Evidence-based medicine is the integration of the best arguments of science with the clinical experience and needs of the patient. It is a detailed and rational use of the best achievements of modern times in the decision-making process in the treatment of patients. Only those arguments obtained from systematic reviews are used. Fundamentals of evidence-based medicine are clinically relevant studies that take into account the interests of the patient. The consequence of the confirmations is the reliability and accuracy of the tests of diagnoses and examinations, the importance of forecast indicators, the effectiveness and safety of therapy, rehabilitation and prevention.
History of appearance
In 1940, the first randomized (randomly distributed) studies of the use of the drug "Streptomycin" in the treatment of tuberculosis were conducted. In 1962, the US Committee, which controlled the quality of pharmaceuticals and food products, introduced rules aimed at studying new types of medicines. Nine years after this, epidemiologist Archi Cochran raised the issue of lack of scientific evidence. Three years later, there were discrepancies between theory and practice. In the late 80's - early 90's, attention was drawn to the need for systematic reviews of clinical guidelines. For the first time, the term "evidence-based medicine" was proposed in 1988 by epidemiologists and clinicians who worked at the Canadian University of McMaster. Archie Cochran gave a description of how to present scientific research to the attention of specialists. In addition, he helped ensure that their results became a criterion for discussion and accurate analysis. Cochran and his colleagues, who are members of the British Medical Research Council, have worked together to make modern evidence-based medicine work together. It was he who in 1979 came to the conclusion that science lacks critical conclusions of randomized controlled trials. The Cochrane founded the first Center for Evidence-Based Medicine, which was named after him. He started working in Oxford 10 years ago. At present, there are 15 such centers around the world. They direct the activities of an international group of researchers.
There are five levels of evidence-based medicine:
- Ask a question to which you can get an answer.
- Find the best evidence.
- Evaluate the critical view of the data.
- Consider evidence, taking into account the clinical expertise and interests of the patient.
- Assess how feasible the use of supporting technologies is.
Principles of Evidence-Based Medicine. Finding the Best Confirmations
Specialists are looking for evidence, based on the keywords: patient, intervention, comparison, outcomes. Initially, systematic reviews and randomized controlled trials should be initiated, as they are more reliable. If evidence is not available, it is recommended that you begin to search for lower-level approvals. These include cohort studies, "case-control" and others.
Critical assessment of evidence
With the help of this assessment, it is possible to determine whether the evidence and the results of the study are reliable. To test the reliability of randomly distributed controlled trials, it is necessary to provide answers to the following questions:
- Was randomization of patients carried out?
- Have all the patients participating in the study completed it?
- Was the analysis of patients in groups in which they were randomized?
- Was the treatment "blind" for researchers and patients?
- Have there been similarities in the groups before starting the study?
- Was the same treatment used, except for the experimental treatment?
In the case of qualitative research, it is possible to proceed with the evaluation of the results.
Analysis of practices
This assessment is accompanied by the following questions:
- What am I doing?
- Why is this done, what result is expected to be obtained?
- What are the guarantees of the effectiveness and safety of this work?
- Is there a better, more suitable method to achieve this goal?
In order for the search for arguments and their critical analysis to be of the highest quality, the clinician must have the necessary experience and time. In addition, he can use journals on discipline and other scientific literature. It is not superfluous to turn to the summary on evidence-based medicine, compiled by other specialists. This may be the Cochran database, M. Enkin's book, other literature on this topic. It is also recommended to read the ready-made protocols, which are prepared on the basis of evidence-based medicine.
Periodic review of literature
Traditional wisdom says that serious scientific evidence has only a small part of medical interventions. It is about 15%. Every day, medical professionals around the world need to obtain new important evidence necessary for the effectiveness and proper treatment of patients. For this, doctors should find special information on this profile. It is recommended to use medical literature, which is now very much. Its number has doubled since 1970. In addition, it grows daily. Each year the editorial board publishes about 6,000 articles in the field of such areas as gynecology and obstetrics. To ensure that the level of knowledge is up-to-date, a doctor needs to read about 20 articles daily. Another question is, is there a medical worker for this time? It is also necessary to take into account that many articles do not meet even the minimum quality standards.
Correctness of activity
Some of the medical knowledge is recognized as erroneous or out of date after five years after graduating from a higher education institution. True, it is not known which part. Literature on medicine can be compared with the jungle, as it increases at a high pace, it has a lot of "dead trees", "spiders" and "snakes", but somewhere hidden treasures.
Evidence-based medicine is a definite approach to decision-making. In this case, the clinician applies the best arguments that are available, and professional experience. The decision is made with the patient, taking into account his interests. Every day, employees working in the field of medicine need different kinds of sources to find answers to periodically arising questions. For example, students studying in this area need basic information combining the causes of the disease and its pathogenesis, physical characteristics and other information. The main data refer to different sciences. This, in particular, physiology, pathogenesis, anatomy, etiology. The basic information is relatively stable, found in reference books, textbooks, and other general medical sources. However, most often doctors need to answer questions related to the care of the patient and his treatment. Here are some examples of such issues that relate to a disease or condition, but do not specifically refer to clinical practice:
- What does ...?
- What is otitis media?
- What microorganisms contributed to the occurrence of otitis media?
Answers to such questions can be found in textbooks, reference books and other sources.
Information on the conduct of the patient
In addition to basic knowledge, the doctor needs information that is directly relevant to the management of the patient, the methods of diagnosis, treatment and prognosis. It is these issues that are involved in evidence-based medicine. The key words here are "diagnosis, treatment, prognosis". To get the best result and the best answer, you need to correctly formulate the question.
You can consider taking the drug "Diethylstilbestrol" to prevent miscarriages in women. As a reason for the use of this drug is the frequent termination of pregnancy. In this regard, the use of estrogen in the role of a drug for preventing miscarriage is considered logical. Patients who took this medication, pregnancy, mostly remained. In the fifties, as a result of six non-randomized studies, the reduction in the number of miscarriages during the use of the drug "Diethylstilbestrol" was confirmed. Also five studies were conducted, during which patients were divided into two groups by random sampling. The first took the drug "Diethylstilbestrol", the second - a placebo. According to the results of the experiment, women who used this drug had miscarriages in 7% of cases. Interruption of pregnancy in the second group was 5%. Due to such results, clear indications were obtained that the drug was not useful. But, despite this, its use still continued. Before 1970, millions of women had been treated. Evidence-based medicine requires not only reading the required materials at certain times. It is important to change the own and other people's practices, taking into account the appearance of new information. Evidence-based medicine provides prerequisites for an objective assessment of the effectiveness of medical interventions, as well as the application of its consequences in clinical practice. Of course, this is not easy, because both in the search for confirmations, and in their dissemination and introduction of changes, one can encounter obstacles that arise throughout the entire process of work.
Evidence-based medicine for everyone around the world is developing in a geometric progression. Since the 90s, the period of its formation, and to this day, the number of monographs, forums and centers of this direction is estimated in dozens, and the number of publications is hundreds. In 1997, 12 such centers received subsidies for 5 years from the US Agency for Policy, Science and Health. These organizations were founded at leading universities and scientific institutions in various states. The number of centers for highly specialized problems has increased, such as child and mental health, first aid and other areas. A common position for them is the application of the principle of evidence at each decision-making level, from the state program to the appointment of individual treatment. In Russia, the most famous institutions are located in St. Petersburg and Moscow. Also the most popular is the Clinic of Evidence-Based Medicine, Nizhnevartovsk. The institution specializes in diagnostics, neurology, pediatrics and urology, andrology and gynecology, gastroenterology and ENT diseases.
Evidence-based medicine in the Russian Federation is also developing at a rapid pace. In Russia there is an Inter-regional community AJOAH. It was registered in 2003. The Society of Evidence-Based Medicine Specialists is a voluntary non-profit association. It operates under the Charter. The main activities of the AJOAH:
- Training work related to the methodological problems of carrying out epidemiological and clinical research, the systematics of information in the field of science, the evaluation of publications and statistical analysis of data.
- Publication of the results of basic scientific experiments.
- Introduction of achievements in medical practice.
- Examination of the quality of scientific publications, patient management protocols and others.
- Socioepidemiological and biomedical research.
Principles of the members of the AJOAH:
- dissemination of scientifically grounded information about the intervention of medicine and options for the acquisition of such data;
- refraining from disclosing information on performance, which has not been scientifically proven;
- Declaring the existing inconsistency of interests.
Employees of the organization are doctors who adhere to these principles and implement them in practice. Today, the association includes 17 regions and more than 300 members. Heads of regional branches are highly qualified specialists in medicine and public health.
Center for Evidence-Based Medicine (Enlightenment, 14, St. Petersburg)
The institution operates from eight in the morning until seven in the evening and has one day off on Sunday. This North-West Center for Evidence-Based Medicine provides a wide range of services for the public. Here you can get advice and therapy from doctors of narrow specializations, undergo laboratory diagnosis, colposcopy, ultrasound, massage course. The Center for Evidence-Based Medicine also performs daily monitoring of ECG + AD. All employees working in the institution are highly qualified doctors. The North-West Center for Evidence-Based Medicine specializes in such diseases as:
- osteochondrosis of the spine, aggravated by vertebrogenic cervicalgia, discogenic radiculitis and lumbar region;
- Compression-ischemic neuropathy, the symptom of which is numbness of the fingers;
- deforming osteoarthritis at different stages (medication-based blockades are used as a treatment, hyaluronic acid is used);
- pathological disorders of tendons and ligaments (tendovaginitis, enthesopathy and others);
- pathology of the articular bags, "spurs" on the heels.
The second well-known institution of St. Petersburg
The Center for Evidence-Based Medicine (Leninsky, 88) works from eight in the morning until eight in the evening. The institution is located in a residential building, on the first floor. Modern equipment, high level of service, advanced methods of diagnosis - this is far from a complete list of advantages that this Center of Evidence-Based Medicine has. The opinions of many patients indicate that here every visitor will be given maximum attention. The quality of the services provided was highly appreciated. Here you can seek help from specialists such as a gynecologist and gastroenterologist, neurologist and therapist, cardiologist and oculist, endocrinologist, urologist, etc. The clinic for evidence-based medicine also offers diagnostic in the laboratory, ultrasound, echocardiography, calposcopy, massage, electrocardiography. The oncologist Dmitry A. Beinusov was appointed the head physician of the institution. The results of the tests can be found by calling or receiving them by mail. In addition to the medical center, the activities of specialists also extend to city hospitals. Consultation of a doctor costs 1200 rubles.