Thursday, August 30, 2007

EBM (or EBC or EBP)

My title alludes to the tendency of nurses (and other non-medicine disciplines?) to prefer the more inclusive terms “evidence-based care” or “evidence-based practice.” Recently, my eye caught some rather disparate articles from the quality literature. (Drew blogged on one of them from JAMA last week, so I won’t dwell on it.)

The first, a NEJM Sounding Board article, emphasized the need for an evidence base prior to instituting changes intended to improve safety and/or quality. The title delivers much of the message: “The tension between needing to improve care and knowing how to do it.” The article posed 7 arguments (from the quality literature) for accelerating change, and then adroitly addressed each with a counter argument counseling caution. The missing evidence in proposals for change (including a well-known one—cutting the hours of house staff) fall into three obvious categories that are constantly overlooked, side-stepped, or blown off: efficacy, possible harms/side effects, strategies for implementation and post-change evaluation. Their closing statement: “Just as in the rest of medicine, we must pursue the solutions to quality and safety problems in a way that does not blind us to harms, squander scarce resources, or delude us about the effectiveness of our efforts.”

Here’s a BMC journal I have not previously seen: Health and Quality of Life Outcomes. The specific article that led me there is “Quality of Life at the End of Life,” from a group at the University of Washington and Bastyr University. They followed over 100 hospice patients for several months to determine patient-perceived QOL over time. The statistics in such studies make my head spin, but basically they found that QOL was better than expected until the last 3 weeks of life, and that in those 3 weeks older patients did worse than younger patients. This is an open access journal, so those of you with the patience to wade through may find the methodology and discussion of some use.

Bioethicist Eric Loewy, MD has an opinion piece in MedGenMed, a Medscape electronic journal, asking if evidence-based medicine and ethics are in conflict with each other. The quality of the writing is a bit disappointing, but the overall messages are pointed: EBM conceptually is great, but it is often misused. Specifically, generating EBM-based guidelines or protocols are excellent learning experiences, but then they become anti-intellectual when followed unquestioningly as shortcuts around thinking, or when applied blindly as if all patients are the same. The harshest criticism is aimed at HMO’s which use EBM-based protocols as bludgeons to control physician prescribing, going so far as to label such organizational practices “practicing medicine without a license.” The ethical issue here is that HMO-mandated guidelines are too often driven by financial considerations, the polar opposite of being patient-centered. There’s little new here in terms of criticism of EBM, except perhaps the emphasis on misuse of EBM being unethical.

A companion article to one that Drew mentioned on last week (on the life-span of published systematic reviews) may be “How evidence-based are the recommendations of evidence-based guidelines?” in the open access journal PloS Medicine. The authors selected prominent guidelines relating to cardiovascular treatments. They used multi-domain standardized instruments to rate the quality of the evidence used in the guidelines. They found that only 28% (range: 21 – 41% across guidelines) of the 369 recommendations were supported by high quality evidence. A major failing was the extrapolation from the “highly selected” research subject samples, to the larger, much more heterogeneous target population for the recommendations.

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