Evidence-based medicine
Evidence-based medicine (EBM, of English evidence-based medicine " based on empirical evidence medicine " ) is a recent trend in medicine that raises an explicit requirement that in medical treatment made patient-oriented decisions as possible, on the basis of empirically proven efficacy should be.
The term was coined in the early 1990s by Gordon Guyatt from the group led by David Sackett at McMaster University, Hamilton, Canada, Department of Clinical Epidemiology and Biostatistics in the. In German-speaking countries was published about the concept for the first time in 1995, with the author in the transfer to the German succumbed to a false friend: While evidence in English depending on the context the meanings of proof ',' evidence ',' Note 'or' testimony ' has is the importance of evidence in the German obviousness (which needs no proof ) (English: obviousness ). Therefore, it was proposed to use in German the term evidence-based medicine, but this has not enforced. In 2000 (§ § 137e, 137f, 137g, 266 SGB V, structured treatment programs for chronic diseases) were " evidence-based guidelines " in the German Social Code introduced.
Definition and Application
Defines evidence-based medicine (EBM or EBM) is originally known as the " conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." EBM is therefore based on the respective current status of clinical medicine based on clinical studies and medical publications that substantiate or disprove a fact - the so-called external evidence.
In clinical practice of EBM, this means integrating individual clinical expertise with the best available external evidence from systematic research; it also includes the patient's preference with a.
EBM may also include the abandonment of therapy, that is, to know when no therapy ( offer / suggest ) is better for the patient than the offering / proposing a specific therapy. A frequently cited example is prostate cancer in elderly men: Depending on your age, life expectancy and the development stage of the cancer is often the non- treat the best decision.
On this evidence-based individual decision for the individual patient (English Evidence-based individual decision, EBID ) building, the term EBM also in the so-called evidence-based health care (English Evidence-Based Health Care - EBHC ) is used. Here, the principles of EBM be applied to organizational and institutional level, that is, a treatment recommendation is not determined for individual patients, but for a group of patients or an entire population; from the results of the research treatment recommendations, guidelines, policies or regulations are derived. EBHC can be applied in all areas of health care; on their findings and decisions to control the health care system can be based.
Method
Evidence-based medicine asks the doctor not only clinical expertise ( ie knowledge at the bedside ), but also the knowledge of how he, the results of recent scientific research appropriates, how he interprets and applies them. Expertise is also required in the conversation with the patient, especially in the discussion of possible risks and benefits of the various diagnostic and treatment options. The aim should be an informed consent.
The implementation of EBM into practice means integrating individual clinical expertise with the best external evidence from systematic research in a multi-stage process. Here is a relevant, answerable question is derived from the clinical case. Based on this question is performed research in the medical literature. The researched literature must now critically with respect to their validity and usefulness are measured (evidence ). It is followed by the application of selected evidence and rated the individual case.
All these steps require the exercise, in particular the literature and their assessment. However, since the entire medical knowledge is currently doubling every five years, even the experienced physician is increasingly overwhelmed, which determine for him Significant in the fullness of the load and the resulting knowledge. Remedy try here EBM - oriented organizations looking through systematic evidence search and appraisal of relevant, often questions specific solutions, so as to make the availability of results from clinical research into practical everyday life simpler and more transparent.
So, instead of taking as in the classical approach of EBM recourse to the original article ( the primary literature ), secondary literature and systematic reviews are here made by the physician in which the rating was already taken by EBM criteria. The objective here is the synthesis of all relevant articles from the primary literature, so that the search for practical everyday life can be possible to save time and specific. These review articles are the basis for so-called health technology assessments (HTA to German: Technology Assessment in Medicine ) and for evidence-based guidelines. One of the most important organizations for the creation of such systematic reviews is the Cochrane Collaboration.
Thus, EBM is itself a young, evolving science is with the aim to evaluate the quality of published medical data and thus to improve. The EBM is not concerned itself with the conduct of clinical studies, but with the systematic exploitation of its results. EBM criteria following - - To go by the evidence for recommendation, have been developed different classification systems. The external evidence after evidence validity in classes is hierarchically organized, which include not only the quality of the individual studies the totality of the evidence to a question. Other classification systems extended the evidence hierarchy to the needs of different issues, consideration of weaknesses in the execution of individual studies and inconsistencies between several studies, for example, the classification system of the Centre for Evidence-based Medicine in Oxford. To assess the quality of clinical trials, quality measurement instruments can be used such as the Jadad scale. Check the formal quality of the conduct of a study, not the results themselves - however, can be drawn from the study quality draw conclusions about the quality of the results draw.
The division in classification systems is important in order to assess the benefits and risks of treatments adequately (including benefits and risks of non - treatment). In addition to the assessment and classification of completed clinical trials EBM principles may well in advance, that is, during the design of clinical trials to be helpful. Well-planned and carried out high-quality, randomized, controlled, double-blind clinical studies that have sufficiently high numbers of patients that meet the criteria to be later divided advantageous according to EBM criteria. Such planning prevents an inefficiency of money and resources.
In order to unify the different classification systems and to consider additional aspects such as relevance and feasibility of, established an international working group, the " GRADE Working Group ", since 2000 a new system. The GRADE system ( Grading of Recommendations Assessment, Development and Evaluation ) to evaluate the evidence and formulation of recommendations has gained international importance and is supported by the WHO, the Cochrane Collaboration guidelines and many organizations.
History
The idea of evidence-based medicine can be traced back to the second half of the 18th century developed by British doctors concept of medical arithmetic. For the first time we find the name in the 1793 articles published on Attempt to Improve the Evidence of Medicine of the Scottish physician George Fordyce.
UK one of the first controlled clinical studies have been conducted. Already in 1753 James Lind published the results of his attempt to treat scurvy with oranges and lemons. In the German-speaking area of the active in Vienna, the Hungarian physician Ignaz Semmelweis comes (1818-1865) joint first for the introduction of " systematic clinical observations " in medical research (1848 ).
The foundation of modern EBM goes to the working group led by David Sackett Department of Clinical Epidemiology and Biostatistics at McMaster University in Hamilton, Canada, back to where David Sackett taught as a founding director of the department since 1968. The 1967 work, which appeared Clinical Judgement of the American physician and mathematician Alvan R. Feinstein and the book 1972 published Effectiveness and Efficiency: Random Reflections on Health Services of the British epidemiologist Professor Archie Cochrane led to an increasing acceptance of clinical epidemiology and controlled studies during the 70s and 80s years and so paved the way for the institutional development of EBM in the 90s. Cochrane's efforts were thus appreciated that an international network for efficacy assessment in medicine - the Cochrane Collaboration - was named after him. Cochrane himself, however, did not live to the founding of the EBM movement and Feinstein evolved into one of its sharpest critics methodological.
Teaching
The distribution of EBM has been promoted in the German area primarily by the institutionalization of the German Network for Evidence -based Medicine ( DNEbM eV ). Objectives of this professional society, the development and dissemination of the theory and practice of evidence-based medicine.
EBM is also taught in many universities. However, the implementation of this teaching from theory into practice is still controversial. So is now known that practical courses ( demonstration of EBM research and the practical Applying EBM in individual patients ) would lead to better teaching results.
In addition to textbooks, there are, inter alia, a freely accessible English-language series of the Canadian Medical Association.
Counter-positions
Arguments of opponents are the following:
At its limits EBM if too little evidence and studies are available. For example, in pediatrics EBM not as advanced as for example in oncology and cardiology. The main reason for this is that large controlled clinical trials in pediatrics are not carried out very often or are difficult to perform in itself. This must is not so much " evidence" available, as would be desirable, instead you just force the " evidence" left ( that is, what is in mind ). This statement is not true for all areas of pediatrics, for example, not for the pediatric hematology - oncology.
Regarding his decision, the individual patient of the information is dependent on which he has made available. In particular, in acute cases, however, treatment is often not enough time to provide this information, so that a strong dependence of the patient by the treating physician arises. For the patient, is often as a backup only the change of the doctor open if no other choice among various therapies offered.
A balancing act can also be a too narrow interpretation of EBM. So there are issues that have long and fully understood, but for the purposes of EBM is no sufficient evidence. As an example for illustration may serve that the so-called Vipeholm study of 1954 was the first and last prospective study of the causation of caries by sugar. Also, for example, was the breakthrough of ciclosporin treatment in immunosuppression after organ transplantation so rapidly that there are relatively few studies of high probative value for comparison with the pre-established scheme ( cortisone and azathioprine ). At a high uniqueness of results ( ie high "evidence " within the meaning of the German word meaning), further prospective randomized comparative studies ban already on ethical grounds; the fact that there is a question little reliable " evidence", therefore should not be interpreted to mean that these should be answered negatively. Is led in this connection that a good evidence in many areas of medicine was not feasible or too cumbersome. Almost all medical acts that are completely uncontroversial (ie German "evident " ), are not detectable based (thus not "evidence based " ) and would never be. Absence of a proven benefit and lack of benefits are not the same.
The downside of a more open interpretation of EBM can not but turn lead to consistent application. It also happens that EBM is not carried out in fields of medicine or in countries where it is actually widely accepted in practice consistently.