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Importance of Evidenced-Based Healthcare for Decision-Making

By Charyse Magdangal"Pharm Doin' Harm" CC Huy Phan

The world of healthcare is in a constant state of flux.  Every year, thousands of peer-reviewed medical articles are published with new findings, and more innovative technologies for screening and treatment are created.  With all of this change, it is imperative that physicians are constantly challenging their practice and their patients are investigative regarding their care. However, there is often a gap between effective research and its implementation in physician and clinical practice, and because of this, there are considerable variations between clinical practices.  As more and more choices in regards to screening, medications, tests, and treatments for serving patients become available, Dr. Mark Ebell, professor of Epidemiology and Biostatistics at the University of Georgia, says that “many physicians fall back on what they learned in medical school or what experts said” (personal communication, April 28, 2015).  Nonetheless, optimal health care means making smart, informed decisions about preventive care such as screening, counseling preventive medicine, tests and treatments.

Evidence-based medicine is the idea that we must use the best available scientific evidence in conjunction with patient values and preferences to select the most effective treatment options for them.

Evidence-based medicine (EBM) is necessary to close this gap between effective research and implementation. Evidence-based medicine is the idea that we must use the best available scientific evidence in conjunction with patient values and preferences to select the most effective treatment options for them.  It evaluates the benefits and harms of various medical interventions for decision-making. It answers the questions: “Does it make you live better? Does it make you live longer? Do the findings matter?” Evidence-based medicine is a framework for how we look at new knowledge and old knowledge and evaluate what is correct, valid or true. Essentially, its goal is to provide a “stronger scientific foundation for clinical work, to achieve consistency, efficiency, effectiveness, quality, and safety in medical care” (Timmermans & Mauck, 2005). In order to utilize EBM, it is essential to understand how it differs from scientific medicine, why it is important to decision making for both physicians and patients, how it is used in healthcare policy in the United States and its limitations.

There is a broad category of Medicine Based on Science, and EBM is a subset of that category. Both of them utilize studies and experimentation.  Specifically, medicine based on science utilizes trials and experimentation for its findings while EBM evaluates this information based on the content, the procedure of the experiment and the conclusions. Between Observational Studies and Randomized Control Clinical Trials, EBM typically employs the latter.

In EBM, Randomized Control Clinical Trials, studies where people are placed at random to receive one of several clinical interventions (Jadad, 1998), are of highest evidence. This is because randomization helps evenly distribute the variables between treatment and control groups, allowing the investigator to “conclude that the intervention causes the outcome of interest” (Hughes, 2011).  Observational studies often lack randomization, and usually the studies conclude that a factor is merely associated with a risk. It is important to note that this generalization has its limitations as observational studies may consist of quality evidence while randomized control trials may not.  Essentially, the usage of Randomized Control Clinical Trials in EBM allows for definitive studies which can be utilized for decision-making in clinical care.

Observational studies often lack randomization, and usually the studies conclude that a factor is merely associated with a risk.

Another way EBM assists in decision-making, is that it narrows down studies that are relevant and important.  Many studies measure outcomes that are not substantial for patients, because “a lot of science is premature when you try to apply it to real life and living patients” (M. Ebell, personal communication, April 28, 2015).  That being said, these studies are not necessarily irrelevant.  They may be steps along the way, and possibly in 10 to 15 years from now they can lead to a change in what physicians do for patients.

After considering which studies are pertinent to real-world clinical practice, it is important that physicians know how to apply evidence-based practice to optimize decision-making. One method for application deals with how doctors keep up with information.  Physicians can remain up-to-date through visiting websites that are centered on EBM. These sites often have medical guidelines, present background information on the issue, review questions and studies, identify key results, discuss the quality of evidence and delineate final conclusions.  Such sites include:

  •  NICE guidelines from the United Kingdom (Find Guidance)
  •  Guidelines.gov (an agency which doesn’t develop guidelines, but finds information and consolidates it)
  • Cochrane collaboration (an international collaboration with thousands of physicians and scientists that do systematic reviews to answer important medical questions) (Home).
  • US Preventive Services Task Force (Home, 2015)

One of the most relevant sources to the United States is the US Preventive Services Task Force. The Task Force “works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications” (Home, 2015). Their suggestions are based upon a rigorous review of peer-reviewed evidence and are intended to help clinicians and their patients decide  whether a preventive service is most beneficial for a patient’s needs. Each recommendation is assigned a letter grade  (A,B,C, or D) based on the strength of the evidence “and the balance of benefits and harms of a preventive service”.

This is necessary, because there are thousands of studies published every year, and a doctor cannot read all of them and “Should ignore most of [those not relevant to patient care].

Physicians who subscribe to the Task Force’s service receive 20-30 summaries of real-world, clinically relevant peer reviewed medical journals every month.  This is necessary, because there are thousands of studies published every year, and a doctor cannot read all of them and “Should ignore most of [those not relevant to patient care]. If you did what the article found, it would improve how long or how well your patient lives.  We call that patient-oriented evidence that matters” (M. Ebell, personal communication, April 28, 2015). EBM and sites like the US Preventive Services Task Force help those in the healthcare profession pay attention to studies that matter most.

Although these resources are available, implementing evidence-based practice in all medical specialties within the United States has been a slow start as a result physician hesitation and the lack of national standardized practice guidelines  (Timmermans & Mauck, 2005). The US does not have a single set of national guidelines for healthcare (M. Ebell, personal communication, April 28, 2015).  “Many countries such as the British and Germans do that.” Ebell says specialist clinicians who did not like the message of EBM prevented the nationalization of guidelines at the federal level back in the 1980’s and 1990’s by shutting down the government agency involved.

While about 30 years have passed, EBM and nationalized guidelines in the US have not made much headway. Some physicians may view EBM as a threat to their autonomy, because it is often misunderstood as  “cookbook medicine”, uniform medicine without variations in practice. Physicians’ resistance to using EBM is rooted in the traditional professional perspective of the clinician as sole decisionmaker (Timmermans & Mauck, 2005).  Instead of viewing EBM as cookbook medicine and a risk to physician practice, Ebell thinks that it is all about physicians having the attitude to question his/her practice, to say, “I wonder if this is still the correct and the best way to manage this problem” (personal communication, April 28, 2015).  With this questioning attitude, those in clinical care can find evidence that leads to the best course of action that results in changes in practice.

Instead of viewing EBM as cookbook medicine and a risk to physician practice, Ebell thinks that it is all about physicians having the attitude to question his/her practice

Despite encouragement for changes in attitude, many physicians may still be resistant to change. In order to solve this issue, many medical schools’ current goals are to teach medical school students humility and that they are not always correct.  As medicine continues to change, what is taught now will be wrong many years from now. For upcoming physicians and current physicians, it is necessary to always ask questions to ensure that optimal health care is always provided.

Even with EBM’s slow proliferation through the United State’s medical world, evidence-based practice is becoming more and more prevalent in Primary Care.  Primary Care includes Family Medicine, General Internal Medicine and Pediatrics.  These specialties have embraced EBM earlier than others because they encompass a breadth of knowledge, and evidence-based practice helps many primary care specialists make sense of that knowledge.  As such, EBM is gradually being adopted by other specialties such as cardiology and gynecology.

Patients can also use the United States Preventive Services Task Force website and the others previously listed to answer questions regarding screening tests and preventive services.

Physicians are not the only ones who can employ EBM. We are all patients at some point in our lives, and we need to be active in the decision-making of our care.  Patients must ask the questions: “Is that finding applicable to me? Does that really benefit me? Is it necessary for my health? Am I at high risk or low risk?”  Patients can also use the United States Preventive Services Task Force website and the others previously listed to answer questions regarding screening tests and preventive services. For example, someone may want to know what cancer he/she should screen for and what age is the best time to start screening.  This person can look through the various websites, find the recommendations for screening and prevention and discuss the grade A and grade B preventive services with his/her doctor. When patients diligently involve themselves with their health care, they can find the best services for their medical concerns.

Ultimately, healthcare policy in the US is transitioning to utilizing evidence-based practice as it provides a scientific basis for the construction of health policy as opposed to relying on the opinions of interested parties. The Affordable Care Act attempts to rectify the gap between studies and applicable clinical knowledge by “funding comparative-effectiveness research, which uses data from clinical trials and real-world treatment settings to determine which health care practices are the most effective” (Ho, 2013). Inclusively, the Affordable Care Act says that anything recommended by USPSTF on the A or B grade will be covered without copay from insurance. For instance, if you have a high risk for breast cancer, screening is covered. Another example is that if you are 50 years old and need a colonoscopy, you are covered (M. Ebell, personal communication, April 28, 2015).

Inclusively, the Affordable Care Act says that anything recommended by USPSTF on the A or B grade will be covered without copay from insurance.

The Task Force also assists in health policy by creating a report to Congress that establishes critical evidence gaps in research related to clinical preventive services and recommends priority areas that deserve further examination (Home, 2015).  This allows policy makers in Congress to focus on funding information that is most beneficial to the public. With this in mind, the actual intention of EBM is not to save money. However, it results in saving money as people are not unnecessarily undergoing treatment. Policy makers are attracted to this idea of EBM, because it provides care more efficiently.

Evidence-based medicine is not without its struggles.  There is always push-back when medical care has been done a certain way for a long time. When there is change in care due to “faulty research”, patients begin to distrust the medical system and physicians. Also, many physicians are reluctant to make changes in practices that they think are true. Another problem is that recommendations for treatment are more complicated as care is more individualized.  There are many distinctive characteristics for each individual, and EBM attempts to identify who is at risk from what.

To demonstrate, many Primary Care providers administered Pap Smear tests (a test for cervical cancer) starting when a female turned 18 and was done once a year. Because of EBM, physicians have a greater understanding of how cervical cancer works  (personal communication, April 28, 2015).  Thus, Paps are now done starting at 21 and are redone every three to five years.  Becoming more complicated as more factors are taken into consideration, Paps can be administered every five years after 30 years old with an HPV test, and then the woman may stop at 65.  As can be seen, age, sex, ethnicity, other medical conditions, and a myriad of aspects influence the complexity of an individual’s care.

The most difficult part is determining what medical conditions are more benign and which are more malignant.

Finally, the last challenge to EBM is discovering that some conditions are better left untreated. The most difficult part is determining what medical conditions are more benign and which are more malignant. To illustrate, physicians are learning that some cancers do not need to be treated.  Without a screening test, the person would have never known they had cancer and would have lived for 40 years and died of another cause. When patients are screened for cancer and it is found, it is often met with aggressive treatment.  Yet, some cancers such as prostate cancer and breast cancer are over diagnosed. Patients with those overdiagnosed cancers unnecessarily underwent aggressive treatment. Over-screening and doing unnecessary preventions can harm the patient. Those in EBM are trying to figure out “which ones would have bothered the person and which ones wouldn’t have” (M. Ebell, personal communication, April 28, 2015).

All things considered, evidence-based medicine promises to build better-informed physicians and patients by “offering collectively agreed-upon and publicly accessible information” in regards to treatment (Timmermans & Mauck, 2005).  Using EBM, Physicians  need to scrutinize their practice and continually explore ways to help their patients live better and live longer. Also, Patients need to be involved in their healthcare by actively searching for applicable preventive services, integrating those services with their values and making informed decisions. Evidence-based medicine is a necessary tool in both clinician practice and healthcare policy, and as more medical phenomena is being understood, it is imperative that those involved in healthcare in the United States is able to integrate that knowledge into medical practice for optimized decision-making.

References

Find guidance (Guidance). Retrieved July 1, 2015, from https://www.nice.org.uk/guidance

Ho, V. (2013, January 10). Using Comparative-Effectiveness Research to Improve Care. Retrieved July 1, 2015, from http://www.hhnmag.com/Daily/2013/Jan/ho011013-5480008802

Home. The Cochrane Foundation. Retrieved July 1, 2015, from http://www.cochrane.org/about-us

Home. (April 2015). U.S. Preventive Services Task Force. Retrieved July 1, 2015 from

http://www.uspreventiveservicestaskforce.org/Page/Name/home

Hughes, G. (July 18, 2011). Evidence-Based Medicine in Health Care Reform. Retrieved July 1, 2015, from http://oto.sagepub.com/content/145/4/526.long

Jadad, AR. (1998). Randomised controlled trials: a user’s guide. Retrieved July 1, 2015, from                   http://www1.cgmh.org.tw/intr/intr5/c6700/obgyn/f/randomized%20tial/chapter1.hml

Timmermans, S., & Mauck, A. (2005). The Promises And Pitfalls Of Evidence-Based Medicine. Health Affairs, 18-28.