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Evidence-based medicine

Evidence-Based Medicine came to the fore in the early 1990s and has become a major driving force for many national healthcare organisations. The term and concept originated at McMaster University. It has been defined as "the integration of best research evidence with clinical expertise and patient values" (Sackett, 2000).
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   Clinical practice guidelines    Clinical pathways    Decision support systems

EBM advocates the use of up-to-date "best" scientific evidence from health care research as the basis for making medical decisions.

For supporters, EBM has three main advantages:

  1. It offers the surest and most objective way to determine and maintain consistently high quality and safety standards in medical practice;
  2. It can help speed up the process of transferring clinical research findings into practice;
  3. It has the potential to reduce health-care costs significantly.

The approach, however, is not without its opponents. These consider that EBM risks downplaying the importance of clinical experience and expert opinion, and that the conditions under which clinical trials used to define best practice take place are hard to replicate in routine practice.

Cochrane Collaboration

The Cochrane Collaboration is a major force in the EBM movement. It was created as a response to a call by Archie Cochrane, a British epidemiologist, to develop up-to-date systematic reviews of randomized controlled trials from all areas of health care the best available evidence could be made available as a basis for making healthcare decisions. The first Cochrane Centre was opened in Oxford in 1992.

The Cochrane Library The Cochrane Collaboration supports collaborative review groups in "preparing, maintaining and promoting the accessibility of systematic reviews of the effects of health care interventions". The main output of the Cochrane Collaboration is the Cochrane Library. This includes:

  • The Cochrane Database of Systematic Reviews
  • The Database of Abstracts of Reviews of Effectiveness (DARE) ("critical assessments and structured abstracts of systematic reviews published elsewhere")
  • The Cochrane Controlled Trials Register and the Cochrane Methodology Register
  • The Health Technology Assessment Database
  • The NHS Economic Evaluation Database

Cochrane links
 bullet  The Cochrane Reviewers' Handbook - "the official document which describes in detail the process of creating Cochrane systematic reviews"  bullet  Index to Abstracts of Cochrane Reviews
Cochrane Centres
Over a dozen Cochrane Centres now exist around the world. These include the following:
 bullet  Australasian Cochrane Centre  bullet  Centro Cochrane do Brasil  bullet  Canadian Cochrane Network and Centre  bullet  en français  Le Réseau-centre canadien Cochrane  bullet  Chinese Cochrane Center, Chengdu  bullet  German Cochrane Centre, Freiburg  bullet  Centro Cochrane Italiano, Milano  bullet  Dutch Cochrane Centre, Amsterdam  bullet  Nordic Cochrane Centre, Copenhagen, Denmark  bullet  Nordic Cochrane Centre, Oslo, Norway  bullet  Nordic Cochrane Centre, Moscow, Russia  bullet  South African Cochrane Centre, Cape Town  bullet  Centro Cochrane Iberoamericano, Barcelona  bullet  UK Cochrane Centre, Oxford  bullet  USA - New England Cochrane Center, Providence, RI  bullet  USA - New England Cochrane Center, Boston  bullet  USA - San Francisco Cochrane Center, University of California
Other evidence-based review centres
 bullet  12 evidence-based Practice Centers in the United States and Canada contracted by the Evidence-based Practice Program of the Agency for Healthcare Research and Quality to "review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities. Public and private sector organizations may use the reports and assessments as the basis for their own clinical guidelines and other quality improvement activities.".
    EBM Toolkit, University of Alberta - "This collection of tools for identifying, assessing and applying relevant evidence for better health care decision-making is based on the work of the Evidence Based Medicine Working Group".    CATmaker - critical appraisal tool [OC]    The EBM Toolbox from the Centre for Evidence-Based Medicine, Oxford

Straus SE, Richardson WS, Paul Glasziou, Haynes RB. Evidence-based medicine: how to practice and teach EBM. Third Edition. Churchill Livingstone: Edinburgh, 2005.


[sample chapter available: chaper 2: How to find current best evidence and how to have current best evidence find us. pp31-65]

" A third edition of the best known introduction to EBM. This is a pocket-sized introduction which tells the reader how to integrate the best available evidence with his or her own clinical expertise, written by world-renowned authorities.

"Following the retirement of David Sackett from the EBM field and the author team of the book, his colleagues have revised the book throughout and, in answer to common criticisms have focussed on how EBM can be practiced in real time in a variety of clinical settings. "

The authors of the Second edition of this book set out a classification of ten main areas (Table 1.2 Page 19) as central to the practice of EBM:

  1. "Clinical findings - history and physical examination
  2. Aetiology - causes of disease including iatrogenic forms
  3. Clinical manifestations - how often and when a disease causes clinical manifestations
  4. Differential diagnosis - possible causes (likely, serious and responsive to treatment)
  5. Diagnostic tests - selection and interpretation of tests to confirm or exclude a diagnosis
  6. Prognosis - likely clinical course and possible complications
  7. Therapy - appropriate treatments
  8. Prevention - risk factors and screening
  9. Patient experience and meaning - empathy with the patient's situation
  10. Self-improvement."

Guyatt G, Cook D, Haynes B. Evidence based medicine has come a long way (Editorial) BMJ. 2004 Oct 30;329(7473):990-1.

[PubMed]   [BMJ]

" Evidence based medicine seeks to empower clinicians so that they can develop independent views regarding medical claims and controversies. Although many helped to lay the foundations of evidence based medicine,1 Archie Cochrane's insistence that clinical disciplines summarise evidence concerning their practices, Alvan Feinstein's role in defining the principles of quantitative clinical reasoning, and David Sackett's innovation in teaching critical appraisal all proved seminal. The term evidence based medicine,2 and the first comprehensive description of its tenets, appeared little more than a decade ago. In its original formulation, this discipline reduced the emphasis on unsystematic clinical experience and pathophysiological rationale, and promoted the examination of evidence from clinical research. Evidence based medicine therefore required new skills including efficient literature searching and the application of formal rules of evidence in evaluating the clinical literature....

Evidence based medicine's biggest future challenge is one of knowledge translation, ensuring that clinicians base their day-to-day decision making on the right principles and on current best evidence. All too often clinicians are unaware of the available evidence or fail to apply it. Because clinicians' values often differ from those of patients, even those who are aware of the evidence risk making the wrong recommendations if they do not involve patients in the decision making process. "

Haynes RB. What kind of evidence is it that Evidence-Based Medicine advocates want health care providers and consumers to pay attention to? BMC Health Serv Res 2002;2(1):3.

[PubMed]    [BioMed Central]    [PubMed Central]
" This paper reviews the origins, aspirations, philosophical limitations, and practical challenges of evidence-based medicine... Advocates of evidence-based medicine want clinicians and consumers to pay attention to the best findings from health care research that are both valid and ready for clinical application. Much remains to be done to reach this goal. "
Greenhalgh T. How to Read a Paper. The Basics of Evidence-Based Medicine. London: BMJ Publishing Group, 1997. EBM primer originally published as a series of articles in the BMJ.

Greenhalgh, T. How to read a paper : getting your bearings (deciding what the paper is about) BMJ 1997; 315: 243-246
Greenhalgh T and Taylor R. How to read a paper: Papers that go beyond numbers (qualitative research) BMJ 1997; 315: 740-743
Greenhalgh T. How to read a paper: Papers that summarise other papers (systematic reviews and meta-analyses) BMJ 1997; 315: 672-675.
Greenhalgh T. How to read a paper: Papers that tell you what things cost (economic analyses) BMJ 1997; 315: 596-599.
Greenhalgh T. How to read a paper: Papers that report diagnostic or screening tests BMJ 1997; 315: 540-543.
Greenhalgh T. How to read a paper: Papers that report drug trials BMJ 1997; 315: 480-483.
Greenhalgh T. How to read a paper: Statistics for the non-statistician. I: Different types of data need different statistical tests BMJ 1997; 315: 364-366.
Greenhalgh T. How to read a paper: Statistics for the non-statistician. II: "Significant" relations and their pitfalls BMJ 1997; 315: 422-425.
Greenhalgh T. How to read a paper: Assessing the methodological quality of published papers BMJ 1997; 315: 305-308.
Greenhalgh T. How to read a paper: The Medline database BMJ 1997; 315: 180-183.

Straus SE. Evidence-based medicine in practice (Editorial). ACP Journal Club. 2002 May-June;136:A11.

[ACPJC]   []

" Discussion of a clinical scenario illustrating the practice of evidence-based medicine in “real time”. "

Haynes RB. Of studies, syntheses, synopses, and systems: the “4S” evolution of services for finding current best evidence ACP Journal Club. 2001 Mar-Apr;134:A11-A13.

[ACPJC]    []

Discussion of information services available to EBM researchers and practitioners.

Cochrane AL. Effectiveness and Efficiency: Random Reflections on the Health Services. RSM Publishing, 1999.

[Royal Society of Medicine]   []

New edition of the original textbook on 'evidence-based medicine', first published in 1972." A new introduction by Prof. Chris. Silagy, "looks at the post-Cochrane agenda, in particular the growth and empowerment of consumers taking more responsibility for their own healthcare decisions, and the influence of consumers on the development of an evidence-based approach to their healthcare."

Haynes RB, Haines A. Barriers and bridges to evidence-based health care practice. BMJ 1998;317:273-6.

[BMJ]    []

A discussion of problems involved "in implementing evidence based medicine and possible solutions".

Bonichon F. How to read a scientific paper. Cancer/radiothérapie Volume 1, Issue 5, November 1997, Pages 397-406.

[PubMed]    [Science Direct]

Discussion of rules for accessing and interpreting relevant papers applied to oncology, especially to papers concerning the effectiveness of therapeutic interventions.

RB Haynes, DL Sackett, JRM Gray, DL Cook, GH Guyatt. Transferring evidence from research into practice. A series of editorials. ACP Journal Club 1996-1997.

1. The role of clinical care research evidence in clinical decisions
2. Getting the evidence straight
3. Developing evidence-based clinical policy
4. Overcoming barriers to application
[]   []

Descriptions of the path leading from health care research evidence to evidence-based health care (1-3) and the application of evidence-based policy in the right way at the right place and time (4).

McGibbon KA Wilczynski N, Hayward RS et al. The Medical Literature as a Resource for Evidence Based Care. Working Paper, Health Information Research Unit, McMaster University (1996).

[PubMed]   []

This article discusses EBM resources and tools for health care professionals. "These include users' guides to the medical literature, strategies for improving the yield of MEDLINE searches, standardized formats for abstracts of journal articles and guidelines, new journals, systematic reviews and meta-analyses, and software tools that bring high quality information to the point of clinical decision making. "

Haynes, RB, Lomas J, Hayward RSA. Bridges between health care research evidence and clinical practice. J Am Med Inform Assoc. 1995 Nov-Dec;2(6):342-50.

[PubMed]   []

" This article discusses a three-step model for bridging research evidence to management of clinical problems: getting the evidence straight, formulating evidence-based clinical policies, and applying evidence-based clinical policies at the right place and time. "

Users' Guides to Evidence-Based Practice

[CCHE]   []

Includes, for example

  • Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine
  • How to Use a Clinical Practice Guideline
  • How to Use a Clinical Decision Analysis

  • " Complete set of Users' Guides originally published as a series in the Journal of the American Medical Association (JAMA). The CHE (Centres for Health Evidence) continue to maintain the full text pre-publication version of this series on behalf of the Evidence-Based Medicine Working Group with permission from the journal. "

    NICHSR Introduction to HSR Class Manual: Evaluating the Literature Quality Filtering and Evidence-Based Medicine and Health

    [NICHSR]   []

    " Quality filtering is a process that sifts the more substantial studies from the less informative ones. ... The need for quality filtering has increased as health researchers and policy makers produce clinical guidelines or conduct meta-analyses.... "

    A. Hill, C. Spittlehouse. What is Critical Appraisal ?

    []   []

    " Critical appraisal is the process of systematically examining research evidence to assess its validity, results and relevance before using it to inform a decision. Critical appraisal is an essential part of evidence-based clinical practice that includses the process of systematically finding, appraising and acting on evidence of effectiveness. Clinical appraisal allows us to make sense of research evidence, and thus begins to close the gap between research and practice. "
    references: ebm and decision support

    Bates DW, Kuperman GJ, Wang S et al. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc. 2003 Nov-Dec;10(6):523-30

    [PubMed]   [PubMed Central]

    " While evidence-based medicine has increasingly broad-based support in health care, it remains difficult to get physicians to actually practice it. Across most domains in medicine, practice has lagged behind knowledge by at least several years. The authors believe that the key tools for closing this gap will be information systems that provide decision support to users at the time they make decisions, which should result in improved quality of care. Furthermore, providers make many errors, and clinical decision support can be useful for finding and preventing such errors. Over the last eight years the authors have implemented and studied the impact of decision support across a broad array of domains and have found a number of common elements important to success. The goal of this report is to discuss these lessons learned in the interest of informing the efforts of others working to make the practice of evidence-based medicine a reality. "

       Clinical Evidence - "The international source of the best available evidence for effective healthcare" (BMJ Publishing Group)    The NHS Centre for Reviews and Dissemination - Database of Abstracts of Reviews of Effectiveness (DARE) (The NHS Centre for Reviews and Dissemination at the University of York)    Effectiveness Matters at the NHS Centre for Reviews and Dissemiantion, University of York. Provides: "updates on the effectiveness of important health interventions for practitioners and decision makers in the NHS"     Effective Health Care bulletins - from the NHS Centre for Reviews and Dissemination, University of York. "Bi-monthly bulletins which examine the effectiveness of a variety of health care interventions."     National Institutes of Health (NIH) Consensus Development Program    Evidence-based Practice at the Agency for Healthcare Research and Quality    Centre for Evidence-based Medicine, University of Toronto    Centres for Health Evidence (CHE), Canada    Core Library for Evidence Based Practice, Sheffield University    Netting the Evidence: A ScHARR (Sheffield University School of Health and Related Research) Introduction to Evidence Based Practice on the Internet    ACPJ Journal Club (Evidence-based medicine for better patient care)    Duke University Medical Center Library - EBM course    Medical Research Library of Brooklyn - EBM resources at the State University of New York Downstate Medical Center    EBM glossary - University of Toronto    EBM glossary - Bandolier, Oxford    Centre for Evidence-Based Medicine at Oxford    University of Massachusetts Medical School's Evidence-Based Medicine (EBM) web site    Critical Care and associated website: the Critical Care Forum    Evidence-Based Medicine at the University of Hertfordshire, UK    Evidence Based Health Care Practitioners Links (McMaster University, Toronto) The Evidence Based Medicine, Clinical Audit & Medical Informatics Portal    EBM material on
    Links: courses, tutorials, information search
     bullet  Free course: An Introduction to Evidence-Based Medicine (concentrating on Information Mastery, EBM, POEMs (Patient Oriented Evidence that Matters), DOEs (Disease-Oriented Evidence)) by nMark Ebell at Michigan State University  bullet  EBM search on Primary Care Electronic Library (PCEL), University of London ( "returns results from Bandolier, Clinical Evidence, Cochrane Collaboration, National Institute for Health and Clinical Excellence, PRODIGY Knowledge and Scottish Intercollegiate Guidelines Network")
    Links: other languages
     In italiano GIMBE®: Gruppo Italiano per la Medicina Basata sulle Evidenze  Auf Deutsch Deutsches Netzwerk Evidenzbasierte Medizin e.V. [German Network for Evidence Based Medicine]  En français  Médecine basée sur preuve, Centre Hospitalier Universitaire de Rouen  En français La médecine factuelle: Bibliothèque de la Faculté de médecine de l'Université de Liège  Hungary  The EBM TUDOR Network, University of Szeged, Hungary
    Journals, bulletins, access to the literature
       EBM Online (BMJ Publishing Group of the BMA, assisted by Stanford University's HighWire Press)    ACP Journal Club (Evidence-based medicine for better patient care) (American College of Physicians)    Bandolier (Evidence based health care journal, est. Oxford 1994)    Evidence-based Healthcare, Elsevier    New Zealand Evidence-based Healthcare Bulletin    BioMed Central - "Publishing peer-reviewed original research papers with open access"    PubMed - at BiomMed    PubMed Central - "a digital archive of life sciences journal literature managed by the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM)."    TRIP Database - Provides hyperlinked access to 'evidence-based' material from over 75 medical information site on the web    Evidence-Based Practice Online (from Dowden Health Media)

       EPOCare: Bringing Evidence to the Point of Care, University of Toronto

    page history
    Entry on OpenClinical: 2002
    Last main update: 13 May 2004; 14 June 2005
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