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Evidence-Based Medicine Introduction


Welcome to the Evidence Based Practice Course
sponsored by the UIC Library of the Health Sciences. The story of evidence based medicine started
in the 1970s with a group of clinical epidemiologists at McMaster University, led by David Sackett
and Brian Haynes, who published a series of articles advising clinicians on how to read
clinical journals. This series on critical appraisal appeared
in the Canadian Medical Association journal in 1980. The term EBM first appeared in print in 1991
in the ACP Journal Club. The term was coined by Gordon Guyatt, who
was the internal medicine residency director at McMaster, where he and Sackett introduced
the concept of EBM as both a philosophy of medical practice and medical education. The McMaster group eventually linked up with
other physicians to form the first EBM Working Group. This group produced a new series of articles
to promote a more practical approach to applying the medical literature to clinical practice. This twenty-five (25) part series, called the Users’ Guide
to the Medical Literature, was first published in JAMA and later as a book. One of the enduring definitions of EBM comes
from the book Evidence Based Medicine: How to Practice and Teach EBM, now a classic text
which has gone through several editions. Sackett, et.al. defined EBM as “the integration
of best research evidence with clinical expertise and patient values.” This definition clearly emphasizes that what
we learn from the research reported in the medical literature is only one third of the
picture. Just as important is the clinical experience
of the health professional and the preferences of the individual patient. It wasn’t long until other health practitioners
began to realize that the principles of EBM were equally applicable to nurses, dentists,
and others. Terms such as Evidence-Based Health Care and
Evidence-Based Practice are more appropriate to cover the whole spectrum, but EBM seems
to have stuck as the generic term used to describe the process. EBM became a MeSH term in 1997, and it wasn’t
until 2009 that other EBP terms were introduced. The EBM process is described in five (5) steps,
which involves 1. Converting information needs into focused
clinical questions. 2. Efficiently tracking down the best evidence with which to answer the question. 3. Critically appraising the evidence for validity
and clinical usefulness. 4. Applying the results in clinical practice. and 5. Evaluating performance of the evidence in
clinical application. During this course, we will be examining the
elements of these five (5) steps and focusing on the skills needed for the first three (3)
steps of the process. Another definition from the EBM Working Group
concentrated on EBM as an education process as well as a patient care process. This definition describes EBM as a “life-long,
self-directed learning” process in which the clinician uses information to solve clinical
problems in practice. EBM was born out of the demands of a changing
health information environment. From 1957 to 1963, the NIH budget increased by
an average of forty percent (40%) annually resulting in an explosion of medical knowledge
and article publication. At the same time, technological capabilities
were expanding which made possible vast searchable databases, and the National Library of Medicine
created MEDLINE to provide better access to the medical literature and to help health
practitioners deal with the overload of new clinical information. In the 1950s, a medical student might graduate
knowing perhaps eighty percent (80%) of what there was to know. Now, graduates might know forty percent (40%),
half of which will probably be out of date in just ten (10) years. Alper, et. al, found that to keep up with the
estimated seven thousand (7,000) articles published monthly in primary care it would take a physician
twenty-nine (29) hours per workday or the equivalent of three point six (3.6) FTE of
physician effort. Studies have shown that it takes an average
of seventeen (17) years to implement clinical research studies fully into general practice. Reducing the time and effort that it takes
research to translate into practice is one of the goals, or outcomes, of EBP. While a 1988 study showed that patients with
acute MI who were treated with streptokinase AND an aspirin had significantly less mortality,
we find a 1999 study which found that patients presenting to an ER with MI only fifty-five
percent (55%) received aspirin. So even when high quality, relevant evidence
exists, it can remain invisible. A newer definition in the evolution of EBM
refers specifically to the role of technology. In the mid-1990s, PubMed became freely available
on the Internet. This free access to the database gave more
health professionals than ever exposure to a vast array of medical literature. Now that many medical libraries offer online,
full-text access to journal articles, health professionals have immediate access to much
of the world’s medical literature. This has truly produced information overload, along with the expectation that every health professional
should be up to date on any medical problem that comes along. Yet we know that some clinicians don’t regularly
consult the literature. What is the biggest barrier? – time. These two (2) elements information explosion
and lack of time has led to some EBM by-products or tools that attempt to provide synthesized
and evaluated summaries of clinically relevant studies at the highest levels of evidence. These tools include systematic reviews, meta-analyses,
clinically focused search strategies, and specialized databases. We will be learning more about these tools
later in the course. In addition to McMaster University in Canada,
other important early leaders were and continue to be active in EBP efforts. These include the Agency for Healthcare Research
and Quality in the United States and the Centre for Evidence Based Medicine in the United
Kingdom. Today the AHRQ has fourteen (14) designated
EBP centers. The charge of these centers is to synthesize
scientific evidence to improve quality and effectiveness in healthcare. The websites of these organizations, especially
the CEBM, offer a wealth of resources and tools, many of which we will introduce in this
course. In closing, let’s address the misconception
that EBP is just about statistics and algorithms. In reality, EBP begins and ends with the individual
clinician treating the individual patient. The clinician extracts the information from
the study, evaluates the findings of the study in the context of his or her clinical judgement,
and finally considers the needs of the individual patient in deciding how to apply the evidence. This concludes this presentation.

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