Reforming Medical Practice Using Evidence

Evidence-based medicine (EBM), as noted in Health Affairs’January/February 2005 thematic issue devoted to that subject,has garnered progressively greater attention over the past severalyears as one prominent voice in the increasingly clamorous choruscharacterizing the movement toward health care system reform.David Eddy, in his Health Affairs EBM paper, cited the mostcommon definition of EBM as "the conscientious, explicit, andjudicious use of current best evidence in making decisions aboutthe care of individual patients." EBM, in many respects, emergedas a reaction to a growing suspicion of a fallacy inherent inthe historical presumption that well-trained and -equipped physicians,working in well-appointed settings in consistent interactionwith similarly situated colleagues, inevitably made optimaland "correct" clinical care decisions for their patients.

In fact, as Eddy tells us, several factors contributed to thedebunking of this long-held maxim and accelerated the salienceand acceptance of EBM. Among these was John Wennberg’sinitial work on practice-pattern variations, the discrepancybetween actual clinical practice and the lessons of clinicalresearch, and the dearth of evidentiary rationale underpinningthe recommendations of often influential informal practice guidelines.And in addition to such environmental drivers, in the face ofyears of budget-busting health spending increases came the realizationthat some other model more reliant on actual evidence of efficacymust be applied to guide medical care and coverage decisionmaking if we are ever to reap health outcomes commensurate withthe massive scale of the U.S. national investment in healthcare.

The papers in this section resonate with the ascendant and relentlessdrumbeat spurring the cause of true evidence-based health caredecision making, by proposing innovative elements of reformto hospital-based patient care and clinical trial reporting.First, Alice Gosfield and James Reinertsen describe the sixevidence-based "planks" of the increasingly popular 100,000Lives Campaign, whose immediate application in the hospitalsetting carries the potential of avoiding upward of 100,000hospital-related deaths annually, the authors assert. Next RodneyHayward, David Kent, Sandeep Vijan, and Timothy Hofer identifythe important shortcomings of the current and dominant modelof clinical trial reporting, including a lack of nuance in identifyingpotential subgroups at risk for harm by a particular treatmentand underestimation of future benefit to other populations.In its place, these authors propose adoption of a more sensitive,risk-stratified approach that is better equipped to negotiatesuch variables and risks.

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Reforming Medical Practice Using Evidence