La prise de décision fondée sur les preuves: les défis actuels et une nouvelle chronique dans le Journal canadien d’anesthésie

Abstract

THE implicit challenge of Archie Cochrane’s 1979 statement, “it is surely a great criticism of our profession that we have not organized a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomized controlled trials”,1 has resulted in the advancement of the systematic review and meta-analysis in evidencebased medicine (EBM). The adoption of EBM has spurred an unprecedented growth in an approach to decision-making based on clinical epidemiology in the belief that this will translate into improved outcomes for patients, improved quality of care and decisionmaking for clinicians, and improved cost-effectiveness for health services. Although EBM has led to gains in the quantitative evidence on which to base clinical decisions, the uptake and translation of evidence into day-to-day decision-making remains a challenge. All too often clinicians are unaware of the available evidence or are uncertain of how to apply it.2 Evidence-based medicine is “the integration of best research evidence with clinical expertise and patient values”.3 At the crux of this definition is the application of “best evidence”, which is often classified hierarchically (Figure).4,5 As one moves down the levels of evidence, from multicentre randomized controlled trials (RCTs) to non-randomized controlled clinical trials, to observational studies, and finally to anecdotal evidence, the certainty of the results and their validity becomes subject to greater limitations inherent in the study design. But, just as one does not dismiss a hotel if it is not “four stars” (especially if it is the only one in town), one does not discount evidence that is not a systematic review or a RCT. Best evidence is the best clinically relevant research evidence available. The challenge is: how do we provide up-to-date information, rated by the quality of the evidence, in a format that is easy to interpret? We believe that publications such as clinical practice guidelines, which systematically review the evidence and translate the results into clinical recommendations, coupled with a simple grading system on the evidence and the strength of recommendations would assist the busy clinician attempting to practice in an evidence-based fashion.