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The Shifting Sands of EBM (Evidence-Based Medicine)
Anthony L. Rosner, PhD, Research Director at Parker College of Chiropractic
Cracks in the foundation of the conventional wisdom of randomized clinical trials (RCTs) began to appear in the 1980s when the quality of observational (cohort, case series) studies was found to improve such that their predictive value in clinical situations could now be compared to that seen in the more rigorous RCTs. [1,2] At the same time, RCTs began to be seriously challenged due to their limited applicability in clinical situations. [3,4] Among other problems, RCTs were found to lack insight into lifestyles, nutritional interventions and long-latency deficiency diseases. [5] Quirks have even surfaced which demonstrate how the exalted meta-analysis is subject to human error and bias. [6]
Evidence-Based Medicine: Best Practices and Practice Guidelines
J Manipulative Physiol Ther 2007 (Nov); 30 (9): 615–616 ~ FULL TEXT
Any thoughtful physician would want to provide the best services for his or her patients, and as far as we know, this has been a precept that has been accepted since the beginning of recorded history as it relates to the practice of healing. This position is one of simple ethical behavior and is part of any vow taken by doctors who practice in one of the branches of medicine. This ethic is characterized by the old and often repeated principle “primum non nocere,” which, interpreted means “first do no harm.”
Quality Tools to Improve Care and Prevent Errors
Agency for Healthcare Research and Quality (AHRQ) Commentary ~ FULL TEXT
The Agency for Healthcare Research and Quality (AHRQ) has funded the creation of quality tools and resources to provide accessible research evidence that can be readily adapted to clinical settings. Quality tools include Web sites, reports, databases, fact sheets, guides, and other mechanisms to assist healthcare professionals, policymakers, health plans, employers, patients, and consumers in the development, promotion, and enhancement of quality within a practice or organization, or in an individual's daily life.
When Evidence and Practice Collide
J Manipulative Physiol Ther 2005 (Oct); 28 (8): 551–553 ~ FULL TEXT
“Until now, we believed that the best way to transmit knowledge from its source to its use in patient care was to first load the knowledge into human minds… and then expect those minds, at great expense, to apply the knowledge to those who need it. However, there are enormous ‘voltage drops’ along this transmission line for medical knowledge.”
Fostering Critical Thinking Skills:
A Strategy for Enhancing Evidence Based Wellness Care
Chiropractic & Osteopathy 2005 (Sep 8) Volume 13 (1): 19 ~ FULL TEXT
Chiropractic has traditionally regarded itself a wellness profession. As wellness care is postulated to play a central role in the future growth of chiropractic, the development of a wellness ethos acceptable within conventional health care is desirable. This paper describes a unit which prepares chiropractic students for the role of "wellness coaches". Emphasis is placed on providing students with exercises in critical thinking in an effort to prepare them for the challenge of interfacing with an increasingly evidence based health care system.
Informatics Skills:
Weakness in the Foundation of Research
Proceedings of the 2002 International Conference on Spinal Manipulation (OCT)
One of the challenges facing today’s health care professionals is the difficulty in keeping current despite the proliferation of medical literature. This need is compounded with the increasing advocacy for evidence-based medicine. Current estimates suggest that clinicians would need to read 19 articles per day, every day of the year to keep abreast of relevant clinical developments.1 Other than consulting colleagues in the field or experts, health care professionals can peruse literature reviews for a concise, qualitative or quantitative meta-analysis of pertinent information. However, expert bias and errors in the literature review process has been shown to be a reason for caution. 2 It is often impossible to separate fact from opinion or to decipher the authors’ methods for selecting material. 3
Accuracy of Data in Medical Abstracts of Published Research Articles
Researchers randomly selected 44 articles from each of five medical journals, including Lancet and The New England Journal of Medicine. The results, published in JAMA 1999 (Mar 24); 281 (12): 1110—1111, showed that between 18 and 68 percent of the 264 abstracts evaluated were inaccurate, meaning there were omissions or inconsistencies between the data in the abstract and the data in the body, tables and figures of the main article. The results are especially troubling because abstracts are widely used, often separate from their text, as in MEDLINE and other databases, and data taken from the abstracts may be reported and disseminated in other works, in other formats and in the media. You may also enjoy the
Editorial ~ JAMA 1999 (Mar 24); 281 (12): 1129—1130 on this topic.
Applying Evidence-Based Health Care to Musculoskeletal Patients as an Educational Strategy for Chiropractic Interns (A One-Group Pretest-Posttest Study)
J Manipulative Physiol Ther 2004 (May); 27 (4): 253–261
The results of this study suggest that having chiropractic interns apply EBHC to actual musculoskeletal patients along with attending EBHC workshops had a positive impact on interns' perceived ability to practice EBHC.
The Evidence-based Case Report: A Resource Pack for Chiropractors
Clinical Chiropractic 2003; 6: 73-84 ~ FULL TEXT
This Adobe Acrobat article (210 KB) states: The need for evidence-based practice has arisen from the rapid advances in medical knowledge and the large number of clinical papers being published. Traditional sources of information such as textbooks razpidly become out of date. Consequently, a disparity develops between disgnostic skills and clinical judgement that increases with experience and dating of academic knowledge, resulting in a decline in clinical performance over time. EBM was developed to bridge the gap between research and practice.
Is Chiropractic Evidence Based? A Pilot Study
J Manipulative Physiol Ther 2003 (Jan); 26 (1): 47 ~ FULL TEXT
When patients were used as the denominator, the majority of cases in a chiropractic practice were cared for with interventions based on evidence from good-quality, randomized clinical trials. When compared to the many other studies of similar design that have evaluated the extent to which different medical specialties are evidence based, chiropractic practice was found to have the highest proportion of care (68.3%) supported by good-quality experimental evidence.
Placebo Surgery
Chiropractic Journal 2002; September
Many scientists and clinicians consider the placebo-controlled trial the "gold standard" for evidence-based practice.
Interestingly, surgical procedures are often exempt from such scrutiny. Ethical considerations are considered barriers to the use of placebo-controlled investigations for surgical procedures. [3,4] Interestingly, there have been five studies where placebo surgery was used as a control. The placebo group generally did as well or better than the group receiving the real operation. Read more about the difficulties of designing a "neutral" sham in a chiropractic (or CAM) trial.
The Evidence House: How to Build an Inclusive Base
for Complementary Medicine
West J Med 2001 (Aug); 175 (2): 79-80
We all want good evidence available when making medical decisions. Evidence, however, comes in a variety of forms and purposes, and what may be good for one purpose may not be good for another. The term "evidence-based medicine" (EBM) has become almost a cliché in recent years, being used as a synonym for "good" or "scientific," both to support and refute the value of complementary medicine practices. But EBM takes a narrow view of what constitutes "good" evidence, and it excludes important qualitative and observational information about the use and benefits of complementary medicine.
Evidence-Based Chiropractic Care Part I: Contribution of Cochrane Collaboration and the Canadian Cochrane Network and Centre
J Canadian Chiropractic Assoc 2002 (Sep); 4 (3): 137-143 ~ FULL TEXT
This Adobe Acrobat article states: Chiropractors are busy health professionals. Like all other health pratitioners today, you do not have the time to read all the literature you ought to review to keep current with new research and the reports of best practices in your profession. Fortunately, there are relaible sources of up-to-date summarized literature available to help you.
Evidence-based Chiropractic Care Part II: Cochrane Systematic Reviews of Health Care Interventions
J Canadian Chiropractic Assoc 2003 (Mar); 47 (1): 8–16 ~ FULL TEXT
This Adobe Acrobat article (292 KB) states: As a chiropracvtor, you want whats best for your patients. In order to make well-informed clinical decisions, you and your patients require high-quality, up-to-date, trustworthy healthcare information. Such information is available in the Cochrane Library of systematic reviews of healthcare interventions.
Evidence-Based Medicine: What It Is and What It Isn't
British Medical Journal 1996 (Jan 13); 312: 71–72 ~ FULL TEXT
Evidence-based medicine is the conscientious, explicit 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. By individual clinical expertise we mean the proficiency and judgement that individual clinicians acquire through clinical experience and clinical practice.
"Evidence-Based Care": From Guidelines to Practice
Specialists of the neuromusculoskeletal (NMS) system have seen tremendous changes in the last decade. "Medicalization" has led to excesses in diagnostic testing and surgery, while chiropractic and psychological approaches have been underutilized. Evidence pointing out that ineffective approaches were overutilized and effective approaches underutilized has been summarized and published in guidelines throughout the world.
The Evidence In Evidence-based Practice:
What Counts And What Doesn't Count?
J Manipulative Physiol Ther 2001 (Jun); 24 (5): 362–366 ~ FULL TEXT
For those who are prepared to buy in to EBP, there is a question that is only now being debated in the chiropractic literature. This question, which is being vigorously debated elsewhere in EBP, is one of exactly what does and what does not count as evidence in EBP. In the working definition of EBP, the "evidence" is characterized as being "sound" and generated from "well-conducted research". But what exactly does this mean? For many, the terms sound and well-conducted research are instinctively interpreted as referring to randomized controlled trials (RCTs). The RCT has been designated – in many cases accurately – the gold standard of research designs. Accordingly, the intuitive assumption that only evidence from RCTs counts in EBP is understandable. However, this position is now being challenged, and other designs, such as observational and qualitative research, are being considered legitimate providers of the evidence in EBP. It might be time to look at how these moves will affect chiropractic research in the future.
Applying Research Evidence to Individual Patients
British Medical Journal 1998; 316 (7139) May 30: 1621–1622 ~ FULL TEXT
At the heart of clinical medicine is an unresolved conflict between the essentially case based nature of clinical practice and the mainly population based nature of the research evidence. While clinicians are exhorted to use up to date research evidence to give patients the best possible care, actually doing so in individual patients is difficult.
Interpreting The Evidence: Choosing Between Randomised And Non-randomised Studies
British Medical Journal 1999; 319 July 31: 312–315 ~ FULL TEXT
Evaluations of healthcare interventions can either randomise subjects to comparison groups, or not. In both designs there are potential threats to validity, which can be external (the extent to which they are generalisable to all potential recipients) or internal (whether differences in observed effects can be attributed to differences in the intervention). Randomisation should ensure that comparison groups of sufficient size differ only in their exposure to the intervention concerned. However, some investigators have argued that randomised controlled trials (RCTs) tend to exclude, consciously or otherwise, some types of patient to whom results will subsequently be applied.
Evidence-based Clinical Guidelines for the Management of Acute Low Back Pain: Response to the Guidelines Prepared for the Australian Medical Health and Research Council
J Manipulative Physiol Ther 2001 (June); 24 (3): 214–220 ~ FULL TEXT
In Bogduk's opinion, the major reason for justifying these guidelines in preference to previous multidisciplinary efforts in both the United States1 and the United Kingdom2 is that consensus or expert opinion is no longer to be accepted as a form of evidence. Bogduk claims that all of his conclusions are preferably based on hard evidence from the published clinical trials, yet nowhere in his treatise is there any indication that his own review of the evidence is either systematic or impartial. As I will make clear in what follows, his analysis of the literature pertaining to spinal manipulation in particular is both flawed and incomplete, seriously undermining the credibility of the entire report.
Behavioral and Physical Treatments for Tension-type
and Cervicogenic Headache
Duke University Evidence-based Practice Center Report
Among the many treatment alternatives supported by evidence, chiropractic is buoyed by substantial evidence in this report as to its efficacy in the management of both tension-type and cervicogenic headaches.
Evaluating the Quality of Clinical Practice Guidelines
J Manipulative Physiol Ther 2001; 24 (3) (Mar): 170–176
The literature reviewed suggests that professional organizations or groups should undertake a critical review of guidelines using available critical guideline appraisal tools. Guideline validity appraisal should be done before acceptance by the chiropractic profession. To avoid unwarranted utilization of poorly constructed guidelines, it is strongly recommended that all future guidelines be reviewed for validity and scientific accuracy with the findings published in a medically indexed journal before they are adopted by the chiropractic community.
Proposal for Establishing Structure and Process in the Development of Implicit Chiropractic Standards of Care and Practice Guidelines
J Manipulative Physiol Ther 1992; 15 (7) Sep: 430–438
This proposal offers a preliminary definition of the structure and process, including a "seed" policy statement and decision flow chart, specific to guideline development. Once the structure and process of guideline development for chiropractic are defined, the profession can then present this product to federal and state agencies, private sector health care purchasers, patient advocacy groups and other stakeholders of chiropractic care.
Qualitative Research and Evidence Based Medicine
British Medical Journal 1998; 316 (7139) Apr 18: 1230–1232 ~ FULL TEXT
Qualitative research may seem unscientific and anecdotal to many medical scientists. However, as the critics of evidence based medicine are quick to point out, medicine itself is more than the application of scientific rules. Clinical experience, based on personal observation, reflection, and judgment, is also needed to translate scientific results into treatment of individual patients.
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