“Knowledge is
with in. It is you who have to discover it” Swami
Vivekananda
J.Orthopaedics 2007;4(3)e2
Introduction:
India is
one of the fastest developing countries in the world. Rapid
changes are taking place in each and every field and more so in
the health care system. With the changing trends in medical
practice clinicians are bound to provide the best possible care
for the patients. Evidence–based medicine (EBM) is one of the
most exciting recent medical developments, found to be highly
logical and systematic approach to clinical practice.
Motivation+ Competence
Performance
=
------------------------------
Barriers
Competence
comes from good practice. Good practice should be based on best
available evidence.
a scaphoid injury.
This led them to refer to this entity as an illusionary
diagnosis.
What
is EBM?
It is
the process of systematically reviewing, appraising and using
clinical research findings to aid the delivery of optimum
clinical care to patients1. In simple terms, EBM is
providing best health care to the patients based on the best
available evidence. But where can we find the information to
help us to make better decisions. The following are common
sources.
·
Personal experience
·
Expert opinion
·
Colleagues
·
Published evidence
We
clinicians would not be human if we ignored our personal
clinical experiences, but we would be better advised to base our
decisions on the collective experience of thousands of
clinicians treating millions of patients, rather than on what we
as individuals have seen and felt. Professor Cynthia Murlow, one
of the founders of the science of systematic review has shown
that experts in particular clinical field are actually less
likely to provide an objective review of all available evidence
than a non-expert who approaches the literature with unbiased
eyes2. In extreme cases, an “expert review” may
consist simply of life long bad habits and personal press
cuttings of ageing clinician.
It is only by
concentrating on the last category that ineffective, dangerous
or costly interventions can be reduced. In clinical care and
health care policy-making one can notice an increased effort to
base decisions on the outcomes of empirical studies. Instead of
so-called ’opinion-based’ decision-making, health care
policy and clinical practice, in this view, should become more
‘evidence based’ by the use of the best available scientific
evidence. The best evidence is evidence that is produced in
randomly controlled clinical trials (RCT), where the association
between a specific intervention and its outcomes is researched
within very strictly controlled conditions
Elements
of EBM:
-
Formulate
a clear clinical question from a patient's problem
-
Search
the literature for relevant clinical articles
-
Evaluate
(critically appraise) the evidence for its validity and
usefulness
-
Implement
useful findings in clinical practice
-
Evaluation
of compliance with agreed practice guidance and patient out
comes-this process includes clinical audit
Forms
of evidence:
The
value of evidence can be ranked according to the following
classification in descending order of credibility1
Level
1a– Systematic review and meta-analysis
Level
1b – Randomised Controlled Trials (RCTs)
Level
3 – Case control study
Level
4 – Cross sectional study
Level
5 – Case reports
It is
one step in the process of evidence-based clinical practice. To
determine what the best evidence is, we need critical appraisal
skills that will help us to understand the methods and results
of research and to asses the quality of research. It can help us
to decide whether we think a reported piece of research is good
enough to be used in decision-making 3.
Advantages
EBM
For
individuals:
-
Enables
clinicians to upgrade their knowledge base routinely
-
Improves
clinicians' understanding of research methods and makes them
more critical in using data
-
Improves
confidence in management decisions
-
Improves
computer literacy and data searching techniques
-
Improves
reading habits
For
clinical teams:
-
Gives
team a framework for group problem solving and for teaching
-
Enables
juniors to contribute usefully to team for patients
-
More
effective use of resources
-
Better
communication with patients about the rationale behind
management decisions
Scope
of EBM in India:
In the
United Kingdom (UK), we observed that clear guidelines exists on
site for most clinical conditions, which are based on best
available evidence and are constantly updated4, 5.
There exists a system where from most junior house officer to
most senior consultant shall have constant appraisals that keep
practitioners up to date with recommended practices. The primary
purpose of the National Health Service (NHS) in the UK is to
secure through resources available, the greatest possible
improvement in physical and mental health of the population6.
The best
way to teach both patient care EBM is by setting an example7.
To start
with in India we do not have many randomised trials or other
studies to produce evidence for a particular clinical condition.
Most of our evidence exists from western-based studies
.Education as medical students in India is textbook based which
are mostly by western authors. These textbooks may not always
contain most recent available evidence based recommendations.
Once post graduate or other higher training is completed most of
the practitioners start their own practice and many of them
practice what they have learnt years ago. Some times the only
way of updating themselves may be knowledge passed on from
medical representatives.
There
is non-uniformity of the standards of the care of patients from
place to place and hospital to hospital. The government
institutions run low in health budget annually. Only the premier
institutes in the country, which are autonomous organizations,
have access to large funds and research facilities. Availability
of modern equipment in the corporate hospitals has led to the
difference in public opinion. A large proportion of affluent
patient population seek health care in corporate hospitals.
There
are differences in the standards of training in various medical
institutions and specialities. This creates a non-uniform
environment where standards of care may be in question.
Therefore one cannot assume that qualification means competence.
There is lack of guidelines and protocols for most disease
situations. Education and training of the allied medical
professionals are inadequate and not everyone in the system
takes equal interest in the quality of care.
There
is also lack of communication between the rural and urban areas,
which leads to ignorance in the rural community regarding the
best practice. The medical practice in some corporate hospitals
and central institutions in India is comparable to that of
developed countries and attracting patients from all over the
world. But uniform standards have yet to be achieved across the
country. So there is need for introduction of concept of EBM in
India with the best patient care being the long-term goal.
Evidence
Based Orthopaedics in the UK
What could we do better? The burning desire to answer
this question, Orthopaedic surgeons across the world are
developing the modern methods of
research and design of trials in realms of joint replacement or
arthroplasty surgery, internal fixation of fractures
and other fields of orthopaedics e.g. Spinal surgery. The
fundamental issue is that the surgeon is part of the
treatment and is, generally speaking, responsible for its
innovation and development. To involve in a large trial involves
a large input from various organizations esp. financial
institutions, research councils, ethical committees and other
charities. Without the large involvement from the implant industry
it is not feasible to provide the implants for trials. Without
sponsorship and financial support surgical trials are
simply impractical. The implant industry is not
compelled to introduce new products with phased trials.
Without sponsorship and financial support surgical trials are
simply impractical. An alternative to trial-based research is
a register, but these have proved difficult to establish. The
success of the National Joint Register in Sweden and
probably in the United Kingdom is a good example of
how levels of evidence could be improved in
orthopaedic surgery.
Examples
of EBM in orthopaedic practice
1.Above
and below-the-elbow plaster casts for distal forearm fractures
in children. A randomized controlled trial
8 -This is a randomised controlled blinded
trial which concluded that below elbow plaster casts are as
effective as above elbow plaster casts in treating distal
forearm fractures in children. So the traditional method of
immobilization of one joint above and one joint below is not
necessary in these fractures.
2.Treatment
of Acute Achilles tendon Ruptures. A Meta-Analysis of
Randomized,
Controlled Trials
9 by Khan RJK et
al.
3. Simple elbow dislocation among adults: A comparative
study of two different methods of treatment. S Naidu Maripuri et
al 10.Injury.in press.
Simple elbow dislocation has been
traditionally treated with plaster immobilization for 2 weeks.
In the above study, we compared the plaster treatment group with
early mobilization group. The early mobilization group returned
to function earlier, required less physiotherapy and the
functional outcome was superior to plaster group. Based on this
evidence it is safe to treat simple elbow dislocation with early
mobilization.
Searching
the literature for best evidence
The
Medline database: Medline is compiled by National Library of
Medicine of the USA and indexes over 4000 journals published in
over 70 countries. Three versions of the information in Medline
are available.
-
Printed
(the Index Medicus, a manual index updated every year from
which electronic version is compiled.
-
On-line
(the whole database from 1966 to date on a mainframe
computer, accessed over the Internet or the electronic
server)
-
CD-ROM
(the whole database on between 10 and 18 CDs, depending on
who makes it).
The
Cochrane Library: Published articles are entered onto the
Cochrane databases by members of Cochrane collaboration, an
international network of medically qualified volunteers who each
take on the hand searching of a particular clinical journal back
to very first issue. The
Cochrane Controlled Trials Register (CCTR), Cochrane Database of
Systematic Reviews (CDSR) are updated quarterly. Abstracts are
available free on
http/hiru.mcmaster.ca/cochrane/revabstr/abidx.htm
Embase:
The database of Excerpta Medica, which focuses on drugs and
pharmacology, but also includes other biomedical specialities.
The CD-ROM version is updated monthly.
EBM
on-line: A website run by BMJ (British Medical Journal) assesses
the quality of published papers. The purpose of Evidence-Based
Medicine is to alert clinicians to important advances in
biomedical literature those original and review articles whose
results are most likely to be both true and useful. These
articles are summarised in value-added abstracts and commented
on by clinical experts.
If one
is computer literate and wants to explore the subject of
evidence based medicine there are over 200 web sites dedicated
to subject of evidence-based medicine 2. Concepts of EBM,
critical appraisal of literature, principles of teaching EBM and
information about resources are well documented in recent
literature.7, 11, 12,13
Obstacles
to EBM practice in India
What if
evidence is available? It may not always be possible to practice
because of various reasons
-
Economic
constraints and limited resources in public sector
-
Not
all patients can afford treatment in fully equipped private
sector
-
Lack
of awareness of Evidence Based Medical Practice in medical
professionals due to non-uniform standards of medical
education
-
Unwilling
to discard therapies validated by tradition and experience
on the account of somebody else’s evidence
Recommendations:
-
Medical
student education should be practical oriented as in the UK
-
Educate
medical students about audit and research and encourage them
to participate as a part of their curriculum
-
Their
reading habits should be oriented towards medical journals,
which help them to update themselves with recent advances
and current evidence
-
Basic
Computer education should be encouraged
-
Formation
of national standards and guidelines for diagnosis and
treatment based on the current evidence
-
Where
applicable evidence can be adopted from studies elsewhere
but local studies and trials should be encouraged as local
epidemiology may differ and factors influencing various
clinical situations are not the same in all places
-
Government
and professional bodies should come forward to encourage
research and provide funding
-
Need of a system where
all practitioners update themselves with best available
treatment modalities and have constant appraisals to check
their practice
The
Orthopaedic Surgeons should be encouraged to organise
and work together towards a common goal i.e. participate in
well-designed studies. Such organisations are far
more likely to persuade charities, research councils
and industry for funding. Government could also help
in improving the standards by providing subsidies and grants to
the implant industry so that they could provide funds for
clinical trials. The answer must be to devise levels
of evidence appropriate for surgical research. The
ideal result would be both a wider participation in research
and an improvement in published evidence upon which to
base best practice. 14
References:
-
Rosenberg W, Donald A.
Evidence based medicine: an approach to clinical problem solving. BMJ 1995; 310:1122-6
-
Greenhalgh T.How to
read apaper-The basics of evidence based medicine 2nd edition BMJ Books
2001
-
Busse JW, Heetweld
MJ.Critical appraisal of orthopaedic literature: Therapeutic and economic analysis. Injury 2006:37: 312-320
-
Scottish
Intercollegiate Guidelines Network (SIGN)
http://www.sign.ac.uk/guidelines/published/
-
National Institute
for Health and Clinical Excellence (NICE)- http://www.nice.org.uk/
-
Department of Health.
Promoting clinical effectiveness: A framework for action in and
through the NHS.London: DoH, 1996.
-
Petrison BA, Bhandari
M.Principles of teaching evidence- based medicine. Injury 2006:37: 335-339
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Bohm ER, Bubbar V,
Yong-Hing K, et al. Above and below-the-elbow plaster casts for distal forearm fractures in children. A
randomized controlled trial. J Bone Joint Surg Am 2006; 88:1–8
-
Khan RJK, Fick D,
Keogh A, Crawford J, Brammar T, and Parker M Treatment of Acute Achilles tendon Ruptures. A
Meta-Analysis of Randomized, Controlled
Trials .J Bone Joint Surg Am 2005; 87:2202-2210
-
Simple
elbow dislocation among adults: A comparative study of two
different methods of treatment. Subramanyam Naidu Maripuri, Ujjwal
K. Debnath , Prabhakar
Rao, Khitish Mohanty.Injury
in press
-
Sacket D.L,
Rosenberg WM, Gray J.A.M, Haynes R.B, and Richardson W.S Evidence based medicine what is it and what it is
not. It is about integrating individual
clinical expertise and the best external evidence.Br Med J 1996:312:71-72
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Bhandari M,
Giannoudis PV.Evidence based medicine: what is it and what it is not. Injury 2006:37:302-306
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Zlowodoski M, Zelle
BA,Keel M,Cole PA,Kregor PJ.Evidence-based resources and search strategies for orthopaedic surgeons. Injury
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