Concept Of Evidence-based Medicine Research Articles

Knowledge and attitude toward evidence-based medicine among medical students in Semnan, Iran.

Evidence-based medicine (EBM) has gained widespread acceptance in medicine. Little is known about the attitudes, knowledge, and behavior of medical students toward EBM in developing countries. This study was designed to assess medical students' awareness and attitudes toward EBM and to obtain the basis required for developing appropriate teaching and learning opportunities. This was a cross-sectional study in which medical students completed a questionnaire to determine their attitudes, knowledge, and perceptions regarding EBM. Completed questionnaires were received from 84% (143) of 170 medical students. Only 24.5% of respondents had good basic information and familiarity with the term of EBM. The majority (89.3%) of participants had positive attitude toward EBM and agreed that it was useful in the management of patients. Mostly were interested in learning the skills of EBM. Most of the respondents (80.2%) had no or little awareness of EBM resources especially the Cochrane, DARE, and Bandolier clinical evidence database. Forty-two (29%) reported having had formal training in search strategies. Most of the respondents did not understand but would like to learn about technical terms used in EBM, and about a third felt able to explain to others the meaning of some of these terms. This study demonstrates lack of adequate knowledge about basic concepts of EBM among medical student. On the other hands, there is an overall positive attitude toward EBM. There is need for educational interventions and incorporating formal teaching of EBM at medical education.

Present Guidelines for Device Implantation

Implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) have become mainstays of clinical cardiology practice for high-risk patients supported by persuasive clinical trial data. Yet, areas of certainty are offset by considerable uncertainty about the criteria for implantation and for reimbursement. This article reviews selected elements of the clinical trial data and reconciles, when possible, guideline recommendations with the Center for Medicare & Medicaid Services (CMS) national coverage determination (NCD). Medical practice guidelines represent the cumulative effort of patients, clinicians, scientists, and statisticians striving to guide patient care on the basis of the best clinical trial science available.1–6 Expert consensus dates back centuries, but the modern era of clinical guidelines is founded on the concept of evidence-based medicine, introduced in the 1980s. Having its origin in the discipline of clinical epidemiology and public health, evidence-based medicine incorporates both best science and best clinical practice. The most commonly used definition by Sackett et al7 states, “Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” Guidelines rank the strength of evidence by class: Class I represents the highest recommendation, Class II requires further physician consideration, and Class III discourages the use of the therapy considered. A complementary grading system considers the relative benefit versus risk as a statement of certainty of treatment effect from A, indicating strongest certainty, to C, indicating lowest certainty.8 Guidelines provide the practicing physician an exhaustive summary of the available literature, including areas of conflict and differences in study protocols and patient cohorts. Without such guidelines, physician and hospital performance metrics would be adrift, and payers would have no objective footprint to assess reasonable standards of care. Although medical practice guidelines are an important tool for physicians faced with clinical …

A survey of complementary and alternative medicine practitioner's perceptions of evidence-based medicine

IntroductionIncreasing numbers of complementary and alternative medicine (CAM) practitioners are interested in evidence-based medicine (EBM). Researchers are in need of further information regarding the current status of CAM practitioners knowledge and use of EBM. Methods and materialsA questionnaire survey was distributed in July 2010 to all Korean medical doctors (n=388) practising in traditional Korean medicine (TKM) hospitals in Korea. ResultsThe response rate was 68.30% (n=265). Respondents tended to have a positive attitude towards EBM. Although 86% of respondents had used general databases in the previous year, they demonstrated a low level of awareness of relevant information sources and basic technical terms. Many respondents thought that applying EBM would make it easier for them to explain their treatment, progress, and prognosis to patients (26%). The majority perceived barriers to practicing EBM included differences in the fundamental concepts of EBM and CAM (30%), lack of evidence (16%) and lack of time (15%). Development of guidelines and protocols (36%) was the most appropriate method of application of EBM. ConclusionCAM practitioners were rather welcoming of EBM but the advantage that they expect from EBM is in contrast to previous research on the use of EBM among practitioners and patients in biomedicine. A high percentage of practitioners had access to general bibliographic databases but failed to know how to apply it. This was the biggest perceived barrier and is another distinctive feature of CAM practitioners. The development of CAM guidelines and protocols are urgently required.This article belongs to the Special Issue: Clinical Guidelines.

Selling evidence over the counter: Do community pharmacists engage with evidence-based medicine?

Community pharmacy has been recently criticised for selling products which do not have a rational or robust evidence base. Available evidence suggests that pharmacists understand and are willing to embrace the concepts of evidence-based medicine (EBM), but it is not often utilised in the community pharmacy setting. Community pharmacists appear to rely more on consumer feedback and personal experience than clinical trial evidence when making over-the-counter recommendations, a practice at odds with the principles of EBM. Limiting factors for the uptake of EBM include a lack of resources and time, as well as a lack of skills in appraising scientific papers. Solutions may include improving pharmacists' awareness of existing EBM information resources, improving critical appraising training, and providing information tailored to the community pharmacy environment.

Intensive care specialists' knowledge, attitudes, and professional use of published research evidence: A mail-out questionnaire survey of appropriate use of research evidence in clinical practice

PurposeThis survey investigates the knowledge, attitudes, and use of published research in clinical practice by intensive care specialists. Materials and MethodsA mail-out questionnaire was sent to randomly selected intensive care specialists registered with the Australian and New Zealand College of Intensive Care Medicine. ResultsThe response rate was 55.9% (133/238). The average score for research knowledge was 2.9 of 6. Eighty-five (65.4%) of 130 respondents reported positive feelings toward using published research evidence in clinical practice, with 96.6% (126/130) reporting use of the concepts of evidence-based medicine at least sometimes. Randomized trials were rated as the most frequently read evidence (rank score, 3.7 of 5), with “Information obtained from the Cochrane Library” the least frequently read (rank score, 2.8 of 5). The most inhibiting barrier to use of published research evidence in practice was “a lack of good evidence providing meaningful answers to clinical problems” (rank score, 3.5 of 5). Eighty-eight (67.7%) of 130 respondents appropriately used published research evidence in clinical practice. ConclusionsRespondents reported generally positive attitudes toward using published research evidence, in clinical practice; however, room for improvement in technical knowledge relating to published research evidence was noted.

La Medicina Basada en la Evidencia: ¿mejoró la medicina que practicamos y enseñamos?

En los últimos años la práctica y la enseñanza médica han incorporado en forma progresiva y creciente el concepto de medicina basada en la evidencia (MBE). La misma se define como la utilización de la mejor evidencia proveniente de la investigación clínica para la toma de decisiones en el manejo del paciente individual. Esta propuesta de cambio en la manera de practicar y enseñar la medicina clínica es, en parte, consecuencia del vertiginoso avance de la investigación científica, particularmente en las últimas décadas, aunque el costo creciente involucrado en la atención de los pacientes ha jugado también un rol importante en su desarrollo y consolidación. La MBE implica la integración de la preparación y experiencia del médico con la mejor evidencia clínica externa accesible, proveniente de la investigación sistemática, proporcionando una visión más crítica en la toma de decisiones clínicas, para ofrecer atención de calidad óptima al paciente, evitando errores en cada una de las diferentes etapas del proceso de diagnóstico y tratamiento. En ausencia de información recolectada sistemáticamente, no es fácil llegar a una conclusión sobre los efectos de la MBE en la práctica y la enseñanza de la medicina en nuestro medio. Sin duda contamos hoy con mayor evidencia científica, incluyendo aquella relacionada a los problemas de salud infantil, y también se ha producido un avance vertiginoso en la tecnología que nos permite acceder a dicha información en tiempo real, a la cabecera del paciente. Sin embargo, si deseamos de veras lograr una mejor medicina, basada en la ciencia y en el respeto a la salud como un derecho que nos asiste a todos, hay necesidad de romper definitivamente con el paradigma predominante de una medicina jerárquica, poco dada a la discusión y a la justificación de las decisiones clínicas, de aprovechar la mejora sustancial ocurrida en el acceso a la evidencia disponible, y de mostrar mayor disposición a compartir amigable y respetuosamente dicha justificación con nuestros pacientes. Del mismo modo, hay la necesidad imperiosa de promover la investigación, la creatividad y el espíritu crítico en todos los niveles de la educación, para contribuir a la evidencia global que permita que la medicina clínica y la salud pública continúen avanzando.

Evidence–Based Dentistry and Clinical Implementation by Third–Year Dental Students

Over the last two decades, the concept of evidence-based medicine (EBM) has become the standard of medical care. Defined by Sackett et al. as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients," EBM recognizes that the practitioner should combine individual clinical expertise with the best available external evidence for optimal care. Consideration of the patient's needs and preferences is also an integral component of the clinical application. Dental educators have to account for the fact that not all dental treatment outcomes have been researched with randomized clinical trials. Dogmas in dentistry still exist regarding restorative treatments and methods taught to next generations of practitioners, while limited evidence is available. The purpose of this study was to determine how third-year dental students at one U.S. dental school select articles to provide supportive evidence related to treatment planning. The results show that knowledge provided in a three-week course in evidence-based dentistry (EBD) for first-year dental students was not efficiently applied when the students reached their third year. A significant percentage of the students perceived the use of literature as not beneficial for sustaining clinical aspects of a treatment plan, and they did not use appropriate tools to access best available resources. As a result of these findings, the article proposes incorporation of specific learning objectives related to EBD principles throughout the curriculum and a simplified method to search for best available evidence that has the advantage of not requiring knowledge and training in rigorous formulation of clinical questions.

Convergence of technologies: the print, web and multimedia united to deliver an integrated basic medical sciences course in a resource limited setting.

This mixed methodology study was conducted at Shifa College of Medicine to see if study guide, module website and multimedia compact disk can be used to deliver an integrated basic sciences course while introducing the concepts of evidence based medicine and how it translates in students' performance. The study guide focused on the management of learning, activities and provision of information. The website was used to introduce evidence based medicine while the multimedia disc provided pictures, videos and animations for organs of special senses. Feedback questionnaire and end of module result were used to evaluate the module and its learning tools. The students agreed that the study guide, module website and multimedia compact disc facilitated their learning experience.

Seminal papers in orthopaedic trauma

Abstract Over recent decades, the concept of Evidence-Based Medicine has come to form the cornerstone of clinical practice in all medical specialities, including Trauma and Orthopaedic Surgery. Management of the trauma patient is part of everyday practice for most Orthopaedic Surgeons. As such, it is important to be aware of the seminal research studies that have informed current clinical practice. It is also important that all surgeons, including surgeons-in-training, follow the process of ongoing professional development such that their clinical practice remains current and up to date. In this article, we critically evaluate a number of important research papers, which have been selected for their impact on contemporary clinical practice, recognized in many orthopaedic teaching programmes.

L’expertise médicale fondée sur les faits

The concept of evidence-based medicine applies to medical activity in general in order to rationalize it. The medical expertise, constantly looking to improve its quality, can no longer ignore this concept. This is the best tool to meet the mission entrusted to experts of assessing the conformity of care to the scientific-acquired features, without neglecting the assessment of the involved practitioner's skills and the particular circumstances of the plaintiff. This article develops the new concept of “Medical expertise based on facts”.

Writing an Evidence-Based Articles in Plastic Surgery Field

Many beginning writers, especially medical residents, feel difficulties in writing journal articles. However, illogical and unscientific papers are not accepted for publication even if their topics are creative and interesting. The authors should do their best to convince reviewers and readers of their opinions using evidence through reasoning, explanation, and data interpretation. The aim of this article is to review evidence-based medicine (EBM) and reporting guidelines and to assist authors in composing plastic surgery papers with a logical argument. The concept of EBM was initially suggested in 1979 by Archie Cochrane, who was a British epidemiologist. Since then, the trend of modern medicine has been toward completely evidence-based decision making [1]. Recently, the American Society of Plastic Surgeons (ASPS) and the journal Plastic and Reconstructive Surgery (PRS) have been actively working to build a foundation for EBM in the plastic surgery field [2]. In August 2010, various plastic surgery researchers and journal editors had a conference in Colorado Springs, US for the integration of EBM into the field of plastic surgery. At the conference, it was decided that the level of evidence and a visual icon of the evidence pyramid would be displayed at the end of the abstract of every article, except some that could not be rated, with classification of the research into one of these categories: diagnostic, therapeutic, prognostic, and risk. This decision has been in effect in PRS since January 1, 2011 [3]. Among the evidence levels assigned in PRS, level 1 represents the highest or strongest level of evidence, while level 5 is the lowest. The types of studies in level 3 include retrospective cohort studies and case control studies. The case series is included in level 4 [4]. The average level of plastic surgery articles submitted to PRS is 3.2 and most are between 3 and 4. The reasons for the relatively low levels in the field of plastic surgery are that each patient has highly variable requirements and some cases are rare due to the nature of plastic surgery, and there are diverse approaches to treating a given diagnosis [5]. To overcome these limitations, PRS estimate the level of evidence on all articles according to subsections. And PRS recommends that researchers aim to produce prospective cohort studies, which are in level 2, and eventually even level 1, randomized controlled studies, even though researchers typically start out by publishing level 3, 4, or 5 articles [3,6]. As the Korean Society of Plastic and Reconstructive Surgeons has revised the submission guidelines for this journal, the Archives Plastic Surgery (APS), it is now recommended that articles be written using five reporting guidelines, which are provided in the appendix, to improve the evidence level (Table 1). Table 1 Reporting guidelines for specific study designs in Archives Plastic Surgery Because there are many articles at levels 3, 4, and 5 due to the nature of the plastic surgery field, referring to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), which is suitable for observational studies, would be useful. Although STROBE is a guideline developed for observational studies in epidemiology, it is also applicable to plastic surgery. In particular, if the STROBE checklist were applied to retrospective cohort studies, case control studies, case series, and case reports, important information that should be in the articles would not be omitted and the transparency of research results would be achieved [7]. On their website (www.strobe-statement.org), the STROBE research group also publicly announces the latest research results on guidelines, and revisions to the guidelines under ongoing development by researchers and editors. In addition, checklists are provided free of charge to readers in PDF and Word formats (Table 2). Table 2 Strengthening the Reporting of Observational Studies in Epidemiology Statement.checklist of items that should be included in reports of observational studies If and when you do a game, you need to know the rules first. Writing an article is much easier when you know the rules and have a set of guidelines to follow. It is hoped that the resources provided here will assist the readers of APS to become successful researchers and authors.

Team-Based Learning of Evidence-Based Medicine: Screening

OPEN ACCESSJune 20, 2013Team-Based Learning of Evidence-Based Medicine: Screening Joan M. Bedinghaus, MD, David Nelson, PhD, MA Joan M. Bedinghaus, MD Medical College of Wisconsin Google Scholar More articles by this author , David Nelson, PhD, MA Medical College of Wisconsin Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.9450 SectionsAboutAbstract ToolsDownload Citations ShareFacebookTwitterEmail AbstractAbstract Introduction: This team-based learning session is one of a series of five developed for a course called “Foundations of Evidence-Based Medicine” for first-year medical students. Of these five, four are published on MedEdPORTAL and cover the topics of randomized controlled trials, case-control and cohort studies, diagnostic testing, and screening. Methods: The resource includes a list of objectives, preparation assignments, slides for a brief in-class presentation, a quiz, and application exercises. An instructor's manual is also included. Students arrive at the session having already reviewed a series of preparatory readings. They are first administered an individual readiness assurance test before being grouped into teams of 5–7 students and retake the same test (group readiness assurance test) as a unit. This is followed by a review of the answers and an informational PowerPoint presentation. Finally, the students complete a series of application exercises while remaining in their groups. Results: The course was given twice (Fall 2011 and Spring 2012), each time with a group of 100–104 students. Discussion: Previously, we had taught evidence-based medicine using 10–12 hours of lecture, three 1.5 hour small group sessions, and two online self-study modules. The course was poorly rated by students and the performance on USMLE in biostats was consistently below national averages. The sessions published here were developed in hopes of improving understanding and retention of evidence-based medicine concepts. Educational Objectives By the end of this session, learners will be able to: Define and identify examples of primary, secondary, and tertiary prevention.List and define the characteristics of an effective screening program.Identify bias and error in the evaluation of screening programs.Identify and evaluate the features of a high-quality systematic review. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Instructor's Manual.pdf Session 5 EBM - APPLICATIONS - Answer Key.doc Session 5 EBM - FAQs.pptx Session 5 EBM - IRAT GRAT.pptx Session 5 EBM-APPLICATIONS.pptx Session 5 EBM-OBJ and PREP-RAT Answer Key.docx To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. Related Team-Based Learning of EBM: Case-Control and Cohort Studies Team-Based Learning of Evidence-Based Medicine: Screening Team-Based Learning of EBM: Randomized Controlled Trials Team-Based Learning of EBM: Diagnostic Testing Copyright & Permissions© 2013 Bedinghaus and Nelson. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsScreeningLead Time BiasEvidence-Based MedicineTeam-Based LearningLength BiasReviewTBLSystematic Review Disclosures None to report. Funding/Support None to report. Loading ...

Evaluating factors affecting the implementation of evidence based medicine in primary healthcare centers in Dubai

ObjectivesTo assess the current evidence based medicine (EBM) knowledge, attitude and perceptions of physicians at Dubai Primary Health Care Sector (PHCS). Further to evaluate barrier and facilitator factors toward implementing the EBM practice. MethodologyA cross-sectional study, at Dubai PHCS, UAE between June and August 2010. The survey was composed of two phases. The first phase was a self administrated questionnaire employed for data collection and the second phase was qualitative method, which was in the form of individual interviews. Statistical Package for Social Sciences (SPSS) was used for data analysis. ResultsIn total 48 participants responded to the survey questionnaire and 13 responded to individual interviews. The response rate was 70.0%. Mean age was 42.18 (SD 10.46). The majority were females (64.6%). The physicians who attended EBM courses reported 70.30% using EBM and showed statistical significance (p=0.002) from those who did not attend the EBM courses. 65.0% believe that 50–75% of the patients are capable of participating in clinical decision while 71.8% disagreed that the concept of EBM is not applicable to their culture. In addition they showed significance (p=0.03) between physician beliefs with regard to patient capacity to take decision. About 67.0% of the family physicians were knowledgeable and followed systematic review as the strongest evidence. They had no access to the EBM resources (37.0%) and had no time to practice the EBM (38.0%). Nearly 40.0% interviewees reported lack of encouragement to attend EBM courses. EBM activities (22.0%) and active audit (18.0%) were top rated facilitating factors. ConclusionsEBM is not fully utilized by indefinite physicians in the Dubai PHC sector. Factors associated with non-utilization of EBM in the PHCS are lack of encouragement to attend EBM courses, senior physicians resist adoption of EBM, lack of time and insufficient dissemination process for implementing the clinical guideline.

La médecine factuelle, ou médecine fondée sur les preuves, appliquée aux nutraceutiques vétérinaires

En médecine vétérinaire comme en médecine humaine, le praticien est amené à prendre des décisions diagnostiques, thérapeutiques ou préventives complexes. Le concept de la médecine fondée sur les preuves (evidence-based medicine ou EBM) est apparu pour la première fois au début des années 1990 en médecine humaine pour améliorer le processus de prise de décision, et consiste à intégrer de manière consciencieuse, explicite et judicieuse les meilleures preuves scientifiques (evidence) du moment dans la prise en charge du patient. Le concept fut introduit en médecine vétérinaire dans les pays anglo-saxons en 2003, et il a depuis été développé dans les pays francophones. Bien que des études récentes montrent que l’EBM ne peut être appliquée en médecine vétérinaire dans les mêmes termes qu’en médecine humaine, les praticiens vétérinaires sont tenus sur le plan éthique de prendre des décisions scientifiquement valides. La promotion de l’EBM en médecine vétérinaire requiert le développement d’outils adaptés, tels que des revues systématiques, ainsi que des améliorations spécifiques des études vétérinaires, avec en particulier l’enseignement d’une démarche de réflexion aux futurs praticiens. Le manque de preuves scientifiques de l’efficacité des nutraceutiques illustre à la fois les obstacles rencontrés pour la prise de décisions parfaitement informées et les faiblesses méthodologiques de la recherche en médecine vétérinaire.

Why Should We Foster Core Specialty Collaboration in Cosmetic Medicine?

Every day in my cosmetic practice, I am faced with the challenge of maximizing patient outcomes through my knowledge of available and emerging energy-based technologies, soft-tissue injectables, and medical skin care products. Keeping up-to-date in these areas is an extremely time-consuming process. To better understand the scope of current research and clinical evidence, it is necessary to familiarize myself with the work coming from 4 distinct specialty groups: plastic surgery, dermatology, facial plastic surgery, and oculoplastic surgery. Although I am encouraged that each of these 4 core specialties in the field of cosmetic medicine has embraced the concept of evidence-based medicine (EBM) at national meetings and in society-endorsed peer-reviewed journals,1,2 I remain frustrated by the lack of widespread collaboration among the specialties to achieve standardized outcome measures that are both safety and patient-centric driven. As Dr Carl Hartrampf's fellow in 1988, I was exposed to the value of EBM. Under his direction, we meticulously evaluated clinical outcomes using prospectively collected data. I was introduced to the concepts of inclusion criteria and, more important, exclusion criteria so that best practices in autologous breast reconstruction could be developed. In 1996, Sackett et al3 wrote, “Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” As American Board of Plastic Surgery-certified doctors, we are charged with developing our own “best practices” through a variety of avenues. First, we must engage in vigorous and ongoing evaluation of our clinical results. We accomplish this through careful observation, meticulous recording and analysis of all relevant data, and meaningful measurement of patient satisfaction. In addition, we draw from the experiences of other qualified practitioners by attending educational meetings and reading peer-reviewed journals. But how many meetings must we attend, and how …

Recommendations of the Brazilian Society of Cardiac Arrhythmias for Holter Monitoring Services

BackgroundThere are innumerous indicators to assure the quality of a service. However, medical competence and the proper performance of a procedure determine its final quality. The Brazilian Society of Cardiac Arrhythmias recommends minimum parameters necessary to guarantee the excellence of ambulatory electrocardiographic monitoring services.ObjectiveTo recommend minimum medical competences and the information required to issue a Holter monitoring report.MethodsThis study was grounded in the concept of evidence-based medicine and, when evidence was not available, the opinion of a writing committee was used to formulate the recommendation. That committee consisted of professionals with experience on the difficulties of the method and management in providing services in that area.ResultsThe professional responsible for the Holter monitoring analysis should know cardiovascular pathologies and have consistent formation on electrocardiography, including cardiac arrhythmias and their differential diagnoses. The report should be written in a clear and objective way. The minimum parameters that comprise a Holter report should include statistics of the exam, as well as quantification and analysis of the rhythm disorders observed during monitoring. ConclusionAmbulatory electrocardiographic monitoring should be performed by professionals knowledgeable about electrocardiographic analysis, whose report should comprise the minimum parameters mentioned in this document.

Is self-sufficiency in haemotherapies a practical or necessary goal?

blood service managers has reiterated the messages embedded in the long-debated and controversial issue of self-sufficiency in haemotherapies. This issue has been part of the debate on blood supply policy for the past 40 years. As blood systems in emerging countries develop in tandem with clinical practice needs, the question of the optimal path to sufficiency is crucial. As the composition of donor populations change through demographic and other factors, and as clinical awareness of the issues around the safety and efficacy of haemotherapies influence usage, principles proposed in the 1970s may benefit from scrutiny through the modern concepts of evidence-based medicine. In particular, the established position of the patient in the centre of all blood transfusion processes may need to transcend the reflections of expert groups, however eminent. Self-sufficiency: historical development The philosophical origins of the concept of selfsufficiency date back to the 1970s, when the World Health Organization (WHO) identified an extensive trade in blood and blood products, which exploited people in poor countries and placed those receiving blood products at risk from pathogen transmission. This led a joint conference of the WHO and the International Red Cross to agree to promote voluntary blood donation systems and national self-sufficiency and a World Health Assembly resolution to that effect (WHA28.72). The context is described in the report of the Canadian Krever Commission, demonstrating the WHO's concern that donors in developing countries were being drawn into the paid plasma system at the expense of their domestic blood supply 2 . Krever also

Measuring Treatment Effectiveness

Every year, hundreds of new surgical devices and techniques are introduced, and plastic surgeons must determine the associated risks, benefits, and costs of these options when incorporating these advances into their armamentarium. This article will discuss the elements of treatment effectiveness by applying the principles of evidence-based medicine to therapeutics. Current efforts to measure plastic surgery outcomes are evolving and rely on case series and retrospective cohort studies. This review will highlight the basic evidence-based medicine concepts and how they can potentially be applied to understand best practices in plastic surgery.

Limitations of Evidence-based Medicine

Advances in statistical science and the development of computers (a result of the digital revolution) have allowed many disciplines, including medicine, to develop a more objective analysis of data as applied to decision making. The concept of evidence-based medicine (EBM) includes that scientific study of disease and treatment efficacy will allow high-quality, cost-effective treatment. The concept of EBM is well established in medical specialties, particularly for cardiovascular disease and cancer, but less developed in the surgical specialties. Multiple factors make evidence-based surgical (EBS) studies more problematic. Entering children into prospective surgical treatment trials remains difficult for the parents and patients who are asked to allow a choice of procedures for a surgical intervention that will take just an hour or two but whose results could change the child's entire life. Comparative effectiveness research, a subset of EBM, is of special interest to surgeons, who often need to decide on an expensive new implant versus a reliable, less expensive, established one. Factors that make the scientific analysis of surgical treatment efficacy more difficult include issues as practical as surgical skill. Prescribing an antihypertensive medication or a lipid-lowering drug has little variability in its delivery. Performance of a complex surgical procedure can vary immensely, allowing a procedure to be very effective in one surgeon's hands but far less applicable by another surgeon (eg, arthroscopic vs. open shoulder surgery). Thus, large patient series with careful follow-up are required to clarify outcome differences. Scientific study of surgical treatment outcomes in childhood orthopaedic conditions remains in its infancy. Because of minimal funding available for such research, most available studies are poorly designed with an inadequate study sample size. As for the near future, neither the government nor industry sources seem to have a strong incentive to study outcomes in childhood surgical diseases that have a low prevalence. Because current research provides little evidence to guide parents and their surgeon (when a choice exists), consumers generally seek what they believe to be the best available "expert opinion." Properly funded, the digital revolution will allow radical advances in establishing EBS decision making. However, the same digital revolution has produced an educated populace, greatly increasing their capacity for critical analysis of available data. Currently, both sophisticated parents and their surgeons remain hesitant to accept results from poorly designed studies when deciding on surgery for their child. As a result, expert opinion remains central to surgical decision making in children's orthopaedics. Knowledgeable surgeons look forward to future quantum improvements in research quality that will allow secure EBS-based decisions for their surgical patients.

Bracing in Adolescent Idiopathic Scoliosis, Surrogate Outcomes, and the Number Needed to Treat

In this manuscript we will present several evidence-based medicine concepts and tools that can be helpful to the clinician seeking answers to clinical questions. The clinical scenario used to demonstrate these concepts is one of the substantial current controversy in pediatric orthopaedics, that is the efficacy of bracing in adolescent idiopathic scoliosis. We hope to provide some important information about how to search and interpret the current literature on bracing but also to discuss the concepts related to "surrogate outcomes" and the "number needed to treat," which we believe are increasingly important in this era of evidence-based medicine. We performed a structured literature review of scoliosis bracing and also a separate analysis of the number needed to treat (NNT) for preventing surgery in adolescent idiopathic scoliosis. Bracing for idiopathic scoliosis significantly reduces the rate of curve progression more than 6 degrees. However, the applicability of the 6-degree surrogate outcome compared with a more important outcome such as progression to surgery is doubtful. Bracing may decrease the risk of progression to surgery although the confidence intervals are large. The NNT for routine scoliosis bracing is about 9 patients for each surgery prevented. The NNT for patients highly compliant with bracing is about 4. We caution that these NNTs are derived from nonrandomized cohorts, and the true values from quality randomized controlled studies may be substantially different. There is no evidence for any particular brace over another although rigid bracing seems better than SpineCor bracing from 1 small randomized controlled study. Systematic reviews support bracing's ability to prevent curve progression of 6 degrees but not for preventing surgery. Analysis of a patient cohort does support bracing's ability to prevent surgery with NNT of 9 for all patients and 4 for highly compliant patients. Systematic review-therapeutic level 2. Cohort analysis-therapeutic level 2.