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                                                                                                                              What is evidence based medicine (EBM)?

Handoll and Smith [1] define EBM as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (p.251). Rosenberg and Donald [2] imply that this must be a systematic “finding, appraising, and using” of studies and trials (n.p.). Sackett et al. [3] state that the focus of EBM is to integrate “individual clinical expertise” with “the best external evidence” (n.p.) available from systematic research [4]. This means not to say that the traditional practice medicine is unreliable, because it lacks evidence or relies only on bad quality evidence, no, it is the thorough and rigid evidence that EBM demands that makes the difference. EBM looks at “evidence that matters” as White [4], (p.52) states.

Why do we need evidence based information?

Practitioners in the care of their patients will come across issues that exceed their present or most up-to-date knowledge of best practice or appropriate therapeutic handling. For clarification therefore, they may require to consult latest knowledge and research on a topic or issue to inform their practice [2]. The studying of information is a time consuming task, as it requires the consultation of vast amounts of literature, from which the qualitatively best papers and reports that have been rigidly conducted with minimal bias, have to be identified before they can be taken into consideration. This is a complicated process and is too time consuming for the busy practitioner running his surgery. For the patient too, who wishes to be well informed, about his condition or therapeutic approaches, qualitatively good information needs to be available and accessible [4].

What makes evidence-based medicine different?

EBM has sought to provide tools that summarize the information available from the vast amount of studies and trials on a specific topic. As such EBM stresses to identify those investigations that are of best quality, of rigid and thorough conduction, with the least possible of bias. These studies are then critically analyzed, and structurally summarized. This quality information is then made accessible for individuals that have no time to conduct investigations themselves, and may also, at times, not have the expertise to separate good research from bad [4].

How is evidence-based medicine presented?

Systematic reviews:

A systematic review is a structured summary of relevant evidence from research. It has a precise question that the data retrieved seeks to answer, and follows a systematic method in the process of searching for papers, selecting those of relevance and critically appraising the data from these studies. From the data that has been extracted then, a conclusive statement can be made concerning the review question [1].

Therefore a systematic review is structured as follows [1], [5]:

– There is a replicable protocol that describes and outlines the procedure to be undertaken in the process of the conduction of the review, and a predefined question that the systematic review seeks to answer and inform on.

– Step 1: It then follows a structured method of identifying studies that provide evidence for the issue investigated. Online databases provide access to published studies and trials.

– Step 2: It applies criteria for the inclusion and exclusion of trials and studies that are select for use in the review.

– Step 3: The quality of studies is then assessed using a predefined framework for the type of studies that are included. It is sought to identify bias in the individual studies. For the quality analysis of random-controlled trials the CONSORT statement may provide guidelines [9].

– Step 4: Data is then extracted and the results are combined.

– Step 5: Following the synthesis of data, a discussion and conclusion serve then to answer the review question.

Meta-analysis:

When the result from a systematic review requires statistical appraisal to synthesize the data from the included trials, a systematic review becomes a meta-analysis [1].

Where can we find EBM?

The conduction of any review presupposes that good quality trials and studies are accessible. Unfortunately the majority of research is published in journals that are available on databases that have subscription access only, or offer articles, studies and trials only pay per view. Unless therefore, the individual practitioner or patient is affiliated to an institution that has a subscription to electronic databases, he has to dispense the costly fees for publications privately. Google, with the Googlescholar search engine, provides a search option for research that can be found published on websites roaming the www. Yet, these are few, and rarely have a peer-reviewed status. There are however some open access databases, that make research available to the general public at no cost. The following are online open access databases:

Biomed Central – http://www.biomedcentral.com/

Directory of open access journals – http://www.doaj.org/

Medline via Pubmed – http://www.ncbi.nlm.nih.gov/pubmed?otool=wiuwiblib (some articles are available as open access)

Free medical journals – http://freemedicaljournals.com/

Oxford journals – http://database.oxfordjournals.org/ (some articles are available as open access)

None-the-less there is no guarantee that published studies on open access databases have been subject to peer-review verification. This can be checked by contacting the journal directly in which the study or trial has been published.

Peer-review in EBM

Peer review is a status and a criterion that EBM and consequently many of the electronic databases have for research they intend to publish. It is a quality verification whereby prior to publication, research is reviewed by experts to the topic or intervention investigated. The peer-reviewers evaluate methodology and study-design of trials, studies, reviews and analyses [6].

Why do we need EBM?

Evidence based medicine helps not only to inform practitioners and patients alike, improving care and practice, but, it may in its execution offer a means of evaluating the effectiveness of treatment approaches, and may consequently inform further research  [2],[6].

The problem with EBM in CAM

There are two aspects where EBM and CAM clash. The first is the opposition of standardization that is genuine to the conventional medical approach, and individualization that is fundamental to the philosophies of CAM practices. The second conflict is that of the tools used in the conduction of research. Whilst the RCT, the random-controlled trial, is the gold standard of conventional medicine; it is a tool that is inappropriate for investigations into the alternative, holistic treatment approaches. RCT´s fail to inform of the non-specific effects, the patients´ experience of the treatment approach [7].

There is much opposition from conventional practice concerning the question of the evidence base of CAM treatments, the notion to believe that the orthodox treatment approach is, and alternative treatment is not evidence-based, is incorrect [8]. The questions at hand are, what evidence is, who says what evidence is, and under what circumstances outcomes are considered as evidence [8]. This is and remains a controversial issue and is repeatedly subject of discussions.

References:

[1] Handoll, H. and Smith, A. (2003) How to perform a systematic review, article from Current Anaesthesia and Critical care last accessed December 2012 at URL http://www.sciencedirect.com

[2] Rosenberg, W. and Donald, A. (1995) Evidence based medicine: an approach to clinical problem-solving, article from BMJ last accessed December 2012 at URL http://www.bmj.com

[3] Sackett, D., Rosenberg, W., Gray, J., Haynes, R., and Richardson, W. (1996) Evidence based medicine: what it is and what it isn`t, article from BMJ last accessed December 2012 at URL http://www.bmj.com

[4] White, B. (2004) Making evidence-based medicine doable in everyday practice, article from Family practice management last accessed December 2012 at URL http://www.aafp.com/fpm

[5] Hemingway, P. and Brereton, N. (2009) What is a systematic review?, article from Hayward Medical Communications  last accessed December 2012 at URL http://www.whatisseries.co.uk

[6] Manheimer, A. and Berman, B. (2005) Exploring, evaluating, and applying the results of systematic reviews to CAM therapies, article from EXPLORE last accessed December 2012 at URL http://www.biomedsearch.com

[7] Yamey, G. (2000) Can complementary medicine be evidence-based?, article from West J Med last accessed December 2012 at URL http://www.ncbi.nlm.nih.gov

[8] Walach, H. (2009) The campaign against CAM and the notion of “evidence-based”, article from The Journal of Alternative and complementary medicine last accessed December 2012 at URL http://www.ehis.ebscohost.com

[9] Schulz KF, Altman DG, Moher D, for the CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. Trials 2010, 11:32. (24 March 2010)

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