Evidence-Based Medicine Is Not For Kids † 1913

Abstract

Parents, payors and preceptors demand proof for what we do, but current, best evidence of efficacy for diagnostic and therapeutic manuevers is hard to come by. New reports appear daily - by the tens of thousands each year - but the busy clinician has little time, and often too few skills to evaluate them critically. A journal is now published by the American College of Physicians whose title [Evidence-Based Medicine(EBM)], editors [Haynes & Sackett], and statement of purpose [Vol 1,p 2] have promised valuable help by providing critical reviews with special focus on practical applications. We examined EBM's content for evidence of a selection bias against pediatric journals and pediatric content during its first year of publication. EBM abstracted and analyzed in detail 143 original articles from 35 peer-reviewed journals from 11/95 to 10/96. Of these, 98 [68.5%] were from 12 General-Medical [GM], 15[10.5%] from 8 Subspecialty-Medical [SM], 22 [15.4%] from 12 Other-Specialty[OS] and 8 [5.6%] from 3 Pediatric [P] journals. EBM abstracted another 7 articles on pediatric subjects,all from GM journals. Thus, < 6% of EBM abstracts were from P journals while almost half [7/15] of citations concerning pediatric topics were from GM journals. A total 17,558 original articles were published in the 35 journals reviewed by EBM as a source for their abstracts. Articles from the GM journals were three-times more likely to be abstracted and presented in detail [98/5,785 or 16.9/1,000] than those from the P journals [8/1,235 or 6.4/1,000; χ2=9.025, p=<0.005. This negative bias was equally evident for work from OS [22/5,488 or 4.0/1,000] and even from SM journals [15/5,050 or 3.0/1,000]. This bias was not explained by the proportion of clinical trials [CT], meta-analyses [MT], or practice guidelines [PG] between journals. The proportion [CT+MA+PG/total original articles] for the GM journals [738/5,785 or 12.8%] was similar to that for the OS [750/5,488 or 13.7%] and for the SM journals [700/5,050 or 13.9%]. In fact, the proportion was significantly higher for the P journals [230/1,235 or 18.6%; χ2=28.971, p<0.001. Yet, EBM abstracted articles four-times more commonly from GM [98/738 or 132.8/1,000 CT+MA+PG] than from P journals [8/230 or 34.8/1,000 CT+MA+PG; χ2=18.293, p<0.001]. Once again, this negative bias was also evident for work from the OS [22/750 or 29.3/1,000] and from the SM journals [15/700 or 21.4/1,000]. In summary, it is clear from these findings that the [unstated] purpose of EBM is to aid clinicians who engage in general medical practice. Those who practice other forms of primary care, specialty, or subspecialty medicine must look elsewhere for help.