Evidence-based medicine (EBM): origins and modern application to spine care

Since the words evidence-based are so pervasively used in our present day practices of medicine in general, and spine specifically, we thought it might be of interest to explore the roots of this movement in greater detail. It is probably always a good idea to look for the origins of medical developments in ancient writings on scientific methods from around the world, particularly Greece and ancient Chinese medicine.

In more modern times, it has been 20 years or more since some of the first references to and basic descriptions of evidence-based medicine (EBM) started appearing in the medical literature [1], [2], [3]. Since then, the concept of EBM has gone through various interpretations and applications, myths and misconceptions, uses and abuses. Tenets of EBM have seeped in to most aspects of patient care in a variety of forms and have impacted areas from clinical practice guidelines to reimbursement and health policy. The precepts of EBM and their application continue to evolve.

Prior to the 1950s, health care decisions were based primarily on anecdotal information, pathophysiology, and the expert opinions of leaders in the profession. In a 1992 article in the Journal of the American Medical Association (JAMA), the author pointed to a „new paradigm for medical practice that is emerging,” and defined this paradigm as the shift away from „intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making” [2]. This opinion-based article introduced the concept of examining evidence from clinical research and applying the findings to clinical practice. Important to the introduction of EBM in clinical practice was that EBM „requires new skills of the physician, including efficient literature searching and the application of formal rules of evidence evaluating the clinical literature.” Some of the earliest arguments in the 1990s for an „evidence-based” approach to medical practice were in the context of systematic development of clinical guidelines [3].

Modern „founders” of EBM, include Archie Cochrane, David Sachett and Gordon Guyatt, and David Eddy among others. Each has contributed to unique areas of what we currently perceive as EBM.

References

• 1 Bhandari M, Zlowodzki M, Cole P A. From eminence-based practice to evidence-based practice: a paradigm shift.  Minn Med. 2004;  87 (4) 51-54
• 2 Rosenberg W M. Evidence-based medicine: a new approach to teaching the practice of medicine.  JAMA. 1992;  268 2420-2425
• 3 Eddy D M. Evidence-based medicine: a unified approach.  Health Aff (Millwood). 2005;  24 9-17
• 4 Jadad A. Randomised Controlled Trials: A User’s Guide. London: BMJ Books 1998
• 5 Stolberg H O, Norman G, Trop I. Randomized controlled trials.  AJR Am J Roentgenol. 2004;  183 (6) 1539-1544
• 6 The Cochran Collaboration .Archie Cochrane: the name behind The Cochrane Collaboration. Available at: „http://www.cochrane.org/about-us/history/archie.cochrane. 2010
• 7 Sackett D L, Rosenberg W M, Gray J A. et al . Evidence based medicine: what it is and what it isn’t.  BMJ. 1996;  312 (7023) 71-72
• 8 Oxford Centre for Evidence-based Medicine Levels of Evidence .Available at: www.cebm.net/?o = 1025 2009
• 9 West S, King V, Carey T S. et al . Systems to rate the strength of scientific evidence.  Evid Rep Technol Assess. 2002;  1-11
• 10 Weinstein J N, Lurie J D, Tosteson T D. et al . Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis: four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts.  J Bone Joint Surg Am. 2009;  91 (6) 1295-1304
• 11 Atkins D, Best D, Briss P A. et al . Grading quality of evidence and strength of recommendations.  BMJ. 2004;  328 (7454) 1490