Evidence-based Medicine Tools Research Articles

Teaching the philosophy and tools of evidence‐based medicine: misunderstandings and solutions*

Teaching the philosophy and tools of evidence‐based medicine: misunderstandings and solutions*

Evidence-based Medicine: Applying Valid Evidence

1. Gary M. Onady, MD, PhD* 1. *Department of Pediatrics, Boonshoft School of Medicine, Wright State University, Dayton, Ohio This fifth article in the evidence-based medicine (EBM) series integrates the first three steps of EBM introduced previously (asking an answerable question, searching the literature, critical evaluation of the literature) into a fourth step that applies valid evidence discerned in those steps to medical decision-making. Integration of EBM with medical decision-making constitutes the foundation of what has been termed evidence-based practice (EBP). By definition, EBP is the integration of best research evidence with patient values and clinical circumstances to make clinical decisions. (1) Developing an EBP involves conscientious decision-making based on evidence combined with knowledge of patient characteristics, situations, and preferences, and requires three additional tasks: This contribution to the EBM series applies previously introduced components from the EBM tool box to convert a problem presented by a patient into a set of rational diagnoses. Additional tools are used for judicious selection of diagnostic testing that prioritizes the diagnoses effectively. Finally, methodology that allows the choice of a definitive action plan is described so a clear decision point can be reached confidently, once a single working diagnosis is given priority. A case referred by an otolaryngologist for preoperative clearance illustrates these points. A 4-year-old girl scheduled for tonsilloadenoidectomy has a history of chronic rhinitis, pharyngitis, and recurrent epistaxis. Family history reveals a grandfather who has type I von Willebrand disease (vWb). Physical examination of the girl reveals multiple bruises in various stages of resolution. The question posed by the surgeon is, “Can you clear this patient for surgery?” The process of defining a problem begins by rephrasing the surgeon's question into a question whose answer facilitates achievement of the real goal, which is to minimize surgical risk. The best initial problem-defining EBM question becomes, “What is the likelihood …

Development in and Challenge for Traditional Chinese Medicine in Australia

Demand for and use of Traditional Chinese Medicine (TCM) has been growing steadily in Australia. This article outlines the growth of TCM in usage, research capacity, and availability of tertiary training. However, there are continuing challenges, institutional recognition of TCM is lagging behind consumer demand, and there is little TCM practiced in the Australian public health system. This article suggests some possible reasons. The tools of evidence-based medicine (EBM) have the potential to provide a bridge between, and a common language for, TCM and Western biomedicine (WB) researchers and practitioners. While there is no sign of a slowing in consumer demand for TCM services, EBM has the potential to increase the legitimacy and institutional recognition of TCM, thereby encouraging the integration of TCM into the Australian health care system.

Trends in Meta-Analysis

While meta-analysis is a well-accepted tool in evidence-based medicine, both the science and the utility of meta-analysis continue to evolve in response to the empirical demands of health care providers, researchers, payers, and policymakers. Three important developments in meta-analysis are summarized, with relevant examples provided for illustration.

Teaching the philosophy and tools of evidence-based medicine: misunderstandings and solutions

Teaching the philosophy and tools of evidence-based medicine: misunderstandings and solutions

Praxisempfehlungen „EbM-Guidelines für Allgemeinmedizin“: Erste Erfahrungen mit Implementierung und Akzeptanz

A German-Austrian version of the practice recommendations "Evidence-based Medicine Guidelines for Primary Care"--an international practice guidelines project originating in Finland--was first published in print in December 2005, and has been available in electronic form since January 2007 under the title "EbM--Guidelines für Allgemeinmedizin". The collection comprises more than 1000 short evidence- and experience-based practice guidelines for general medicine, thus generating an easily and very rapidly accessible, reliable and practice-oriented knowledge base for daily use and use in consultation. Links to databases and clinical guidelines provide further effortless access to evidence-based medicine tools and should help to reduce barriers between science and practice, thus changing the culture of medical decision-making. It is conceived of as a "work in progress": international co-operation and exchange as well as an integrated user feed back tool imply continuous learning on the part of the editors' from all the countries involved. With due caution, first data can be interpreted as an indication of this concept's effectiveness. Thorough evaluation and further implementation strategies are in planning stage.

The role of evidence‐based medicine and clinical trials in rare genetic disorders

The drive to empirically evaluate and analyze tools for the screening, diagnosis, management and monitoring of disease captured by the phrase 'evidence-based medicine (EBM)' has firmly entrenched itself as part of standard clinical care. However, rare genetic disorders, by their very nature, challenge the generation and application of EBM. This review presents many of the challenges encountered in applying EBM to rare genetic disorders, highlighting areas of recent emphasis in establishing multi-institutional collaborative research networks and in the systematic evaluation of developing therapies. Resources for identifying EBM tools for the practitioner are discussed, and the features and limitations of such resources are presented. Although the application of EBM to rare genetic disorders has definite limitations, a foundation has been established, and ongoing efforts seeking to systematically summarize and critically evaluate available evidence will continue to help identify the most effective tools for screening, diagnosis, management, and monitoring.

Evidence-based medicine targets the individual patient, part 1: how clinicians can use study results to determine optimal individual care

Despite increasing acknowledgement of its importance,1 some continue to characterise evidence-based medicine (EBM) as focusing on groups of patients and neglecting the individual.2 3 In this 2-part commentary, we will...

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.

Show Me the Evidence: Using Number Needed to Treat

This article reviews one of the basic tools of evidence-based medicine, the calculation and interpretation of Number Needed to Treat (NNT) and Number Needed to Harm (NNH). Especially appealing is the simplicity of extracting this information from journal articles that report binary outcomes, such as medication response or emergence of adverse events. On-line resources and calculators can help the clinician in determining confidence intervals for these metrics. After a discussion of absolute versus relative risk, P-values, and the mechanics of calculating NNT and NNH, the application of NNT and NNH to a large clinical trial, the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) for schizophrenia, is described.

MEDLINE: A Guide to Effective Searching in PubMed and Other Interfaces

MEDLINE: A Guide to Effective Searching in PubMed and Other Interfaces

Meta-analysis in public health: potentials and problems

Meta-analysis has evolved as a primary tool for evidence-based medicine. Initially, meta-analysis was seenas a technique that could improve statistical power in a research world of small, underpowered studies.We increasingly recognize that meta-analysis is a critical tool that can help us measure and understand notonly summary effects, but also heterogeneity (diversity) and bias. Here I discuss some key themes and chal-lenges for “meta-epidemiology”. These include the contrast between randomized and observational evi-dence; the evolutionary nature of biomedical evidence; the contrast between small and larger studies; thedifficulties in appraising study “quality” and its potential impact on the study effects; and the scandal ofmissing even minimal, key information on the harms of interventions that are otherwise postulated to beeffective. I discuss a general outlook about the validity of the evidence in medicine and public health. I sug-gest that we should learn to live with uncertainty, since the evidence that is available is often limited, biased,or both. This means that we should be prepared to dismiss big chunks of biomedical dogma, including per-haps whole specialties and sub-specialties of current medicine, as false, erroneous, irrelevant or even poten-tially dangerous for the health of individuals and populations. An effort should be made to shift the accu-mulation and synthesis of evidence towards answering critical public health-related questions.This paper is based on a lecture presented at the European Public Health Association 2005 annual confer-ence in Graz, Austria

和雑誌特集記事のエビデンス

Background: There are many feature articles in Japanese journals; these articles are frequently used by busy clinicians and trainee doctors. However, the characteristics of these feature articles have not been investigated.Objective: To investigate the characteristics of evidence-based medicine of feature articles.Method: Eight typical monthly journals of internal medicine issued by different publishers from July through September or October 2004 were investigated in terms of the references cited, the year of publication, reference errors, and the first author. These monthly journals were compared with one weekly journal. To determine the type of article, the PubMed publication type and the Ichushi-web article type were investigated. In particular, the PubMed publication type of clinical studies was investigated as evidence of evidence-based medicine. The first author's affiliation and position were examined with the up-to-date data.Result: Seventy-five percent of articles cited were from foreign journals. Ninety-five percent of these articles were journal articles. Twenty percent of these journal articles were clinical studies, including randomized controlled trials and meta-analyses. Approximately 5.5% of all references contained errors. The official position of half of the authors could not be confirmed.Conclusion: Feature articles do not necessarily contain a sufficient quantity of evidence, although they cite many articles from foreign journals and quote many current articles. We can suggest feature articles to clinicians, if they can't find good evidence with evidence-based medicine tools or they don't have enough time to read English articles.

Retrolective study design - a new tool of evidence-based medicine

Retrolective study design - a new tool of evidence-based medicine

Evidence-Based Medicine In The United States—De Rigueur Or Dream Deferred?

Although evidence-based medicine (EBM) is an important concept for promoting value in health care, meaningful application of EBM tools in commercial settings has proceeded slowly. Barriers to the use of EBM include patient preference, physician resistance, the lack of automated decision support systems, managed care failures, lack of research on which to base decisions, and the inherent subjectivity of interpretations of evidence. Political concern has mirrored these barriers; consequently, Medicare still lacks clear authority to apply many evidence-based decision tools. Dialogue and consensus will be critical in bridging public concern and the eagerness of researchers to apply EBM.

EPO or not-EPO? An evidence based informed consent.

Informed consent is crucial in therapeutic choices; however, the forms presented to patients are often locally developed and information may not be homogeneous. To prepare an evidence-based model for informed consent, applied in the case of erythropoietin therapy (EPO) as a teaching tool for medical students. Methodological tools of Evidence-Based Medicine (EBM) were developed within the EBM Course in the Medical School of Torino, Italy, as problem solving and patient information tools (5th year students work in small groups under the supervision of statisticians, epidemiologists and experts of internal medicine--nephrology in this case). Methodological and ethical problems were identified: in the pre-dialysis field, evidence from randomized clinical trials (RCT) is scant; how to use evidence gathered in dialysis? How to deal with implementation? How with the mass media? Do we need to discuss the drug choice with the patients? How to deal with rare and severe side effects?). The "evidence" was searched for on Medline/Embase, by using key-words and free terms. About 680 papers were retrieved and screened. Forms available on the Internet were retrieved and a general scheme was drawn: it included 5 areas: title, aim and targets (patients and family physicians); search strategies and updating; pros and cons of therapy; alternative options; open questions. EBM may offer valuable tools for systematically approaching patient information; the inclusion of this kind of exercise in the Medical School EBM courses may help enhance the awareness of future physicians of the correct communication with patients.

The Vermont Oxford Network

After completing this article, readers should be able to: 1. Describe the topics of study of the Neonatal Intensive Care Quality Improvement Collaboratives. 2. List the four key habits of clinical improvement. “The nation’s health care system lacks… the capabilities to ensure that services are safe, effective, patient-centered, timely, efficient and equitable… Between the health care we have and the care we could have, lies not just a gap but a chasm.” IOM 2001 (1) “More people die in a given year as a result of medical errors than from motor vehicle accidents, breast cancer, or AIDS.” IOM 2000 (2) In 2000 and 2001, the Institute of Medicine (IOM) of the National Academy of Sciences issued two landmark reports that presented a clear and compelling challenge to all health care professionals. (1)(2) We must improve the quality and safety of the medical care for the patients and families that we serve. In this article, we describe the Vermont Oxford Network (VON) and the quality improvement (QI) activities it has undertaken to meet this challenge. The VON is a not-for-profit organization whose mission is to improve the quality and safety of medical care for newborns and their families through a coordinated program of research, education, and quality improvement. (3)(4) VON currently has more than 440 member neonatal intensive care units (NICUs) from North America and around the world. Members participate in a range of Network activities, including randomized controlled trials, outcomes research, and a variety of QI projects. The focus of this article is QI. Descriptions and references for other VON activities are available on the VON Internet site (http://www.vtoxford.org). In support of its mission, VON maintains a database that includes information about the treatment and outcomes for high-risk infants receiving neonatal intensive care. Importantly, all …

情報科学の展開とＤＤＳ ゲノムインフォマテックスと治療の最適化

The Human Genome Project is now almost completed, and we are now about to move into the post-genome sequence era of Functional Genomics. The advent of genome science had markedly changed the way how the life science research including medical study is conducted ; thus, systematic and integrated, “genome-wide” survey is feasible, Human Genome Project provides insights so profound that it has the ability to change everything we know about medicine and how medicines are developed. Genetic factors contribute substantially to variable drug effects and constitute a critical element of a product's profile that must be considered in clinical use. Pharmacogenomics is a rapidly emerging field focused on understanding the genetic factors underlying drug action and applying this information to improve the clinical use and development of pharmaceutical products. In clinical practice, the understanding of how genetic variation leads to variable drug effects can be used to prescribe drugs selectively to individuals in regimens and doses that are most likely to be safe and effective (Personalized Medicine). Also, pharmacogenomics will promote to develop novel pharmaceutical products targeted to the normal genetic variance of human populations. In drug development, knowledge of genetic variation that may affect drug action can be used to reduce the cost and complexity of clinical trials, increase the success rate of achieving regulatory approval, and achieve approvals for new classes of diagnostic and therapeutic products. Pharmacogenomics programs, thus, enhances the development, commercialization, and clinical use of conventional pharmaceutical products for common diseases, and eventually a powerful tool for Evidence-Based Medicine.

Pharmacogenomics: the frontiers of genome medicine

The Human Genome Project provides insights so profound that it has the ability to change everything we know about medicine and how medicines are developed. Pharmacogenomics is defined as studies to identify the genes that are involved in determining the responsiveness to a given drug and to distinguish responders and non-responders to a given drug. Genome sequencing, transcriptome, and proteome analysis are of particular significance in pharmacogenomics. Transcriptome analysis can be done by methods of random cDNA sequencing, mRNA display and, differential hybridization (i.e., cDNA microarray and associated methods). Our results suggest that the pharmacogenomic transcriptome analysis and pharmainformatics have potential as strategies for defining novel drug targets in various diseases. Pharmacogenomics enhances the development, commercialization, and clinical use of conventional pharmaceutical products for common diseases, and it will eventually become a powerful tool for Evidence-Based Medicine. It is also important to predict interindividual pharmacokinetic differences by genetic polymorphisms of transporters or pharmacokinetic changes by transporter-mediated drug interactions during drug development. Pharmacogenomics and pharmainformatics enable us to move quickly and efficiently from targets to appropriate medicines.

CPR--guidelines 2000. New international guidelines for cardiopulmonary resuscitation

The "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. An International Consensus an Science" are the first true international CPR guidelines in the history of resuscitation medicine. Experts from major international resuscitation organizations (International Liaison Committee on Resuscitation, ILCOR) achieved a consensus of recommendations which had to pass a rigorous review procedure applying the tools of evidence-based medicine: all proposed guidelines or guideline changes had to be based on critically appraised pieces of evidence which had to be integrated into a final class of recommendations. The most important changes compared to previous recommendations from either the European Resuscitation Council or the American Heart Association are presented and commented upon.