Evidence-based healthcare practice in Qatar: A need to move forward

Abstract

Evidence-based medicine (EBM) is considered the gold standard approach to therapeutic decisionmaking in modern medicine. It was first described in the 1990s as a way to improve patient outcomes by promoting rational therapeutic decision-making through translation of high quality clinical studies. It was originally defined as the conscientious, explicit, and judicious use of the best available evidence to make decisions regarding the care of individual patients. By translating results of high quality clinical trials into the therapeutic management of patients, better outcomes can be achieved. Additionally, it allows for standardized therapeutic management of disease and evaluation using audit and feedback. The practice of EBM goes hand on hand with individual clinical expertise and the use of available evidence. The five steps of evidence-based practice are summarized in Table 1. The initial step in the process involves the creation of a specific clinical question, commonly referred to as a PICO (Patient or Problem, Intervention, Comparator, Outcomes) question. Using the elements contained within the PICO question, a systematic search of available evidence would then occur (Step 2). Subsequently, critical appraisal of identified literature occurs with assessment for relevance, internal quality, interpretation of findings and applicability to the patient or problem defined by the original clinical question (Step 3). Finally, the practitioner makes an informed decision based on the evidence identified and appraised (Step 4). While these steps complete the EBM process for patient care, a final stage of evaluation and feedback may occur by auditing individual clinician’s practices to benchmark evidence-based practice among peers (Step 5). There is a traditional belief that high quality evidence refers to only randomized controlled trials, or systematic reviews with meta-analysis. When well conducted, these studies usually represent high internal validity but may lack external validity, or generalizability to real-life patients. Therefore, other types of evidence (epidemiological studies, population based studies, case-series and even case reports) cannot always be ignored. The type of evidence selected for appraisal and therapeutic decision-making is largely based on the patient of interest or the problem at hand. For instance, a public health authority searching for evidence regarding immunization programs for influenza may be better suited to appraise epidemiological and population-based studies, rather than randomized controlled trials of individual patients. Another example would be a question relating to management of a rare adverse drug reaction or diseases, for which only case reports are available. Although this type of evidence is not ideal due to high susceptibility to bias and confounding, it may be the only existing source available. Any chosen evidence must be appraised and assessed for quality and relevance, prior to incorporation into clinical decision-making. Sources of evidence range from online medical literature databases such as PubMed to international organizations offering evidence summaries and appraisals of published studies. The Cochrane Collaboration is a commonly cited source of high quality systematic reviews that are synthesized using objective, standardized methods. Additionally, organizations such as the Britain’s Centre for Reviews and Dissemination at the University of York strive to standardize reporting and dissemination of high quality evidence reviews. Publications from these organizations can greatly