Evidence-Based Medicine (EBM) Overview

Why Evidence-Based Medicine (EBM) Matters

• Clinical decision-making is complex with shades of gray, not black and white, due to patient differences like comorbidities, lifestyle, medication costs, adherence, and preferences for alternative therapies.
• The goal is to make the optimal decision using the best available evidence, prioritizing patient safety and avoiding harm from incomplete or poor evidence.
• Clinicians and researchers generate a lot of information daily, and it is essential to evaluate evidence using the EBM framework.
• EBM is fundamental throughout the pharmacy program and career.

Defining EBM

• Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
• EBM needs training to be used conscientiously, explicitly, and judiciously.
• "Current best evidence" means relevant evidence, even if old.
• EBM is not solely for evidence's sake; it focuses on applying evidence to individual patient care.
• Similar courses on evidence-based practice are taken by many healthcare professionals.
• EBM emphasizes that the best evidence should inform clinical decision-making.

Alternative Definition of EBM/EBP

• Evidence-based practice integrates the best research evidence with clinical expertise and patient values.
• EBM considers clinically relevant research, clinical expertise, and patient values/preferences.
• Clinical expertise comes from experience.
• Patient values and preferences are unique to each patient.
• EBM requires the balance of all three components.

Types of Evidence

• EBM uses the best external evidence to answer a clinical question.
• Although higher levels of evidence are preferred, lower levels of evidence can be used if it's the best available.
• EBM considers the entire spectrum of evidence found in the literature.

Steps for Applying EBM Framework

• Each step begins with the letter A.
• Step 1: Asking
  • Ask an appropriate and answerable question.
  • If this step is not done properly, every other step is pointless.
  • The PICOT framework helps generate an answerable clinical question.
  • Clarifying drug information questions to address the patient's needs is critical.
• Step 2: Acquiring
  • Develop a search strategy for evidence using databases like PubMed or Google Scholar.
• Step 3: Appraising
  • Critically evaluate the relevance and value of the literature found.
• Step 4: Applying
  • Apply the appraisal of the evidence to solving a specific patient's problem.
• Step 5: Assessing
  • Assess whether the application of evidence led to better patient outcomes and quality improvement.

Review of Major Points

• The process starts with a patient experiencing a clinical problem.
• This leads the clinician to ask a question that must be answerable and appropriate to the patient's clinical presentation.
• EBM includes medical literature, healthcare providers' expertise, and patient preferences.
• EBM leads to safer care, better patient outcomes, and lower healthcare costs.

Brief History of EBM

• Previously, physicians based decisions on clinical experience, relying on an apprentice model.
• In the early 19th century, animal models helped understand pharmaceuticals' efficacy and safety.
• In the mid-1800s, the numerical method involved using small human trials.
• The experimental evidence phase uses formal research questions, developing hypotheses, and hypothesis testing.
• The terms evidence-based medicine and evidence-based practice emerged in the early 1990s, integrating evidence with clinical expertise and patient values.
• Gordon Guyatt coined the term EBM in the early 1990s.
• Sackett published the widely accepted definition in 1996.

Misconceptions About EBM

• EBM is not "cookbook medicine" but more "guideline-driven".
• EBM is based on the best available evidence, appraising evidence for its validity.
• High-quality evidence can be based on surrogate outcomes.
• EBM's direct goal is to enhance quality.
• EBM does not require extensive resources.

Barriers to Implementing EBM

• Some healthcare systems implement guidelines dogmatically, but many allow for deviation through consultation.
• EBM can be corrupted by biased promotional practices, so clinicians should not rely on potentially biased data.
• There is often too much evidence with too little time to practice good EBM; there is a need to find efficient ways to evaluate evidence.
• Clinicians may not be familiar with EBM concepts and practices.
• There is no or incomplete or conflicting evidence for many clinical questions, requiring clinicians to extrapolate existing evidence with caution.
• Clinicians can learn to use their clinical training to extrapolate existing evidence to their patient's situation and understand the limitations of doing so.