Evidence-based healthcare

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chapter 2 Evidence-based healthcare

POTENTIAL AND LIMITATIONS OF EBM

As history is written, the exponential growth in EBM gained momentum in the late twentieth century. Published data increasingly revealed:

The Cochrane Collaboration was formed out of this movement, and its systematic reviews follow a transparent process ‘intended to minimise bias’. We accept this as almost a motherhood statement, but the processes inherent in EBM contain a number of major flaws.

In recent decades, EBM has rightly assumed a leading role in informing medical practice. Stratifying and analysing the results of all published trials for a disease or an intervention provides some guidance on the three pillars—quality, safety and efficacy—and allows for comparisons to be made. To make clinical decisions and formulate clinical guidelines that are contrary to evidence is at best ineffectual and wasteful of resources, and at worst harmful to the patient.

However, a bland statement that the clinician should make decisions that are evidence-based is not as simple as it seems, for a number of reasons.

Some particular limitations of EBM in the general practice setting are summarised by Stephenson:2

It is for these reasons that the best approach to clinical decision-making will combine knowledge of the best available evidence with:

Many complementary therapies are particularly affected by the points raised above. Naturally occurring products, for example, are not patentable, and so they don’t attract the large research budgets that patentable pharmaceuticals do. Even where there is mounting evidence that a particular complementary therapy is safe and effective, it is often treated with scepticism by the medical mainstream because it falls outside the imaginary boundary of conventional medical practice. As clinicians we need to be interested in what is safe, works and is cost-effective regardless of which side of an artificially created demarcation line between complementary and conventional therapies it comes from.

LEVELS OF EVIDENCE

EBM experts tend to refer to the ‘level of evidence’ for or against a particular therapy or intervention. Broadly speaking there are four main levels of evidence, although there are subdivisions within these:

Obviously, level 1 evidence is considered the highest; the relative weight given to each of the others diminishes as you go down the levels. In reality, however, it is not as simple as this. For various reasons, some interventions or issues do not lend themselves to RCTs or cannot attract the necessary funding for high-quality RCTs and will therefore never have level 1 evidence supporting them. This does not mean that they are invalid, but simply that one needs to be flexible in interpreting evidence and that EBM needs to be supported by common sense and clinical experience.

Meta-analyses also rely on the publication of all available studies. Because publication bias is more likely to exclude negative findings, meta-analyses of published studies tend to skew to positive findings.

EBM reviews sometimes provide challenging findings. For example, a meta-analysis published in The Lancet gave surprising results on the efficacy of homeopathy, finding that the odds ratio for positive trial results was 2.45 in favour of homeopathy.3 Though more high-quality RCTs are required, either homeopathy is clinically effective for a range of conditions or there is a publication bias in favour of homeopathy. Thus, even with ‘level 1 evidence’ a clinician still needs to interpret the findings and decide what to make of them.

Patients and the general public are often not aware of levels of evidence, and nor can they easily interpret evidence for themselves. Furthermore, they can be significantly affected by misleading marketing. The GP therefore has a vitally important role in helping people to:

The evidence that most patients regard first and foremost is the evidence from their own personal experience or the experience of people close to them. The question most relevant to them is, ‘Does it work for me?’ A doctor telling a patient that a therapy, such as a herbal treatment, is not supported by evidence when it is clearly providing benefit for them will not convince them and could alienate them from the doctor. It may be more useful to say that it has been little researched but that the person’s experience is also a valid form of evidence. It is also unconvincing for the patient to be told that a therapy is well supported by evidence when it is not working or they are experiencing side effects that are worse than the condition for which they are being treated. Thus the findings and recommendations arising from EBM need to be interpreted and communicated with sensitivity and in a way that is appropriate to the individual patient.

A SYSTEMATIC APPROACH TO EVIDENCE

Because of limited time and skills in searching the medical literature, many GPs look to educational seminars and conferences, or up-to-date review articles in general practice or family medicine journals that are tailored to GP management of various conditions. It is assumed that the speaker or author has reviewed the evidence in an objective and unbiased way and is able to clearly summarise it. Such articles and talks can be a simple, helpful and time-efficient way to get an overview of a topic, but there are potential limitations. The material may be presented by a specialist who does not understand the particulars of general practice mentioned above, or it may be less objective and unbiased than we would hope for.

Exploring a clinical question or decision for oneself can be very informative and excellent practice in critical thinking. Box 2.1 gives an outline of a systematic approach to exploring an issue through EBM.

BOX 2.1 An approach to evidence-based medicine

Step 1 Identify the need for information to inform a decision and then frame the question.
Step 2 Find the best evidence to answer the question.
Step 3 Critically appraise the evidence for validity (is it true), impact (effect size) and applicability (relevance to your practice).
Step 4 Integrate the results of the appraisal with your clinical judgment, the circumstances and the patient’s values.
Step 5 Evaluate your performance and reflect on ways to improve performance.

(from Sackett et al4)

Having skills and knowledge about how and where to find reliable evidence is a prerequisite for the abovementioned approach. (Some resources are listed at the end of this chapter.) It takes time to learn to search the medical literature in an efficient and targeted way. Using the right search words and strategy can mean the difference between a long, fruitless search and a short, fruitful one.

PUBLICATION BIAS

A clinician can only make decisions based on the quality of evidence or advice that is available. We generally trust that when we consult a medical database or the opinion of an expert body we will receive unbiased and objective information. Unfortunately, this is often not the case. All evidence is not equal.

Retail spending on prescription drugs in the USA climbed from $US78.9 billion to $US154.5 billion between 1997 and 2001.5 With such amounts at stake, market forces commonly influence research, publication and the interpretation of research data. Thus, even with the best intentions, the basis upon which clinicians make decisions will often be biased as a result. For example, pharmaceutical companies have an interest in promoting antidepressant prescribing. Not only is it advantageous to increase the potential market—for example, prescribing for younger patients—but it is also advantageous to lower the threshold for prescribing. However, although most of the antidepressant trials published show a positive effect, in many of these trials the data have been interpreted in a way that makes the findings look more positive than they really are, and almost none of the negative trials are published.6 The actual effect size of antidepressants is more than 30% lower than published trials would have one believe. A fuller analysis of both the published and the unpublished data suggests that antidepressants actually have no more than a placebo effect for mild to moderate depression and only a marginal effect for severe depression,7 with approximately 80% of the clinical effect being attributable to the placebo response.8 Concerns about the effect of publication bias on other medication categories such as chemotherapy also exist.9

For systematic reviews to be meaningful, there needs to be an assessment of all trials, positive and negative, and complete honesty and transparency about findings. Although we like to think that drugs which make it to market have been intensively scrutinised, researchers from the University of California, San Francisco, found troubling evidence of suppression and manipulation of data in studies published in (or often withheld from) peer-reviewed medical journals.10 They compared the information that companies shared with the USA’s Food and Drug Administration (FDA) about those drugs on application for approval to market, with what was eventually published in medical journals. Only three-quarters of the original trials were ever published, and those with positive outcomes were nearly five times as likely to be published as those that were negative. There may be many reasons for this—commercial reasons for the pharmaceutical companies, professional or academic issues for the researchers who want to be associated with a ‘successful’ drug development, decisions by the editors of peer-reviewed journals who may feel that positive results make better reading and give them headlines in the mainstream press.

The huge investment in getting pharmaceuticals to market also brings with it a reluctance to reveal adverse outcome data, as we saw in the case of Celebrex and Vioxx (the COX 2 inhibitors), as well as the wholesale prescription of hormone replacement therapy (HRT) to perimenopausal and menopausal women prior to the release of the Million Women Study and the Women’s Health Initiative Study showing the relationship between HRT and increased rates of breast cancer and myocardial infarction.

MEDICAL PRACTICE, MARKETING AND EBM

The entanglement of clinical medicine with the pharmaceutical industry is widespread and has almost infinite potential to influence practice.11 Many expert bodies that determine therapeutic guidelines have multiple members with conflicts of interest due to their association with pharmaceutical companies. Sponsors of medical educational seminars and conferences are also known to influence the speaker list and content. Many of the medical stories promoted by the media are industry-driven, although this is rarely transparent to consumers or doctors.12 Transparency is therefore a vital part of a doctor’s ability to make an informed decision about how much weight to give to a particular guideline or opinion.

Many common medical practices that had been accepted for decades have been found to be contrary to evidence when tested by studies. For example:

Well-supported, safe and effective therapies such as omega-3 fatty acids in the management of hyperlipidaemia, glucosamine for osteoarthritis and exercise for improving cancer survival should be considered first-line therapy options. Rapidity in adopting newly approved pharmaceutical treatments, slowness in rationalising or ceasing use of a conventional therapy or practice that is unfounded, or slowness in adopting an unconventional therapy that is well founded, points to factors other than evidence affecting clinical decisions. These factors could include such things as marketing, peer expectations, medico-legal concerns, political forces, complacency and habit.

There are other CAM modalities for which there is no convincing evidence, such as iridology or Vega machines as diagnostic tools. These may waste resources but be harmless enough unless the advice given about their use misleads the patient or delays important diagnosis and treatment. Patient concerns, fears and expectations can have a significant impact on a doctor’s clinical decisions, for better or worse. For example, in some countries pharmaceutical companies can market drugs directly to patients. Advertising aimed at encouraging patients to request a drug from a doctor will increase many-fold the likelihood that the doctor will prescribe the medication even in the absence of any clinical indication. Similar concerns can arise about the inappropriate use of CAM, particularly where patient fears are greatest, such as in cancer patients.

What lessons can we glean from the abovementioned examples? First, even with the best intentions, standard medical practice is often contrary to guidelines, and guidelines can be contrary to evidence. Sometimes the continued use of unproven therapies can be costly or produce adverse events. Unfortunately, industry rather than good evidence often drives practice, leading to inappropriate practice and over-prescribing. This, combined with a lack of healthy scepticism about therapies, whether conventional or complementary, can have significantly negative effects for doctors, patients and the healthcare system.

REFERENCES

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2 Stephenson A. A textbook of general practice. 2nd edn. London: Arnold, 2004.

3 Linde K, Clausius N, Ramirez G, et al. Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo controlled trials. Lancet. 1997;350(9081):834-843.

4 Sackett D, Straus S, Richardson W, et al. Evidence-based medicine: how to practise and teach EBM. 2nd edn. Edinburgh: Churchill Livingstone, 2000.

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