Need for evidence-based medicine

Sheenu Jhawar

Within the ever evolving vista of healthcare management, there is a yet new entry. That of ‘Evidence based Medicine’, or the better known: ‘EBM’. Some of us may comment- “we already know about it”

Fair enough. But has the industry begun to imbibe it yet?

Evidence based medicine is a concept that has emerged relatively recently to describe the explicit process of applying research evidence to medical practice. It can be described as:

“A practice that involves the conscientious and judicious use of current best evidence, in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

It is an ongoing process of integrating evidence with the clinician’s training and expertise for the care of patients and patient population. Thus, it has implications for not only secondary and tertiary care, but primary care as well. In evidence-based practice, clinicians act as coaches and share decision making with patients.

Although it is true, that this concept derived from the ‘west’ might not find applicability in major cities in the Indian context, but then who said that Rome was built in a day. It is first of all a change in mindset, followed by a change in practice.

The practice of evidence-based medicine is the centerpiece for healthcare transformation. Its consistent application results in improved care, reduced inappropriate variability in practice-patterns and improved efficiency. All of us do realise that the patient is becoming more demanding with time. There is a sea change in patient attitude and behaviour compared to the yesteryear's, and why not, as with everything else, ‘care’ is commodity and the patient a customer. He expects the best for the price he is willing (or not, as with the nature of healthcare) to pay.

Evidence based practice is a tool not only for the best practice in healthcare but is also an armour for the clinician. Since he becomes a mediator between what is evidence- based clinically sound practice and the patient, a blameless scenario is created.

Individual clinical expertise, the best available evidence from controlled clinical trials, and knowledge of patients’ values and expectations are all vital elements of evidence-based medicine. Physicians can improve patient care by habitually combining these components in weighing treatment options.

Even though most clinicians do practice evidence-based medicine, yet it is more often than not based on using information obtained while in a residency programme. This knowledge base has to be occasionally updated through focused and specific ‘Continuing Medical Education’ as and when the opportunity arises. However this presents its own challenges due to the following:

(1) The mega expansion of scientific investigation has made staying abreast, challenging for clinicians, (2) most clinicians lack adequate tools and technologies to stay abreast, and (3) some clinicians prefer to practice out of habit rather than apply new scientific findings to patient care.

To cite an example, in a European study, 6000 steelworkers were health-screened and 300 of these were found to be untreated for uncontrolled hypertension. They were evaluated by researchers and their hypertension confirmed over 3 months. They were next referred to 85 GP clinics. Six months later, it was found that only 2/3 of these 300 had been started on therapy.

Upon further study, it was concluded that determinants of the clinical decision to treat some, but not the other hypertensives was based on the following:

• The level of diastolic blood pressure
• The patient’s age
• The amount of target-organ damage
• The year the physician graduated from medical school, in an inverse relationship.

Literature review shows that practicing EBM requires two dimension introspection:

That of ‘Background information’ and ‘Foreground information’.

To understand these:

(1) Background information:

General clinical questions regarding a topic such as what is the disorder; what causes it; how does it present; what are some treatment options. These questions can be answered by using ‘background’ resources such as textbooks and narrative reviews.

(2) Foreground information:

Specific questions a clinician has regarding a patient. Foreground resources can be divided into primary sources such as original research articles published in journals; and secondary sources such as systematic reviews of the topic, and synopses.

As is commonly said, Evidence-based medicine is not ‘cook-book’ medicine, meaning that it requires that the best external evidence be integrated with individual clinical expertise and patient-choice in a bottom-up approach. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is the latter that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision.

Further studies carried out on the effectiveness of EBM have demonstrated that majority of the patients adhere to the clinician’s advice and treatment protocol, when shown how this has been proven beneficial through the citation of the correct evidence.

Infact, consistent adherence to evidence-based guidelines has also been shown to result in improved quality of care and lower costs.

It shall definitely take several years before such a concept can be widely practiced in the Indian context, however atleast an awareness of the concept should be the first step towards this goal, and such is the aim of this article.

The author is managing director of health / hospital management consultancy: ACE Vision Health Consultants Pvt Ltd, Jaipur.