Evidence-based medicine

It's been a catchphrase in health care for three decades; now evidence-based medicine is becoming an imperative for hospitals thanks to increasing pressure from regulators and payers. But uncertainty surrounds the concept. What specifically constitutes EBM? Whose definition prevails? And how do you decide where in your hospital it should be a priority?     

Evidence-based laboratory medicine

Patients and society expect physicians to base their approach to any type of clinical problem on informed diagnostic reasoning. Informed diagnostics means that clinicians understand and readily apply the principles of diagnostic decision making, which include an estimate of the pre-test probability (prevalence) of diseases and information about the characteristics and discriminatory power of the applied investigations. Despite the crucial importance of the appropriate use of diagnostic tools in clinical decision-making, many diagnostic tests have not been subjected to rigorous evaluation to establish the diagnostic accuracy and clinical utility of laboratory investigations using modern standards of clinical epidemiology. The lack of good quality research in the field not only contributes to inappropriate utilization of laboratory services but also to wasting significant resources. Evidence-based laboratory medicine tries to combat this problem by combining methods from epidemiology, biostatistics, clinical and social sciences with basic sciences to evaluate the role of investigations in clinical decision making and outcomes for patients. Evidence-based laboratory medicine aims to advance clinical diagnosis and management of diseases through systematic researching and disseminating generalisable new knowledge which meets the standards of critical review on clinically effective practice of laboratory investigations. The main phases of practicing evidence-based laboratory medicine are 1. question formulation, 2. systematic literature search, 3. critical appraisal of literature, 4. implementation of evidence into practice, and 5. evaluation of impact in a clinical audit cycle. The use of evidence in laboratory medicine requires systematically compiled databases of standardised and critically appraised information on the test characteristics and diagnostic accuracy of laboratory investigations. Such an approach is the Bayes Library that provides information on the global and specific measures of test performance in different patient groups and settings, in addition to prevalence data of common diseases. The Bayes Library will support informed diagnostic decisions and improve patient outcome by integrating evidence-based medicine into the diagnostic service, education and training of laboratories. The process of constant questioning and reviewing the evidence for rational diagnosis of diseases provides a practical tool to identify gaps in our knowledge and thus it generates new research ideas in laboratory medicine.     

Evidence-based medicine and cost-effectiveness

Most available medical management techniques compare the practice patterns of providers with other providers but overlook the inherent value of interventional medical therapies to patients and society. The authors present a methodology for objectively evaluating the quality and cost-effectiveness of medical interventional therapies, and comparing them to each other using the common denominator of cost per quality-adjusted life-year ($/QALY). Advantages of this methodology include the fact that it: (1) compares the cost-effectiveness of different treatment regimens, (2) incorporates patient preferences, (3) employs evidenced-based medical data, information that is most reliable and reproducible, (4) factors in the effect of treatment on the quality of life and length of life, (5) offers an evaluation of the clinical efficacy of a treatment, (6) identifies both superior and marginal treatments, (7) maximizes the effective use of scarce resources, and (8) simplifies the understanding of health care procedures for consumers, payers, and providers.     

Evidence-based medicine grows up

By strategically addressing the challenges and user requirements of EBM, healthcare organizations can implement EBM systems that leverage their existing clinical investments and garner fast clinician adoption.     

Evidence-based medicine as Bayesian decision-making

We review two recent trends: the emergence of evidence-based medicine and the growing use of Bayesian statistics in medical applications. Evidence-based medicine requires an integrated assessment of the available evidence, and associated uncertainty, but there is also an emphasis on decision-making, for individual patients, or at other points in the health-care system. This demands consideration of the values and costs associated with potential outcomes. We argue that the natural statistical framework for evidence-based medicine is a Bayesian approach to decision-making that incorporates an integrated summary of the available evidence and associated uncertainty with assessment of utilities. We outline a practical agenda for further development.     

循证医学与职业卫生实践

在过去的十余年里 ,循证医学 (evidence basedmedicine)正在逐渐成为一种被广泛接受的连接医学研究和医学实践的有效方法。与之相似 ,循证医学的原则和思想也逐渐渗透到职业医学领域。本文拟在介绍循证医学基本概念的基础上 ,尝试对循证医学原则和方法在职业卫生实践中的应用进行回顾 ,并讨论其应用前景。一、循证医学与循证实践循证医学是指最佳证据、临床经验和患者价值取向三者的有机结合 ,亦即在医学决策的制定过程中仅仅依靠经验是不够的 ,应当基于当前最佳的科学研究成果 ,并且充分考虑患者的选择、关注和期望 ,做出的循证临床决策。…