Evidence-based Medicine

Evidence-Based Medicine

The concept of “Evidence-based Medicine”, or “medicine, evidence-based” (EBM) was proposed by Canadian scientists at the University of poppy Masters in Toronto in 1990. Soon, the concept has spread rapidly and has found supporters around the world. In many countries, including Russia, organized centers of evidence-based medicine, are beginning to play a significant role in the national health services.

There are various definitions of medicine based on evidence. In accordance with one of them, evidence-based medicine – is fair, accurate and meaningful use of the best results from clinical trials to select the treatment of specific patient. It is obvious that evidence-based medicine – is not new science. Rather, it can be regarded as a new approach, the direction or the technology of collecting, analyzing, synthesizing and interpreting scientific information.

Closely enough medicine based on evidence, is closed with clinical pharmacology. It is in the field of clinical pharmacology of the most widely used principles of evidence-based medicine. However, evidence-based medicine is not limited to the analysis of randomized clinical trials. Principles of its applicability to any area of medical science, including the general problem of how best health care system.

Why is there a need for evidence-based medicine?

One of the obvious reasons – an increase of scientific information, particularly in the field of clinical pharmacology. Every year in clinical practice are being introduced more and more new drugs. They are actively studied in numerous clinical studies whose results are often ambiguous and sometimes diametrically opposed. At the same time facilitate access to scientific information. Today, any Internet user can in a few minutes to obtain information about hundreds or thousands of articles of interest to the problem. However, to use information obtained in practice, it is necessary not only to carefully analyze and generalize.

Another reason – lack of funds associated with increasing health care costs. In this situation, among a large number of drugs necessary to choose the means which have the highest efficacy and better tolerability. It should be noted that the novelty or the high cost of new drugs are not a guarantee of its higher efficiency. The problem of management of funds is particularly relevant for our country, because on the one hand the Russian health care budget is clearly insufficient, on the other hand still widely used drugs, whose effectiveness is not proven (or vice versa proved ineffective) or in doubt. It is obvious that there is no point in trying to reduce the cost of treatment through the use of inexpensive, but very few effective drugs (eg, use of garlic preparations or nicotinic acid – instead of statins for dyslipidemia), but we need to know – profiles of hyperlipidemia (they are 5 species). But it is equally pointless to prescribe expensive drugs in cases where no less or even greater effect may provide a cheaper means. And then, and something else will eventually lead to increased costs. But for this there are dozens of pharmacoeconomics and clinical pharmacists, posted on the Ministry of Health of dying, the alienation from the profession, do not want to enter the rates of these professionals in hospitals.

The term “evidence-based medicine” may cause ambiguous attitude of doctors, as the need to confirm the efficacy and safety of medicines is unlikely to have anyone in doubt. The question is what can serve as proof of efficacy and safety of treatment. Apparently, every doctor reasonably believes that he has in his practice focuses on real scientific facts, but whether this is really the case? One way of developing new drugs is to study the mechanisms of disease development, which allows to determine the “target” for the action of drugs. Accordingly, doctors usually suggest that the drug, a positive effect on one or another link in the pathogenesis of the disease, is effective in its treatment. But in practice we often encounter the reverse situation. For example, one of the major mediators of bronchospasm is histamine, but antihistamines are not effective in the treatment of bronchial asthma.

Examples of unreasonable approaches to treating common ailments:
Application of sulfonamides in acute respiratory viral infections;
Widespread use of clonidine and combined drugs (such as Adelfan) at the first stage of the treatment of hypertension;
Using the so-called hepatoprotectors for the treatment of cirrhosis of the liver;
The use of cocarboxylase, Riboxin for the treatment of heart failure;
Parenteral administration of vitamins to the auxiliary treatment of diseases of internal organs;
Antibiotic patients’ infectious-allergic “myocarditis;
Using “immunomodulators” in herpetic infection;
The use of antihistamines for the treatment of moderately-severe asthma;
Appointment angioprotectors for the treatment of diabetic microangiopathy.

In medicine the important role played by subjective factors, such as doctor’s personal experience, expert opinion, etc. In certain situations, for example, when choosing an antibiotic for empirical treatment of infections, individual experience is – very important, but in other cases, he can not bring any benefit. Example – use of aspirin for secondary prevention of myocardial infarction. Obviously, when deciding whether prophylactic treatment of a doctor can rely solely on the results of clinical studies. Sometimes personal experience leads to the formation of misconceptions about drugs. For example, doctors often try to use the new funds under the most severe forms of the disease. The absence of any effect often leads to their complete disappointment, although the same drug might be an indispensable tool for treatment of mild or medium – severe disease or patients to any particular group (the elderly, patients with concomitant diseases, etc. .).

In recent years there has been a clear trend towards greater use of proven therapies of proven effectiveness in adequate clinical trials. Reflecting this trend are attempts to standardize approaches to the treatment of common diseases (guidelines for treatment of hypertension, HIV infection, pneumonia, chronic hepatitis, etc.). Such attempts may cause criticism from supporters of individualized treatment, but such objections hardly justified. First, the recommendations tend to leave a wide enough room to maneuver (for example, recommendations for the treatment of hypertension involves the selection of first-line among the six groups of antihypertensive drugs), which allows an individual approach to therapy. And, secondly, most importantly, these recommendations are based on real facts and eliminate the use of inappropriate treatments.

Unfortunately, Russia has increasingly faced with the opposite situation. Inexplicable popularity continues to enjoy a completely unfounded therapies, some of which are listed above. In fact, they are stereotypes, which are replicated in scientific articles and some tutorials.

Some of these provisions do not require discussion. For example, it is obvious that it makes no sense to apply the sulfonamides in patients with viral infections or to appoint a so-called hepatoprotectors for the treatment of liver cirrhosis.

Principles of medicine based on evidence, are of great importance, for teaching. Students and young doctors who do not have experience in treating patients, the most susceptible to subjective factors, so they quite easily form misconceptions about the approaches to the treatment of various diseases. Of course, no need to introduce into the curriculum in medical schools a new subject, but it should be taught at the institute desire to critically analyze scientific information.

By the way, in teaching we are confronted with yet another intractable problem. Textbooks used by students, usually out of date already by the time of publication, since their preparation requires several years, and during this period many things are changing.

Who should do the evidence-based medicine? The answer to this question is obvious. Principles of medicine based on evidence required for each physician, clinical pharmacist, pharmacists, which must critically analyze and interpret scientific data and use them in practice. Today, there are different views on medicine based on evidence. There are many critics of this approach. For example, the U.S. evidence-based medicine is often compared with the cookbook that contains recipes treat disease. On the other hand the radical supporters of medicine based on evidence brought to the absolute value of randomized controlled trials. Of course, the truth lies in the middle (need to find a middle ground). Modern medicine is close to the exact sciences, but still she never will not, therefore, individual experience and personality of the doctor always had, and will be – important. Today, however, it would be wrong in choosing treatment rely solely on the feelings and ignore the results of research work, specially engaged in the relevant issue. Ultimately, the practice of evidence-based medicine involves a combination of individual clinical experience and the best evidence obtained through systematic research.

I personally have always worked only evidence-based medicine prior to the introduction of the term. For me it was important to give the effect of using a particular drug or therapy. This is a matter of my professional honor, and what you all wish you, dear colleagues.