Chapter 003. Decision-Making in Clinical Medicine (Part 9)

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Evidence-Based Medicine The "art of medicine" is traditionally defined as a practice combining medical knowledge (including scientific evidence), intuition, and judgment in the care of patients (Chap. 1). Evidence-based medicine (EBM) updates this construct by placing a much-greater emphasis on the processes by which the clinician gains knowledge of the most up-to-date and relevant clinical research. The key processes of EBM can be summarized in four steps: 1. Formulating the management question to be answered 2. research data Searching the literature and on-line databases for applicable 3. and relevance Appraising the evidence gathered with regard to its validity 4. Integrating this appraisal with knowledge about the unique aspects...

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Chapter 003. Decision-Making in Clinical Medicine (Part 9) Evidence-Based Medicine The "art of medicine" is traditionally defined as a practice combining medical knowledge (including scientific evidence), intuition, and judgment in the care of patients (Chap. 1). Evidence-based medicine (EBM) updates this construct by placing a much-greater emphasis on the processes by which the clinician gains knowledge of the most up-to-date and relevant clinical research. The key processes of EBM can be summarized in four steps: 1. Formulating the management question to be answered
2. Searching the literature and on-line databases for applicable research data 3. Appraising the evidence gathered with regard to its validity and relevance 4. Integrating this appraisal with knowledge about the unique aspects of the patient (including preferences) Steps 2 and 3 are the heart of EBM as it is currently used in practice. The process of searching the world's research literature and appraising the quality and relevance of studies thus identified can be quite time-consuming and requires skills and training that most clinicians do not possess. Thus, the best starting point for most EBM searches is the identification of recent systematic overviews of the problem in question (Table 3-3). Table 3-3 Selected Tools for Finding the Evidence in Evidence-Based Medicine Name Descriptio Web Address Availab n ility
Eviden Comprehe http://www.ovid.com Subscrip ce-Based nsive electronic tion required; Medicine database that available Reviews combines and through integrates: medical center libraries and 1. The other Cochrane institutions Database of Systematic Reviews 2. ACP Journal Club 3. The Database of Abstracts of Reviews of Effectiveness Cochra Collection http://www.cochrane.org Subscrip
ne Library of EBM databases tion required; including The abstracts of Cochrane systematic Database of reviews Systematic available free Reviews—full online; some text articles countries have reviewing funding to specific health provide free care topics access to all residents ACP Collection http://www.acpjc.org Subscrip Journal Club of summaries of tion required original studies and systematic reviews; published bimonthly; all data since 1991 available on Web
site, updated yearly Clinica Monthly http://www.clinicaleviden Subscrip l Evidence updated directory ce.com tion required; of concise free access for overviews of UK and for common clinical developing interventions countries MEDL National http://www.nlm.nih.gov Free via INE Library of Internet Medicine database with citations back to 1966 Note: ACP, American College of Physicians; EBM, evidence-based medicine. Generally, the EBM tools listed in Table 3-3 provide access to research information in one of two forms. The first, primary research reports, is the original
peer-reviewed research work that is published in medical journals. Initial access to this information in an EBM search may be gained through MEDLINE, which provides access to a huge amount of data in abstract form. However, it is often difficult, using MEDLINE, to locate reports that are on point in a sea of irrelevant or unhelpful information and being reasonably certain that important reports have not been overlooked. The second form, systematic reviews, comprehensively summarizes the available evidence on a particular topic up to a certain date and provides the interpretation of the reviewer. Explicit criteria are used to find all the relevant scientific research and grade its quality. The prototype for this kind of resource is the Cochrane Database of Systematic Reviews. One of the key components of a systematic review is a meta-analysis. In the next two sections, we will review some of the major types of clinical research reports available in the literature and the process of aggregating those data into meta-analyses.