includes critical questioning, study design and levels of evidence

2. Systematic retrieval of best evidence available

3. Critical appraisal of evidence for internal validity that can be broken down into aspects regarding:

• Systematic errors as a result of selection bias, information bias and confounding
• Quantitative aspects of diagnosis and treatment
• The effect size and aspects regarding its precision
• Clinical importance of results
• External validity or generalizability

4. Application of results in practice

5. Evaluation of performance

Using techniques from science, engineering and statistics, such as the systematic review of medical literature, meta-analysis, risk-benefit analysis, and randomized controlled trials (RCTs), EBM aims for the ideal that healthcare professionals should make "conscientious, explicit, and judicious use of current best evidence" in their everyday practice. Ex cathedra statements by the "medical expert" are considered to be the least valid form of evidence. All "experts" are now expected to reference their pronouncements to scientific studies.

The systematic review of published research studies is a major method used for evaluating particular treatments. The Cochrane Collaboration is one of the best-known, respected examples of systematic reviews. Like other collections of systematic reviews, it requires authors to provide a detailed and repeatable plan of their literature search and evaluations of the evidence. Once all the best evidence is assessed, treatment is categorized as "likely to be beneficial", "likely to be harmful", or "evidence did not support either benefit or harm".

A 2007 analysis of 1016 systematic reviews from all 50 Cochrane Collaboration Review Groups found that 44% of the reviews concluded that the intervention was "likely to be beneficial", 7% concluded that the intervention was "likely to be harmful", and 49% concluded that evidence "did not support either benefit or harm". 96% recommended further research. A 2001 review of 160 Cochrane systematic reviews (excluding complementary treatments) in the 1998 database revealed that, according to two readers, 41.3% concluded positive or possibly positive effect, 20% concluded evidence of no effect, 8.1% concluded net harmful effects, and 21.3% of the reviews concluded insufficient evidence. A review of 145 alternative medicine Cochrane reviews using the 2004 database revealed that 38.4% concluded positive effect or possibly positive (12.4%) effect, 4.8% concluded no effect, 0.69% concluded harmful effect, and 56.6% concluded insufficient evidence.

Generally, there are three distinct, but interdependent, areas of evidence-based medicine. The first is to treat individual patients with acute or chronic pathologies with treatments supported in the most scientifically valid medical literature. Thus, medical practitioners would select treatment options for specific cases based on the best research for each patient they treat. The second area is the systematic review of medical literature to evaluate the best studies on specific topics. This process can be human-centered, as in a journal club, or technical, using computer programs and information techniques such as data mining. Increased use of information technology turns large volumes of information into practical guides. Finally, evidence-based medicine can be understood as a medical "movement" in which advocates work to popularize the method and usefulness of the practice in the public, patient communities, educational institutions and continuing education of practicing professionals.