 aylor Health Care System has
always been dedicated to providing the highest quality
health care. As we enter the next millennium, new ideas
and strategies for health care improvement continue to be
explored. Evidence-based medicine (EBM) is a concept that
is being emphasized to improve patient care.
Physicians have typically
practiced medicine under the guise of “traditional
care.” This usually involves basing decisions on the
current standard of practice, which relies on colleagues,
panels of experts, and other groups of decision makers.
Decisions based on habits should be replaced with
decisions based on objective research, which provides a
scientific basis for treatment choices.
Today, there is a clear
trend towards the use of EBM, in which clinical science
helps the practicing physician formulate treatment plans.
Of course, this does not mean that practicing medicine
will be a more simplistic endeavor. Judgment based upon a
patient's unique circumstances always plays a role in any
decision. In actuality, EBM should be used as a guide in
formulating treatment decisions and must never be
automatically accepted. The prudent physician should
carefully weigh sound evidence as it relates to a
particular scenario, incorporate the data as appropriate
given the myriad variables involved, and discuss the
information openly with the patient to make decisions
together on a particular treatment. Shared decision
making becomes an integral part of this process.
An overwhelming amount of
information is available to both patients and physicians.
Interpreting scientific data can be a formidable chore
that discourages objective, critical appraisals of the
literature. Trying to discern what constitutes the latest
evidence in a particular subject can be challenging.
In an attempt to promote
an efficient, timely search of the literature, I provide
a list of sources to help the clinician wade through the
clutter of information to make the best possible
treatment decisions. Most sources are on the Internet, as
this is the easiest way to acquire pertinent information
quickly. However, the Internet can provide its share of
frustration, particularly with general Web searches,
which frequently provide useless information. Many
medical-based Web sites do not provide the data we seek
or at best are of inconsistent quality.
Some “jewels”
do exist, which have been found to help the clinician
find the relevant data needed to practice EBM. These Web
sites have been recommended through the help of Group
Health Cooperative of Puget Sound (Washington), regarded
as a world leader in EBM. The following sites have a
common approach to acquiring, critically appraising, and
integrating information for day-to-day practice.
WEB-BASED RESOURCES
FOR OBTAINING EVIDENCE
1. The Cochrane
Library: http://updateusa.com/clibpw/clib.htm
The Cochrane Library is a
worldwide effort to make available critically appraised
randomized controlled trials. Many studies are included
in meta-analyses. The library makes use of information
from a number of sources, including published reports
available from databases such as MEDLINE as well as
unpublished data. A password is required.
2. Bandolier: http://www.jr2.ox.ac.uk/Bandolier
Oxford has produced this
monthly journal since 1994. Bandolier has a specialist
subsite index and presents bullet points of EBM.
3. Nation's Health
Service [UK] Centre for Reviews and Dissemination: http://nhscrd.york.ac.uk/welcome.html
This site allows search
of 2 publicly available databases of structured
abstracts: the Database of Abstracts of Reviews of
Effectiveness (DARE) and the NHS Economic Evaluation
Database (NEED). It is especially helpful for developers
of clinical guidelines.
4. Centre for Research
Support: http://www.ceres.uwcm.ac.uk/frameset.cfm?section=trip
This Web site contains
the TRIP database, which allows simultaneous searching of
26 databases of hyperlinks from evidence-based sites
worldwide. At present there are >10,000 links
to evidence-based topics and >4000 reviews. This Web
site is an excellent way to find critical systematic
reviews as well as appraisals of individual studies.
5. ACP journal club: http://www.acponline.org/journals/acpjc/jcmenu.htm
Through this site, the
user has access to recent studies and reviews that
warrant immediate attention. The club reviews >100
journals, selects articles according to certain criteria,
provides a structured abstract for them, and adds a
commentary by a clinical expert.
6. UpToDate: http://www.uptodate.com
UpToDate is a clinical
reference tool for internal medicine generalists and
subspecialists. It offers thousands of original topic
reviews written by experts. Each review provides detailed
recommendations.
7. Clinical Evidence: http://www.clinicalevidence.org
The text version of Clinical
Evidence has recently been made available to Baylor
physicians, and print subscribers have access to the
online version as well. Clinical Evidence
summarizes evidence for a variety of clinical conditions.
This user-friendly, practical resource is updated twice a
year. It uses explicit methodology for selecting which
evidence to summarize, identifies gaps in the evidence,
and balances the benefits and harms of a particular
intervention.
8. Traditional
databases organizing the medical literature (e.g.,
MEDLINE)
To use traditional
databases effectively, the clinical team poses questions
and works closely with a librarian to refine search
strategies and decide what databases to search. This
approach requires critical appraisal before application
to clinical practice. Two sites are used most frequently
for searching:
Grateful Med: http://igm.nlm.nih.gov/ This traditional access for
MEDLINE is versatile, but assistance is frequently needed
in addressing specific questions.
PubMed: http://www4.ncbi.nlm.nih.gov/PubMed/clinical.html This improved access to MEDLINE
includes filters to search for answers to specific
clinical questions--i.e., information about diagnosis,
etiology, prognosis, and therapy.
WEB-BASED RESOURCES
THAT SUPPORT EBM PRACTICE AND SKILLS
1. Nation's Health
Service [UK] Centre for Evidence-Based Medicine: http://cebm.jr2.ox.ac.uk/
This center in Oxford
promotes EBM and supports anyone who wants to make use of
it. The toolbox feature on the site is particularly
helpful; it provides resources such as a glossary of EBM
terms and a description of levels of evidence as well as
assistance in applying calculations such as pretest
probabilities and likelihood ratios. Overall, this site
is considered excellent.
2. User's guide to the
medical literature: http://www.cche.net/principles/
This site features the
entire JAMA series on evaluating the medical
literature. It has links to tools for improving EBM
skills and describes approaches to critically appraising
the literature.
3. New Zealand
Guidelines Group--tools for guideline development: http://www.nzgg.org.nz/tools.cfm
This page explains the
steps involved in developing clinical guidelines. It also
has links to pages that discuss development of guideline
teams, the benefits of developing new guidelines vs
evaluating and adapting existing guidelines, and
resources for critical appraisal.
THE FUTURE: PATIENT
CARE SITES THAT PRESENT EVIDENCE
Web sites directed to
patients that list evidence-based recommendations for a
particular condition are beginning to emerge. This is the
future of health care, as influenced by EBM and shared
physician-patient decision making. The best example is
the University of California San Diego mammography site
(http://mammography.ucsf.edu/inform/index.cfm), which
provides women with quantitative information about the
benefits, harms, and uncertainties of mammography.
The role of EBM in
shaping the drive towards a more informed patient and
towards shared decision making with physicians is quite
profound. As clinicians we must be able to adapt to these
important changes since society demands that we do so.
This will shift the focus away from a paternalistic
relationship with patients towards a partnership. The
physician is now a team leader, coordinator, teacher, and
navigator. Patients develop a greater sense of
involvement in and responsibility for their treatment.
Objectively improved patient outcomes and an enhanced
sense of satisfaction for both patient and physician are
the ultimate results.
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