Concept Of Evidence-based Medicine Research Articles

Corticosteroids for Recurrent Pericarditis

We have known for decades that acute pericarditis may recur after apparent cure.1 In spite of recent advances, recurrence, after an initial attack of acute pericarditis, remains a challenge for many reasons. For example, the exact rate of recurrence is not known because many, if not most, cases go unreported, especially those that have a benign course and respond quickly and completely to a nonsteroidal antiinflammatory agent (NSAID), such as ibuprofen, indomethacin, or aspirin. The evidence that, in most cases, recurrence is an autoimmune response to the initial pericardial insult is compelling,2 but we still lack an inexpensive, harmless, readily available test that reliably separates autoimmune reoccurrence from recurrence of another cause, notably infection. The distinction is important, because corticosteroid therapy is required for some of the immunogenic cases of recurrent pericarditis but is contraindicated in cases caused by infection. Reports from tertiary referral centers include a high proportion of patients who did not improve after treatment with prednisone, or had serious steroid-induced side effects. Article p 667 Pericardial disease is not rare but is far less common and much less likely to be a threat to survival than are, for example, ischemic heart disease, hypertension, valvular heart disease, and the metabolic syndrome. Also, the drugs used to treat it are generic, making it improbable that investigators can find funds for placebo-controlled large trials in a broad spectrum of patients with recurrent pericarditis. High-dose corticosteroid became the accepted standard treatment for recurrent acute pericarditis long before the concept of evidence-based medicine and guidelines was introduced and therefore was based on the anecdotal experience of medical and surgical cardiologists whose subspecialty was pericardial disease. One of the most influential of these was …

How patients make treatment choices

The medical field has undergone a quiet revolution during the past three decades. Patients have been brought into the treatment decision process as never before. Gone are the days when the patient was delivered the diagnosis and simply told how their disorder was to be treated. Rather, widespread use of shared decision making has changed the way that patients and their physicians interact. The development of best clinical practices from concepts of evidence-based medicine has shown that, for many disorders, the various treatment options result in near-equivalent outcomes. More recently, the democratization of medical information by the internet has made the patient a much better informed consumer, and thus a more active participant in his or her own care.

Verbesserung der Therapieergebnisse durch Patientenwissen?

Non-compliance in patients is rarely provoked by intention or laziness. Thus, patients should not be the first to be blamed for lack of therapeutic success. Non-compliance from health care providers to supply patients with necessary information and skills, though, is an important cause of insufficient treatment outcomes. Patient knowledge can improve health outcomes. But this knowledge must be evidence-based and relevant for the patient. In addition, knowledge must enable patients to assume an important part in disease control and treatment. Evaluation of patient information or self-management programmes should consider that knowledge is just one component of a complex intervention. Self-management programmes for type 1 diabetes or severe asthma are examples of where patient knowledge as part of a complex intervention may lead to substantially improved treatment outcomes. Disease-unspecific self-management programmes like the expert patient programme do not lead to important changes of relevant outcome measures. Patients and consumers want to participate in medical decision-making. However, there is a lack of evidence-based patient information for most indications. Informed decision-making by patients may lead to intelligent non-compliance and worsening of treatment outcome according to conventional assessment criteria. Direct-to-consumer advertising (DTCA) hits a public that lacks competencies in critical health literacy. Critical health literacy which combines the concept of evidence-based medicine and health literacy should be integrated into existing school curricula.

Continuing Professional Development of Dental Practitioners in Prato, Italy

The three objectives of this study were 1) to evaluate the frequency of access to instruments of continuing education by dental practitioners belonging to the Order of Dental Practitioners of the Province of Prato, Italy; 2) to ascertain their understanding and use of evidence-based medicine; and 3) to identify their preferences for obtaining continuing education in dental therapy. Of the 177 members of this order, 123 (69 percent) responded to a telephone interview. The typical dentist of Prato reads articles in Italian journals once a week, consults colleagues once a week, reads books once a month, accesses the Internet every three months, goes to congresses or courses every six months, and does not read articles published in international journals. Forty-one percent of those interviewed did not know the meaning of the term "evidence-based medicine." Practical training was considered the most important form of update in therapy and reaches statistical significance (p<0.05) when compared to consultation with colleagues, videos, and the Internet (which received the lowest score). The conclusions were that dentists of Prato obtain continuing education episodically and in a passive way. They do not understand the concept of evidence-based medicine and often employ it superficially.

Limitations of Evidence in the Practice of Evidence-based Medicine

&lt;p&gt;Evidence-based medicine is a concept that has become widely described, discussed, criticized, and studied in the medical literature. The broad goal of evidence-based medicine is to address two main kinds of decisions — population-based policies and individual medical decisions — that serve to improve health outcomes through the use of the most proven effective treatments. As a result, there have been increased efforts to apply evidence-based medicine concepts to develop treatment guidelines, support medical education, inform individual decision making, and justify insurance coverage policies. The essence of evidence-based medicine is to use evidence (typically research data) related to the effectiveness of medical interventions to guide decisions about whether to use those interventions in clinical practice. In other words, the principles of evidence-based medicine suggest that good policies and clinical practice are based on using evidence that treatment X is helpful for treating disease Y in patient Z. Therefore, the quality of evidence is the critical component in understanding and using evidence-based medicine. &lt;/p&gt; &lt;h4&gt;ABOUT THE AUTHOR&lt;/h4&gt; &lt;p&gt;Robert H. Howland, MD, is Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania.&lt;/p&gt; &lt;p&gt;Address correspondence to Robert H. Howland, MD, Associate Professor of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, 3811 O’Hara Street, Pittsburgh, PA 15213; e-mail: &lt;a href="mailto:HowlandRH@upmc.edu"&gt;HowlandRH@upmc.edu&lt;/a&gt;.&lt;/p&gt; &lt;p&gt;Dr. Howland has disclosed no relevant financial relationships.&lt;/p&gt; &lt;h4&gt;EDUCATIONAL OBJECTIVES&lt;/h4&gt; &lt;ol&gt;&lt;li&gt; Assess the concept of evidence-based medicine.&lt;/li&gt; &lt;li&gt;Describe the kinds of evidence used in the practice of evidence-based medicine. &lt;/li&gt; &lt;li&gt;Discuss some limitations of evidence used in the practice of evidence-based medicine. &lt;/li&gt; &lt;/ol&gt;

Outcomes for Trauma: Is There an End (Result) in Sight?

In the following address I will discuss the role that EAST has had in developing an evidence-based approach to the practice of trauma, why it is important, who has made it important, and what the future of trauma outcomes will likely resemble. This talk is the third in a series, a series that started in the early 1990s, and hopefully will continue into the future. It also reinforces and extends the thoughts that Dr. Russell left us with yesterday in his address regarding the future of quality assessment in surgery. In 1994, in his presidential address to the Seventh Scientific Assembly of EAST, Dr. Michael Rhodes introduced us to the concepts of evidence-based medicine and practice management guidelines. Evidence-based medicine is defined as a method of patient care, decision making, and teaching that integrates high-quality research evidence with physiologic reasoning, experience, and patient preference. Patient management guidelines are systematically developed statements designed to assist practitioners in making decisions about appropriate healthcare for specific clinical circumstances. The five major purposes of practice management guidelines are to assist clinical decision making by patients and practitioners, educate individuals or groups of individuals, assess quality of care, guide the allocation of resources, and reduce the risk for legal liability. In his discussion, Dr. Rhodes stressed that the idea was to base clinical decisions on the best available evidence and understand the power or quality of that evidence. Evidencebased practice involves, at its core, a fundamental acknowledgment that our clinical convictions can be wrong as well as the fact that we invariably underestimate the power of the placebo effect and assume that because most patients we treat in a certain way feel better, the treatment must be effective. Obviously, these concepts were not universally embraced when they were first introduced, and a great deal of work has been put forth to arrive at where we are today with evidencebased practice. In addition to patients and practitioners, it was felt that guidelines could be useful to purchasers of healthcare, legislators, and regulators. Further, it was felt that guidelines must be used to decrease unnecessary practice variation, formulate necessary research proposals, and most importantly, evaluate outcomes of care. Only through such measures can patientspecific guidelines be developed and improvements in care be realized. Dr. Rhodes challenged the organization to move forward in developing such guidelines and EAST responded. Subsequent to his address, a jointly sponsored conference by EAST and HRSA (Health Resources and Services Administration) was held to define the methodology for practice management guideline development, leading to the creation of the first subcommittees addressing specific trauma related topics for guideline creation. This ultimately led to the 1998 Journal of Trauma article in which practice management guidelines for screening for blunt cardiac injury, cervical spine clearance, prophylaxis for venous thromboembolic disease, and antibiotic prophylaxis for penetrating abdominal trauma were presented. At around the same time, EAST established its Website and began placing the guidelines on the site thereby making them available to the membership and others interested in trauma care. Today, there are 27 guidelines, as well as a primer describing the evidence-based methodology for guideline development available for viewing. To date, there have been 283,056 downloads of the various guidelines, and on average, there are 775 hits per day on the guideline section of the EAST Website. Importantly, EAST, recognizing the evolution of acute care surgery, has charged the Guidelines Committee to begin to develop guidelines on emergency and acute care surgery subjects, and they have responded by preparing several relevant guidelines that will be presented later at this meeting during the plenary session on Friday. In 1999, Dr. Timothy Fabian addressed the 12th Scientific Assembly, reminding us that EAST had made an early and profound impact on evidence-based medicine through the management guidelines project. In a Star Wars analogy, he noted that we, like the crew of the Millennium Falcon, had begun a journey not quite sure whether our ship would make it to wherever we were going, but knowing that we could adapt and Submitted for publication October 11, 2007. Accepted for publication October 17, 2007. Copyright © 2008 by Lippincott Williams & Wilkins From the Department of Surgery, Lehigh Valley Hospital, Allentown, PA. Presented as the presidential address at the 20th Annual Meeting of the Eastern Association for the Surgery of Trauma, January 16–20, 2007, Fort Meyers, Florida. Address for reprints: Michael D. Pasquale, MD, FACS, FCCM, Div. Trauma/Surgical Critical Care, Lehigh Valley Hospital, P.O. Box 689, Cedar Crest & I-78, Allentown, PA 18105-1556; email: sally.lutz@lvh.com.

Ｅｖｉｄｅｎｃｅ‐Ｂａｓｅｄ Ｍｅｄｉｃｉｎｅの意義と限界―疫学の立場から―

Evidence based medicine (EBM) was proposed by Guyatt in the early 1990s. Sackett and colleagues have established basic concept of EBM. They defined that EBM was the conscientious, explicit, and judicious use of current best evidence in making clinical decisions for each patient. Recently, although many clinicians recognized epidemiology as an importance tool for EBM, there were some misunderstandings in the decision-making process to use evidence level. Some clinicians believe EBM must need randomized-controlled trials (RCT). However, RCT is not always best available evidence. RCT is not suitable to examine harmful exposures, such as smoking, due to ethical problems. Furthermore, to clarify very week association, such as dietary habit and stroke, RCT requires too huge sample size to perform practically. When we are looking for second best evidence, the consistency is a main target. For example, cohort studies anywhere on the globe showed the positive relationship between smoking and cerebral infarction. Although EBM is substantially made to resolve a one-on-one clinical relationship (one therapy and one outcome), clinical questions usually consist of more complex matters with many-to-many, many-to-one, one-to-many associations. We should combine the best available external evidence with our clinical expertise, and neither alone may work enough.

Evidence-Based Medicine Resources for Physician Assistant Faculty: DynaMed

INTRODUCTION When we took the first tentative steps years ago to develop a new clinical problem-solving curriculum that embraced the concepts of evidencebased medicine (EBM), there was little we could say to students who asked, “But how are we going to do this in the clinic”? The concepts were sound but the immediate application to patients, the only thing that really matters, was stymied by the lack of useful tools. Fortunately, innovation and technology have progressed rapidly and placed a number of devices in the hands of clinician educators that they can use at the bedside and in the exam room. The computer-based electronic health record (EHR) has become ubiquitous. The dog-eared notebook “peripheral brains” of our generation, loaded with clinical facts and held together by a rubber band, have been replaced by sleek and speedy PDAs with instantly accessible voluminous libraries and databases. Many clinicians have become so dependent on these tools that to suffer a system crash, or even to leave them by accident at home, produces instant anxiety. I (DK) have made a mad dash from clinic back to home to retrieve mine more than a few times. Since purchasing Epocrates, a medication database, I have not looked at a Physicians’ Desk Reference text. I’m not even sure the clinic still has one. PDAs have become a necessity for the majority of PA educator/clinicians; however, the choice of software can be overwhelming and is often made with the gut rather than the head. The decision to purchase Epocrates, for example, was made after a brief exposure through a colleague and a free trial. There was no careful weighing of the pros and cons of other products — and this is probably true of many clinical educators. As a new tool is used, we grow familiar and comfortable with the interface and it becomes literally an extension of our bodies. We tend to stay with the same tools not only because they are good, but also because we don’t want to take time to learn a new system. For instance, we have colleagues who swear by LexiComp, another medication database, but we have no interest in investing time to learn a new tool that would replace one that has already become indispensable. Our students often have technology skills that exceed those of faculty. It is important for faculty to become facile with the available resources to support our students’ evidence-based clinical practice. For this reason, the EBM feature in this journal will occasionally review tools that may assist PA educators with their EBM curriculum and help them make choices in a more systematic way. The focus of this review is a computer and PDA database application called DynaMed, which has been designed from the ground up on the principles of EBM.

Epidemiologija u praksi novog javnog zdravlja

Epidemiology is the scientific basis of public health. That is why it has a special place within new public health; analysis of the collected data does provide evidence about risk factors which influence health of a population. This is the foundation of the complete concept of evidence-based medicine and public health, based on the same postulates. When we talk about the state- of the- art epidemiology, we can not make a clear distinction between infectious and non-infectious diseases. Moreover, it has been proven that certain microorganisms are directly responsible for the occurrence of most frequently seen chronic non-infectious diseases. In recent years, the system of epidemiological surveillance has been based on laboratory confirmation of a disease. This type of surveillance does not refer only to infectious diseases; it encompasses non-infectious ones, injuries, and other health-related conditions, risk factor related to life styles; environmental pollution and utilization of the right to health care. Nowadays, when we have been facing global health threats, World Health Organization has innovated International Health Regulations, with the purpose of preventing, protecting, controlling and providing the response of Public Health to those threats and the threat of international spread of diseases. The importance of epidemiology in Public Health is reflected in the fact that epidemiological information is used in planning, evaluation of strategies and disease prevention processes. It is also a guide in the process of treatment of the patients in whom the disease had already developed. Additionally, epidemiology provides the tools for evaluation of health problems and policies, based on populations and their needs. Serbian reform of the system of health care has resulted in adoption of the national health policy, defined priorities and development planning strategies for health care, strategies of Public Health. The latter defines the support in realization of the social assignment of care for health and provision of conditions in which the populations may be healthy. The discussion in our paper lists the problems and difficulties in realizing this Strategy and gives conclusions from the Conference of Serbian Specialists in Epidemiology. Both stress that it is necessary to define the role and place of epidemiologists in creating and defining legal provisions and realization of public health measures in practice. .

How to measure critical health competences: development and validation of the Critical Health Competence Test (CHC Test)

Consumers' autonomy regarding health increasingly requires competences to critically appraise health information. Critical health literacy refers to the concept of evidence-based medicine. Instruments to measure these competences in curriculum evaluation and surveys are lacking. We aimed to develop and validate an instrument to measure critical health competences (CHC test). Development and testing of the questionnaire covered three phases: (1) test construction (and feasibility, (2) first field test of scalability and items revision (3) second field test to validate the instrument. Model fit analyses were performed for both field tests for Rasch-, Mixed Rasch- and Hybrid model. Participants were secondary school and university students with and without prior training in evidence-based medicine (1. field test n = 322; with training n = 87; 2. field test n = 107; with training n = 13). The second field test resulted in Rasch scalability of all items in one person class. Mean values (+/-SD) of person parameters were 716.14 (+/-53.74) for trained students and 470.11 (+/-59.63) for untrained students. Reliability of the instrument was 0.91 (WINMIRA ANOVA). In conclusion the CHC instrument is a feasible, reliable and valid instrument to measure critical health literacy. The generalizability of the instrument is to be explored in ongoing studies in different educational settings.

Making medical messages stick

Making medical messages stick

Evidence-Based Medicine, Part 1. An Introduction to Creating an Answerable Question and Searching the Evidence

This article, the first in a series of six articles, introduces the concept of evidence-based medicine and describes the first two steps of practicing it: formulating an answerable clinical question and searching the available evidence. The types of clinical questions practitioners can ask are examined and a hierarchy of how to search for the best and most authoritative evidence is provided. The skills learned from creating an answerable question and searching the evidence, as outlined in this article, provide a solid basis for life-long learning and improved patient care.

Journal clubs in practice: time well spent?

IN veterinary practice today it is more important than ever to maintain an awareness of the current literature and to have an appreciation of the concept of evidence-based medicine. The...

Perceptions of evidence‐based medicine: traditional acupuncturists in the UK and resistance to biomedical modes of evaluation

Acupuncture and other types of 'complementary and alternative medicine' (CAM) are proving increasingly popular in the UK. As attempts to incorporate acupuncture into allopathic medicine have grown in number, the issue of assessing its effectiveness in ways consistent with the concept of evidence-based medicine has become more urgent. The nature, relevance and applicability of such assessments remain controversial however. This paper reports a qualitative study of acupuncturists' own perceptions of evidence and evidence-based medicine in relation to their therapeutic interventions. The material is presented in two main sections: explaining how acupuncture works, and resisting evidence-based medicine. The interviews reveal a great deal of scepticism and ambivalence and a deep questioning of the salience of conventional (biomedical) modes of evaluation of interventions.

How to write a systematic review.

Evidence-based medicine (EBM) is the combination of the best available research evidence with clinical experience and patient needs. The concept of EBM as a part of clinical decision making has become increasingly popular over the last decade. In the hierarchy of studies meta-analysis and systematic reviews occupy the highest levels. A systematic review of a clinical question can be performed by following a relatively standard form. These techniques as described here can be performed without formal training. Systematic reviews conducted in this fashion can be used as a higher form of current concepts or as review articles and replace the traditional expert opinion narrative review.

Symposium Integrating Evidence-Based Medicine into Clinical Practice*

Evidence-based medicine represents the combination of the best available clinical research evidence with clinical experience and expertise and the needs and expectations of patients. Evidence-based medicine as a concept has been available for years, but it has become increasingly important over the last decade. Some evidence has suggested that it began as early as the ancient Chinese medicine practices, while other evidence has indicated its origins were in postrevolutionary France with the systematic patient observations of Pierre Louis1. Gordon Guyatt led a group at McMaster University in the early 1990s that introduced many of the current concepts of evidence-based medicine. This led to a major increase in interest in the area. One paper had been published in the literature in 1992, but by 1998 over a thousand manuscripts had been published in the field1. Evidence-based medicine utilizes the best available research evidence. In the hierarchy of medical evidence, systematic reviews including meta-analyses represent the highest form of evidence if inclusion is limited to Level-I or II studies (Table I). Systematic reviews of Level-III or IV observational studies can be performed, but they represent Level-III or IV evidence. Frequently, in orthopaedics, systematic reviews or meta-analyses may not be available and clinicians may need to rely upon randomized controlled trials, cohorts, case-control studies, case series, or, in some areas, expert opinion. Orthopaedists may not yet recognize this hierarchy. During the 2005 Annual Meeting of the American Orthopaedic Association (AOA), the audience was asked the question: “Findings from which type of study design are most likely to influence your clinical practice?” The responses indicated that a randomized controlled study design was used by 49%; a systematic review and/or meta-analysis of Level-I studies, by 44%; expert opinion, by 5%; and case series, by 3%. View this table: TABLE I Medical Evidence Hierarchy At a symposium …

An Approach to Teaching Medical Students Evidence-Based Medicine and Basic Research Concepts

Abstract Introduction The emergency department (ED) is the primary teaching site for emergency medicine residency training programs where the diversity of patients' medical needs provides learners ...

Teaching Bayesian analysis to Emergency Medicine residents

Our objective was to determine if a brief didactic would improve Emergency Medicine (EM) resident performance at using a key evidence-based medicine (EBM) concept. We used a prospective, before and after, assessment of EM resident estimates of post-test pulmonary embolism (PE) probability for a defined pre-test probability, computed tomography (CT) and D-dimer results. The survey provided test sensitivity, and specificity for D-dimer and CT. Three months later, residents attended a brief didactic conference on how to use Fagan's Nomogram and likelihood ratios (LRs) to calculate post-test probability of disease. The accuracy of estimates of post-test PE probability was reassessed. The absolute percentage difference in resident estimates from the true post-test PE probabilities decreased from 14.5% (95% confidence interval [CI] 9.7%-19.9%) to 4.5% (95% CI 2.0-6.8%) after the educational intervention. This 10% effect size was statistically significant, p = 0.002. The study demonstrates the efficacy of the lecture method in teaching an EBM concept to EM residents.

Learning Evidence-Based Veterinary Medicine through Development of a Critically Appraised Topic

Evidence-based veterinary medicine is a relatively new field of study. Increased knowledge of medicine coupled with the increased ability of computers and other electronic devices present overwhelming information. The critically appraised topic (CAT) is one method to gather and evaluate information related to a clinical question. CATs in informatics are short summaries of evidence, usually found through literature searches, in response to a specifically stated, clinically oriented problem or question. This article describes a study in which each first-year veterinary student developed a CAT as a class project. The results of this project indicate that students were able to successfully develop CATs and that this exercise helped them understand evidence-based veterinary medicine concepts. Though some modification in this project will be made in the future, overall it was a worthwhile effort and will remain as an activity in the course.

German ambulatory care physicians' perspectives on clinical guidelines – a national survey

BackgroundThere has been little systematic research about the extent to which German physicians accept or reject the concept and practice ofa) clinical practice guidelines (CPG) andb) evidence based medicine (EBM)The aim of this study was to investigate German office-based physicians' perspective on CPGs and EBM and their application in medical practice.MethodsStructured national telephone survey of ambulatory care physicians, four thematic blocks with 21 questions (5 point Likert scale). 511 office-based general practitioners and specialists. Main outcome measures were the application of Clinical Practice Guidelines in daily practice, preference for sources of guidelines and degree of knowledge and acceptance of EBM. In the data analysis Pearson's correlation coefficient was used for explorative analysis of correlations. The comparison of groups was performed by Student's t-test. Chi2 test was used to investigate distribution of two or more categorical variables.ResultsOf the total study population 55.3% of physicians reported already using guidelines in the treatment of patients. Physicians in group practices (GrP) as well as general practitioners (GP) agreed significantly more with the usefulness of guidelines as a basis for patient care than doctors in single practices (SP) or specialists (S) (Student's t-test mean GP 2.57, S 2.84, p < 0.01; mean GrP 2.55, SP 2.80, p < 0.05). 33.1% of the participants demonstrated a strong rejection to the application of guidelines in patient care. Acceptance of guidelines from a governmental institution was substantially lower than from physician networks or medical societies (36.2% vs. 53.4% vs. 62.0%). 73.8% of doctors interpret EBM as a combination of scientific research and individual medical knowledge; 80% regard EBM as the best basis for patient care.ConclusionDespite a majority of physicians accepting and applying CPGs a large group remains that is critical and opposed to the utilization of CPGs in daily practice and to the concept of EBM in general. Doctors in single practice and specialists appear to be more critical than physicians in group practices and GPs. Future research is needed to evaluate the willingness to acquire necessary knowledge and skills for the promotion and routine application of CPGs.