THE ELEMENTS OF EBM?
At its essence, EBM means applying the best evidence available for the benefit of patients. In this series, we will review the basic elements of EBM:
- Constructing an answerable clinical question;
- Searching for the best evidence for the question at hand;
- Critically appraising the evidence for its validity, importance, and relevance to your patient; and
- Applying the best evidence to your clinical practice.
Each of these deserves a brief comment. To find the information most relevant to a clinical question, it is helpful to have a well-defined query of appropriately narrow scope. If we
want information on perioperative beta-blockade in the scenario outlined above, it may not be helpful to apply evidence derived from vascular surgery patients over age 65 with known coronary artery disease. If information were available on outcomes in younger patients undergoing lower-risk procedures, this might be more relevant to our question. Thus, an approach to constructing effective clinical questions is a critical skill for EBM.
The best clinical question cannot help us if we don’t know how to find the evidence relating to that question, however. Therefore, EBM requires some understanding of the relative benefits of sources such as Ovid MEDLINE (www.medscape.com) or UpToDate (www.uptodate.com), in addition to how to navigate through these sources to get to the evidence. Thankfully, these databases are becoming more powerful all the time, while also working to remain user-friendly. An approach to effective searches is clearly an important skill for EBM.
Once we have found the evidence for our question, we need to know how to evaluate the quality of the evidence. There are many guides available for individual types of clinical questions, but there are consistent themes across all types of questions, including assessment for potential bias, proper interpretation of study results, and deciding whether the results can be applied to your patient. Understanding these themes and then taking the evidence back to the bedside is the culmination of the EBM process for our patients.
SUMMARY
EBM is an approach to making patient care decisions incorporating the highest quality available evidence. This is of great relevance to hospitalists, especially given the central role hospitalists play in the care of patients across multiple disciplines. This series will serve as an introduction to the many facets of EBM, focused to a practicing hospitalist audience. TH
Dr. West practices in the Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn.