Evidence-based medicine is the integration of optimal science arguments 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. The basics of evidence-based medicine are clinically relevant studies that take into account the interests of the patient. Consequence of confirmations are the reliability and accuracy of tests of diagnosis 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) study of the use of the drug "Streptomycin" in the treatment of tuberculosis was conducted. In 1962, the US Committee, which controlled the quality of pharmaceuticals and food, introduced rules aimed at studying new types of medicines. Nine years after that, epidemiologist Archi Cochran raised the issue of the 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 instructions. 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 studies. 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, which is possible to 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
Experts look for evidence based on the key words: 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 Evaluation of Confirmations
With the help of this assessment, it is possible to determine whether the evidence and the results of the study are reliable. To verify the reliability of randomly distributed controlled trials, it is necessary to provide answers to the following questions:
- Was randomization of patients performed?
- Have all the patients participating in the study completed it?
- Was the analysis of patients in the 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 applied, 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 to search for arguments and their critical analysis were the most qualitative, 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 of evidence-based medicine, compiled by other specialists. This may be the Cochran database, M. Enkin's book, other literature in this direction. It is also recommended that you familiarize yourself with the finished 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 are required 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 at this time a medical worker? 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 it becomes obsolete after five years after the student graduates 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 great pace, there are 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 require 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 directly to the care of the patient and his treatment. Here are some examples of such questions 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 related 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 formulate the question correctly.
You can consider taking the drug "Diethylstilbestrol" to prevent miscarriages in women. As a reason for the use of this tool is the frequent termination of pregnancy. In this regard, taking estrogen as a drug to prevent miscarriage is considered logical. In patients who took this medication, pregnancy, in general, persisted. In the 1950s, 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. Until 1970, millions of women were 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 meet the obstacles that arise throughout the entire process of work.
Evidence-based medicine for all around the world is developing in a geometric progression. Since the 90s, the period of its formation, and to the present day the number of monographs, forums and centers of this direction is estimated in tens, and the number of publications - in 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 on highly specialized problems, such as child and mental health, first aid and other areas, has increased. 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 rapidly. 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 members of the AJOAH:
- dissemination of scientific evidence on 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 carries out 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 with vertebrogenic cervicalgia, discogenic radiculitis and lumbar region;
- neuropathy of a compression-ischemic nature, the symptom of which is numbness of the fingers;
- deforming osteoarthrosis at different stages (as a medication, medicamentous blockades are used, 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 to 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 gynecologist and gastroenterologist, neurologist and therapist, cardiologist and oculist, endocrinologist, urologist, etc. The clinic for evidence-based medicine also offers diagnosis 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.