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PROLOGUEEvidence-Based Medicine: History And ContextPROLOGUE: As the sharp partisan rhetoric of the 2004 election cycle vividly illustrated, medical malpractice reform is the houseguest who just won’t leave. Once again the nation faces the spectacle of health care providers descending upon state capitals in parts of the country that are experiencing a new wave of spiking liability insurance premiums. However, a national discourse, fueled by election-year politics, that is preoccupied with discussion of caps on the noneconomic-damages component of jury awards has prevented serious exploration of other remedial policy initiatives, such as efforts to improve patient safety. In fact, while the World Health Organization announced on 27 October 2004 a new push to improve patient safety by initiating a dialogue among health ministers, academics, and patient groups, voices calling for results in minimizing medical errors have found themselves largely drowned out, despite the Institute of Medicine’s famous 1999 report, To Err Is Human, which estimated that deaths due to medical errors exceeded the number attributable to the eighth leading U.S. cause of death. Evidence-based medicine (EBM) has been touted as an effective series of mechanisms not only for improving health care quality, but also for reducing medical errors precipitated in part by clinical practice variation. John Wennberg and colleagues have compiled a body of work documenting the great variability in care that patients receive often by virtue of where they live. The variation inevitably translates into sometimes sizable disparities in the quality and safety of care that patients ultimately receive. Ideally, EBM strikes at the heart of the poor health outcome end of the spectrum by reducing some of this variation. The papers that follow take us from the theoretical to the application of EBM principles to clinical care and medical innovation. First, David Eddy traces two distinct streams of thought in the development of the "evidence based" concept and suggests that understanding and integrating these two constructs is the only way forward. Stefan Timmermans and Aaron Mauck then deconstruct the appeal of 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 notion of health care professionalism to improve the efficacy of such tools. Annetine Gelijns, Lawrence Brown, Cory Magnell, Elettra Ronchi, and Alan Moskowitz next consider the difficulties inherent in the endeavor of applying clinical and economic evidence to govern the decision-making process underlying management of medical technology. Such challenges emanate from the innate dynamism of innovation, as compared with the more stationary nature of evidence, the idiosyncrasies of the analytic enterprise, and political considerations influencing policy making.
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