M A N A G E M E N T B R I E F

Created by the Management Decision & Research Center, HSR&D, Office of Research & Development.

What is Evidence-based Medicine?

Evidence-based medicine (EBM) is the conscientious,

explicit and judicious use of current best evidence in

making decisions about the care of individual patients.

Evidence-based medicine promotes the collection,

interpretation, and integration of valid, important and

applicable patient-reported, clinician-observed, and

research derived evidence. The best available evidence,

moderated by patient circumstances and preferences, is

applied to improve the quality of clinical judgments.

Broadly, evidence-based medicine prescribes that clinical

decisions concerning diagnostic testing and therapeutic

choices are based on scientific evidence demonstrating

effectiveness (1,2,3).

There is a paradigm shift from “Doing what seems

best,” relying on clinical experience, and knowledge of

pathophysiology, to “knowing what is best.” That is,

basing decisions and actions on appropriate evidence from

health care research. Physicians of this new paradigm

integrate clinical findings with knowledge of the rules of

evidence, and the ability to access, select, and interpret

useful references from the medical literature (4,5).

The evidence comes from randomized controlled studies,

as well as from study results combined in order to draw

conclusions that could not be drawn solely on the basis of

a single study. These secondary syntheses, technology

assessments and systematic reviews, are core activities of

evidence-based medicine (see the glossary for definitions).

Often, evidence conflicts or is difficult to interpret, which

is why syntheses of evidence are important to both

clinicians and managers.

Why is Evidence-based Medicine important to VHA

managers?

By more carefully understanding and applying the

evidence, “what works” in the veteran patient population,

VHA managers can better frame policy and resource

allocation or purchasing decisions. For example, a recent

systematic review of ways to change physician

performance found that widely used continuing medical

education (CME) methods such as conferences have little

direct impact on professional practice, and that more

effective methods are under utilized (6). Evidence about

the effectiveness of clinical interventions can be applied by

managers as well as clinicians.

Dissemination is key!

VHA and other health care systems face a unique

challenge to improve their current apparatus for transferring research evidence to clinical practice. The clinical

practice change and health policy development processes

are enhanced and informed through energetic dissemination of research evidence. Streptokinase is an example of

the formerly slow pace of clinical practice change based on

research evidence. Streptokinase was shown to be

effective in treating myocardial infarction in 1959.

Convincing evidence mounted in the seventies. The first

multi-trial meta-analysis (see the glossary) demonstrating

its efficacy was published in the early eighties. Formal

advice that streptokinase was useful in the routine

treatment of myocardial infarction came in the late

eighties— a full 13 years after close examination of the

literature would have indicated the treatment’s value.

(7,8,9).

EBM— RESEARCH IN VA

Terazosin — effective therapy for BPH

Benign prostatic hyperplasia ( BPH), prostate gland

enlargement, occurs in a quarter of the male veteran

population causing a range of distressing symptoms. This

VA Cooperative Study tested terazosin and finasteride for

safety and efficacy as single drug and combination drug

therapies in 1229 veterans across the country. VA researchers found terazosin effective therapy, while finasteride

either alone or in combination was found no more

effective than the placebo — surprising results, as there

had been studies reporting finasteride to be effective. The

editorial accompanying the report describes why the

study design and patient criteria were critical to these

results. (Lepor H, Williford WO, Barry MJ, et al. The efficacy

of terazosin, finasteride, or both in benign prostatic hyperplasia.

NEJM 335:533-539, (editorial page 586), Aug 22, 1996.)

Evidence-based Medicine: Making a Difference in Veterans’ Health Care

“Evidence-based medicine, a new priority for an old paradigm, can make a critical difference in veterans health care access, delivery and

practice. Now, more than ever, high quality research should provide evidence to inform health care decision making. Our professional

responsibility compels us to develop scientifically credible evidence to guide our clinical decisions.”

John R. Feussner, M.D., Chief Research & Development Officer, VHA

Number 5 February 1997
Routine screening for HIV - when is it cost-effective?

Routine screening for HIV is often recommended for

patients and suggested for physicians, yet it can be quite

expensive. Two studies at the Palo Alto VAMC explored

the benefits versus the cost of screening. They looked at

two populations: patients and surgeons, and found strong

evidence for screening patients when the local population

has a seroprevalence of HIV infection of 1% or more. Yet,

for surgeons, evidence from a cost-effectiveness analysis

showed the opposite. Screening surgeons for HIV to

prevent HIV transmission to patients requires expenditures per year of life saved considerably in excess of those

of most accepted health interventions. (Owens DK, Nease

RF, and Harris RA. Cost-effectiveness of HIV screening in acute

care settings. Archives of Internal Medicine 156:394-404,

February 26, 1996. Owens DK, Harris RA, Scott PM, Nease

RF. Screening surgeons for HIV infection. 122:641-652, May 1,

1995.)

Routine lab tests increase only costs NOT benefits.

Routine testing of severely impaired nursing home

residents i s a common practice to detect illnesses that may

be masked by the patients’ often severe existing impairments. In this Bedford HSR&D study the usefulness of this

practice was assessed. Evidence showed little value in the

use of routine lab asses sments. The results suggest that

selective use of the routine tests could minimize costs

without patient harm. (Kim DE, Berlowitz DR. The limited

value of routine laboratory assessments in severely impaired

nursing home residents. JAMA 272: 1447-1452, Nov 9, 1994.)

VA AND AHCPR SUPPORT DEVELOPMENT OF

EVIDENCE-BASED PRACTICE CENTERS.

On December 23, 1996, the Agency for Health Care

Policy and Research began soliciting proposals to fund

M A N A G E M E N T B R I E F Number 5, February 1997, Page 2

REFERENCES:

1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS.

Evidence-based medicine: what it is and what it isn’t. BMJ 1996;

312(7023):71-2.

2. Feussner JR. Evidence-based medicine - new priority for an old

paradigm. Journal Of Bone And Mineral Research 1996; 11(7):877-882.

3. Evidence-based Medicine Working Group. Evidence-based

medicine, a new approach to teaching the practice of medicine.

JAMA 1992; 268(17):2420-2425.

4. McKibbon KA, Wilczynski N, Hayward RS, Walkerdilks CJ,

Haynes RB. The medical literature as a resource for health care

practice. Journal Of The American Society For Information

Science 1995; 46(10).

5. Johnston ME, Langton KB, Haynes RB, Mathieu A. Effects of

computer-based decision support systems on clinician performance and patient outcome. A critical appraisal of research.

Annals of Internal Medicine 1994;120(2):135-142.

6. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing

physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995: 274(9): 700-705.

7. Mulrow CD. Rationale for systematic reviews. BMJ 1994;

309(6954): 597-9.

8. Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A

comparison of results of meta-analyses of randomized control

trials and recommendations of clinical experts. Treatments for

myocardial infarction. JAMA 1992; 268(2): 240-8.

9. Heathfield HA, Wyatt J. Medical informatics: hiding our light

under a bushel, or the Emperor’s new clothes? [letter].

Methods of Information in Medicine 1993; 32(2): 181-2.

This is our fifth MANAGEMENT BRIEF. Please give us your suggestions:

Topics for future Briefs:

Comments on the MANAGEMENT BRIEF:

Name:

Title:

Phone: FAX:

E-mail:

Address:

Please send me the MANAGEMENT BRIEFby: E-mail ____ or FAX ____

The Management Brief is produced by the Management Decision

and Research Center, a program within the VA’s Office of Research &

Development, Health Services Research and Development Service.

The purpose of the Management Brief is to provide VA senior

managers with a concise and timely overview of a specific health

care topic that includes topic definition, benefits, VA activities, and

resources for further information.

Please send comments to Gerry McGlynn, MDRC 152-M, 150 South

Huntington Avenue, Boston, MA, 02130. Or, by phone at,

FTS 700-839-4433 or COM 617-278-4433 FAX: 617-278-4438.

Evidence-Based Practice Centers. These centers will

produce evidence reports and technology assessments for

use in developing clinical guidelines, clinical quality

improvement tools, and for making decisions related to

the effectiveness or appropriateness of specific health care

technologies. FAX: 301-443-7523 to get a copy of the RFP.

Send name, affiliation, address, phone and FAX numbers.

Proposals are due March 24, 1997.

The MDRC Technology Assessment Information

Service

The Technology Assessment Information Service (FTS

700-839-4469 and COM 617-278-4469) provides syntheses

of evidence to senior managers and clinicians who need to

make decisions regarding provision of specific health care

services or purchasing. The Program also has an extensive

collection of evidence reports and technology assessments

from the literature and from other agencies. Finally, the

Program has prepared evidence based documents that are

of interest to managers such as the recent Transferring

managed care principles to VHA (August 1996 MTA-96-

023-01). A similar review of the effects of integrating

health care systems is currently in preparation.

NEXT MANAGEMENT BRIEF:

Positron Emission Tomography - How useful is it?

The MDRC Technology Assessment Program is just

releasing an evidence-based assessment of Positron

Emission Tomography. The PET report, summarized in

the next Management Brief, includes systematic reviews of

the evidence for PET’s usefulness in diagnosing

Alzheimer’s disease and cancer.
Evidence-Based Medicine Resource List

Evidence-based medicine and evidence-based health are information intensive, engendering a substantial body of information resources.

To assist your investigation of the principles and practice of evidence based research and practice, we have compiled the following lists of

resources. This list does not attempt comprehensiveness, but rather an overview of the rich E.B.M. resources available.

ADDITIONAL JOURNAL ARTICLES:

Ham C, Hunter DJ, Robinson R. Evidence-based policy

making. BMJ 1995; 310: 71-72.

Haines A, Jones R. Implementing findings of research.

BMJ 1994; 308: 88-92.

Users’ guides to the medical literature. I - XI. JAMA 1993-

1996. Excellent series by the Evidence-based medicine

working group.

I. How to get started. 1993;270:2093-7

II. How to use an article about therapy or prevention.

A.Are the results valid? 1993;270:2598-2601.

B. What were the results and will they help me in

caring for my patients? 1994;271:59-63.

III. How to use an article about a diagnostic test.

A.Are the results of the study valid? 1994;271:389-91.

B. What are the results and will they help me in

caring for my patients? 1994;271:703-7.

IV. How to use an article about harm. 1994;271:1615-9.

V. How to use an article about prognosis. 1994;272:234-7.

VI. How to use an overview. 1994;272:1367-71.

VII. How to use a clinical decision analysis.

A.Are the results of the study valid? 1995;273:1292-5

B. What are the results and will they help me in

caring for my patients? 1995;273:1610-3.

VIII. How to use clinical practice guidelines.

A.Are the recommendations valid? 1995;274:570-4.

B. What are the recommendations and will they help

you in caring for your patients. 1995;274:1630-2.

IX. A method for grading health care recommendations.

1995;274(22):1800-4.

X. How to use an article reporting variations in the

outcomes of health services. 1996;275(7):554-8.

XI. How to use an article about a clinical utilization

review. 1996;275(18):1435-9.

BOOKS

Evidence-based health care: how to make health policy and

management decisions. Muir Gray. London: Churchill

Livingstone. 1996. Pages 175. ISBN: 0-443-05721-4.

Evidence-based medicine: how to practice and teach EBM.

David L. Sackett, W. Scott Richardson, William Rosenberg,

R. Brian Haynes. London: Churchill Livingstone. 1996.

Pages 250. ISBN: 0-443-05686-2.

PRINT & WWW ACCESSIBLE JOURNALS

ACP Journal Club & Annals of Internal Medicine

Published bi-monthly by the American College of

Physicians. Contact: The American College of Physicians

800-523-1546 or FAX: 215-351-2799. On the WWW:

http://www.acponline.org/journals/acpjc/jcmenu.htm

Annals of Internal Medicine:

http://www.acponline.org/journals/annals/annaltoc.htm

Archives of Internal Medicine Journal Club

Published by the AMA provides a critical discussion of

research articles & topics. On the WWW:

http://www.ama-assn.org/public/journals/pubhome.htm

Bandolier

Concise reviews of clinical topics and practice guidelines

from the Center for Evidence-based Medicine at Oxford

University. On the WWW:

http://www.jr2.ox.ac.uk:80/Bandolier

Evidence Based Medicine

A bi-monthly journal jointly published by the American

College of Physicians and the BMJ Publishing Group.

Contact: American College of Physicians at 800-523-1546 or

ebm@acp.mhs.compuserve.com

On the WWW:

http://www.acponline.org/journals/ebm/ebmmenu.html

Journal Watch

A monthly, critical, review of the evidence reported in

newly published randomized controlled trials. Contact:

Massachusetts Medical Society 1- 800-843-6356.

New England Journal of Medicine

Also published by the Massachusetts Medical Society,

NEJM includes research articles, editorials, clinicopathologic conferences, and comments. On the WWW:

http://www.nejm.org/

International Journal of Technology Assessment in

Health Care

Official journal of the International Society for Health Care

Technology Assessment. Cambridge University Press, New

York, NY.

M A N A G E M E N T B R I E F Special Supplement No. 5, February, 1997

Created by the Management Decision & Research Center, HSR&D, Office of Research & Development.
Web Sites

The world wide web or WWW is a complex information resource, found on the Internet, incorporating text

and images. Each web site has a unique address known as a URL. One reaches a web site by pointing

your web browser, also called a client (Netscape or Explorer) to this URL address. For additional

information, assistance, or training, check with your local Library Service.

WEB SITE NAME URL - UNIFORM RESOURCE LOCATOR NOTES

Evidence Based http://www.epi.bris.acuk/rd/publicat/ebpurch/index.htm For purchasers of health care

Purchasing products & services uses

EBM to guide purchasing

decisions.

Coordinating Center for http://www.wiphm.soton.ac.uk/hta Very new site. Information

Health Technology about UK NHS technology

Assessment of the assessment programme.

National Health Service Lists ongoing projects and

topics under way.

Center for Reviews http://www.york.ac.uk/inst/crd/welcome.htm Reviews of the efficacy

& Dissemination & cost effectiveness of

healthcare interventions.

Center for Evidence http://www.cebm.jr2.ox.ac.uk/ Provides support &

Based Medicine resources promoting

evidence-based health care.

Ohio State University http://ohsu.edu/bicc-informatics/ebm/ebm_topics.htm Evidence-based topics &

Medical Informatics links to many EBM web sites

McMaster University http://HIRU.MCMASTER.CA/ebm/default.htm The premier EBM web site.

Health Information A wealth of resources on

Research Unit, Canada EBM & the Cochrane

Collaboration

NICHSR http://www.nlm.nih.gov.nichsr.dir/nichsr.html Part of the US National

National Information Library of Medicine

Center on Health Services providing information &

Research and Health Care links to other sites

Technology

LIST SERV Discussion Lists

LISTSERV lists are electronic discussion lists that distribute messages/discussions via E-Mail to large

numbers of users who have an interest in a particular topic i.e., Evidence-based medicine. To subscribe to a

particular listserv, send an E-mail message with the subject blank and the body containing only: subscribe

listname your firstname lastname. For example: Subscribe CPAE Joanne Smith

LISTSERV NAME TOPIC SEND SUBSCRIBE MESSAGE TO:

EVIDENCE-BASED Evidence-based medicine and health mailbase@mailbase.ac.uk

HEALTH

BIOMED-L Biomedical Ethics listserv@vm1.nodak.edu

CPAE Center for Professional & Applied Ethics listserv@catfish.valdosta.peachnet.edu

HEALTH-TECH Health Technology majordomo@csn.net

Related Lists:

HEALTH MGMT Health Care Management listproc@ursus.jun.alaska.edu

QP-HEALTH Quality issues in health care majordomo@quality.org

Management Decision and Research Center FTS: 700-839-4433 COM: 617-278-4433 Fax: 617-278-4438

M A N A G E M E N T B R I E F Special Supplement EBM Resource List, Page 2
Glossary

TERMS DEFINITIONS

Clinical guidelines Also called clinical practice guidelines, they are systematically developed

statements designed to assist practitioners and patients in making decisions about

appropriate health care for specific clinical circumstances.

Decision analysis A systematic approach for weighing the relative value of one or more different

tools decision options, using the best available evidence. Decision models often are

shown in the form of decision trees with decision points, branching steps,

outcomes and values associated with those outcomes. These tools are used to

predict outcomes and develop clinical guidelines.

Effectiveness The extent to which a treatment or technology produces favorable outcomes

under usual or everyday conditions. This measure answers the question: does it

do more good than harm?

Efficacy A measure of the benefit of using a technology to address a particular problem

under ideal conditions (e.g., within the protocol of a carefully managed

randomized trial, involving patients meeting narrowly defined criteria).

Evidence-based The practice of medicine that is guided by or based on scientific fact.

medicine The judicious use of best evidence in making decisions about the care of patients.

The practice of evidence-based medicine integrates individual clinical expertise

with the best available external clinical evidence from systematic research.

Meta-analysis A series of methods for systematically combining information from more than one

study in order to draw a conclusion which could not be drawn solely on the basis

of the single study.

Randomized A carefully controlled study/experiment in which participants are randomly

Controlled Trial allocated to receive or not receive an experimental preventive, therapeutic, or

diagnostic procedure and are then followed to determine the effect of the intervention.

Registries (databases) A variety of repositories, often computerized, for observations and related

information about a group of patients, a disease, an intervention, or other events

or characteristics. These can be useful sources for evidence about the natural

history of a disease, how it is managed, and the outcomes of treatment. VHA has

several, such as the Spinal Cord Dysfunction Registry, Vietnam Era Twin Registry,

and the National Registry of Women Veterans.

Management Decision and Research Center FTS: 700-839-4433 COM: 617-278-4433 Fax: 617-278-4438

M A N A G E M E N T B R I E F Special Supplement EBM Resource List, Page 3

Want to Stay in touch with Evidence-Based Medicine?

Coming soon— a monthly E.B.M. bibliography. This bibliography includes articles about

evidence-based medicine as a subject, practice, and process, along with meta-analyses,

guidelines, and systematic reviews on clinical topics.

For more information on how to get this bibliography, send an email to:

g.mdrc-idp@forum.va.gov

The MDRC is a program within VA‘s Office of Research and Development,

Health Services Research and Development Service.

The MDRC’s mission is to enhance the delivery of the highest quality health care by providing

VA senior staff with consultation, technical assistance, management research and research dissemination.