Editorial - Vol 2, No 9:  Evidence-based Medicine

This month’s edition of Healthcare Review – Online^TM focusses on an area of increasing importance in health care, that of evidence-based medicine and the application of the principles of evidence-based medicine to health care delivery in general.

Evidence-based medicine is defined as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise (acquired through clinical experience and clinical practice) with the best available external clinical evidence from systematic research. ¹

The evidence-based medicine movement, to date, has been most marked in clinical practice. However, the rationale that such principles, if they are appropriate in clinical practice, could be applied more widely across other non-clinical disciplines in health care has opened some key discussion around such an evidence-based health care system.

The broader concept of evidence-based health care extends the application of the principles of evidence-based medicine to all professions associated with health care, including purchasing and management. ²

Evidence-based decision-making needs to be grounded in a systematic appraisal of the best evidence which may not be readily available. There is, as yet, little agreement over the importance of these principles nor a common understanding of how this process should be approached.

Enigma Publishing is delighted to have the opportunity this month to present two papers from Professor John Ovretveit, Professor of Health Policy and Management at the Nordic School of Public Health in Goteborg, Sweden, which address the concept of evidence-based health care and this need for access to best evidence.

Together these two papers consider the ways in which the principles of evidence-based medicine can be applied more broadly in health care but also highlight issues associated with such an approach.

In his first contribution, Ovretveit considers the role that evaluation research can play in policy and management decisions. He defines evaluation-informed management and outlines how managers can use evaluation to make more effective decisions and run more effective projects.

Ovretveit describes in detail three elements in evaluation informed management: evaluating external research in appropriate areas, small scale local evaluation of a planned change to build objective and systematic evidence, and the use of evaluation concepts in management decision-making.

It is the combination of these approaches to a new unproven approach, for example in health care policy, which will assist to build a body of evidence before full scale implementation.

Ovretveit considers the limitations of evidence-based medicine methods when applied to management decisions. This paper concludes with the need for more and better research, in this case management research, and a better understanding of different research designs and their use for answering different questions.

The problem related to the lack of certainty in research in the management and policy areas has an equivalent in the lack of an appropriate evidence base for use in quality programme development. In his second contribution to this edition, Ovretveit discusses evidence-based health care and its convergence with the quality movement.

He argues that future quality programmes will need to be more evidence-based to make them more effective, through the use of a more reliable knowledge base.

Ovretveit raises the issue of a lack of an adequate evidence base for quality programmes. Evaluation of information from internal quality initiatives is not fully utilised for several reasons which are outlined in more detail. In addition, evaluating a quality programme is more difficult than evaluating a treatment or service; few evaluations of quality programmes in other organisations produce conclusive evidence.

However, internal and external evaluations of quality programmes do take place and research techniques are in development to assist in evaluating quality interventions.

Increasing pressure on resources is driving the moves toward evidence-based health care. To date, many health care decisions have been based principally on values and resources - opinion-based decision-making. As demands on resources in health care increase, decisions will have to be made more explicitly and publicly with a strong and clear evidence base. Thus, pressure on resources will mean a transition from opinion-based decision-making to evidence-based decision-making. ³

While there is marked enthusiasm for and interest in evidence-based health care, it has been widely criticised, with issues ranging from it being out-moded to it being a dangerous innovation serving cost-cutters and suppressing clinical freedom. These and the issues raised by Ovretveit will need to be addressed in order to move forward and to more effectively apply the principles of evidence-based medicine to decision-making in health care management in general.

Increasing interest is being shown in evidence-based approaches to health care and Enigma Publishing will return to this important area in later editions to further review issues around evidence-based medicine and other approaches to quality in health care systems.

The next edition of Healthcare Review – Online^TM will return to the series on integrated care which started with the March, May and June editions. The edition will review that funding and development processes play and important part in integrated care development and will bring you viewpoints from some of those people who are most influential in the development of integrated care in New Zealand.