Evidence-Based Medicine: History And Context

PROLOGUE: As the sharp partisan rhetoric of the 2004 electioncycle vividly illustrated, medical malpractice reform is thehouseguest who just won’t leave. Once again the nationfaces the spectacle of health care providers descending uponstate capitals in parts of the country that are experiencinga new wave of spiking liability insurance premiums. However,a national discourse, fueled by election-year politics, thatis preoccupied with discussion of caps on the noneconomic-damagescomponent of jury awards has prevented serious exploration ofother remedial policy initiatives, such as efforts to improvepatient safety. In fact, while the World Health Organizationannounced on 27 October 2004 a new push to improve patient safetyby initiating a dialogue among health ministers, academics,and patient groups, voices calling for results in minimizingmedical errors have found themselves largely drowned out, despitethe Institute of Medicine’s famous 1999 report, To ErrIs Human, which estimated that deaths due to medical errorsexceeded the number attributable to the eighth leading U.S.cause of death.

Evidence-based medicine (EBM) has been touted as an effectiveseries of mechanisms not only for improving health care quality,but also for reducing medical errors precipitated in part byclinical practice variation. John Wennberg and colleagues havecompiled a body of work documenting the great variability incare that patients receive often by virtue of where they live.The variation inevitably translates into sometimes sizable disparitiesin the quality and safety of care that patients ultimately receive.Ideally, EBM strikes at the heart of the poor health outcomeend of the spectrum by reducing some of this variation.

The papers that follow take us from the theoretical to the applicationof EBM principles to clinical care and medical innovation. First,David Eddy traces two distinct streams of thought in the developmentof the "evidence based" concept and suggests that understandingand integrating these two constructs is the only way forward.Stefan Timmermans and Aaron Mauck then deconstruct the appealof EBM as a vehicle for reducing clinical practice variation,provide insight into the uneven performance of practice guidelines,and explore the potential of a more broadly constructed notionof health care professionalism to improve the efficacy of suchtools. Annetine Gelijns, Lawrence Brown, Cory Magnell, ElettraRonchi, and Alan Moskowitz next consider the difficulties inherentin the endeavor of applying clinical and economic evidence togovern the decision-making process underlying management ofmedical technology. Such challenges emanate from the innatedynamism of innovation, as compared with the more stationarynature of evidence, the idiosyncrasies of the analytic enterprise,and political considerations influencing policy making.

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Evidence-Based Medicine: History And Context