Evidence Based Medicine a Movement in Crisis Box 1

Crisis in Evidence Based Medicine

• The evidence based “quality mark” has been misappropriated by vested interests (QUAILITY MARK = MISAPPOPRIATED)

• The volume of evidence, especially clinical guidelines, has become unmanageable (VOLUME = UNMANAGABLE)

• Statistically significant benefits may be marginal in clinical practice (SS = MARGINAL)

• Inflexible rules and technology driven prompts may produce care that is management driven rather than patient centred (TECH = MANAGEMENT NOT PATIENT CENTRIC)

• Evidence based guidelines often map poorly to complex multimorbidity (EBG = POORLY TO MULTIMORBIDIDTY)

Quality mark has been …

misappropriated and distorted by vested interests

How is this done?

The drug and medical devices industries increasingly set the research data

THEY CONTROL A LOT

• They define what counts as a disease and pre-disease (risk states)

• setting inclusion criteria to include those who respond to treatment

• They decide what tests and treatments will be compared in empical studies

• Outcome that would be read and determine efficacy

• Overpowering trials to ensure small differences are stat sig

All in all : Critics have condemned the role of the drug industry in influencing the policy makers who introduced them

Too MUCH EVIDENCE

Clincal guidenlies - the amount of them is both unmanagable and unfathomable

Example of TOO MUCH EVIDENCE

One 2005 audit of 24 hour intake of the hospital idenfitied 18 patients with 44 diagnosis and 3679 pages (122 hrs reading) related to there immediate care

Marginal Benefits

Overpowering, small differences appear as signfiicant while they make no clincal difference

Overemphasis on rules (More management driven then patient centric) - Example

Diabetes - following the template severe issues not pertaining to diabetes may not be picked up on

Multi morbidity

Having 2+ chronic conditions at the same time

Why is multimorbididty a barrier in Evidence Based Practice

The chances for a patient with a single condition that maps unproblematically to another condition is become a rarity, the effects of one disease may exacerterabe another

comorbidities

Two or more medical or mental health conditions that exist the same time in a patient