Evidence-based medicine

Short description: Illness diagnosis, treatment and prevention based on data collection and analysis

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Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."[1] The aim of EBM is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians about individual patients.[2]

The EBM Pyramid is a tool that helps in visualizing the hierarchy of evidence in medicine, from least authoritative, like expert opinions, to most authoritative, like systematic reviews.[3]

## Contents

* 1 Background, history, and definition
* 1.1 Clinical decision-making
* 1.2 Evidence-based guidelines and policies
* 1.3 Medical education
* 1.4 Progress
* 1.5 Current practice
* 2 Methods
* 2.1 Steps
* 2.2 Evidence reviews
* 2.3 Assessing the quality of evidence
* 2.4 Categories of recommendations
* 2.5 Statistical measures
* 2.6 Quality of clinical trials
* 3 Limitations and criticism
* 4 Application of evidence in clinical settings
* 5 Education
* 6 See also
* 7 References
* 8 Bibliography
* 9 External links

## Background, history, and definition

Medicine has a long history of scientific inquiry about the prevention, diagnosis, and treatment of human disease.[4][5] In the 11th century AD, Avicenna, a Persian physician and philosopher, developed an approach to EBM that was mostly similar to current ideas and practises.[6][7]

The concept of a controlled clinical trial was first described in 1662 by Jan Baptist van Helmont in reference to the practice of bloodletting.[8] Wrote Van Helmont:

> Let us take out of the Hospitals, out of the Camps, or from elsewhere, 200, or 500 poor People, that have fevers or Pleuritis. Let us divide them in Halfes, let us cast lots, that one halfe of them may fall to my share, and the others to yours; I will cure them without blood-letting and sensible evacuation; but you do, as ye know ... we shall see how many Funerals both of us shall have...

The first published report describing the conduct and results of a controlled clinical trial was by James Lind, a Scottish naval surgeon who conducted research on scurvy during his time aboard HMS Salisbury in the Channel Fleet, while patrolling the Bay of Biscay. Lind divided the sailors participating in his experiment into six groups, so that the effects of various treatments could be fairly compared. Lind found improvement in symptoms and signs of scurvy among the group of men treated with lemons or oranges. He published a treatise describing the results of this experiment in 1753.[9]

An early critique of statistical methods in medicine was published in 1835.[10]

The term 'evidence-based medicine' was introduced in 1990 by Gordon Guyatt of McMaster University.[11][12][13][14]

### Clinical decision-making

Alvan Feinstein's publication of Clinical Judgment in 1967 focused attention on the role of clinical reasoning and identified biases that can affect it.[15] In 1972, Archie Cochrane published Effectiveness and Efficiency, which described the lack of controlled trials supporting many practices that had previously been assumed to be effective.[16] In 1973, John Wennberg began to document wide variations in how physicians practiced.[17] Through the 1980s, David M. Eddy described errors in clinical reasoning and gaps in evidence.[18][19][20][21] In the mid-1980s, Alvin Feinstein, David Sackett and others published textbooks on clinical epidemiology, which translated epidemiological methods to physician decision-making.[22][23] Toward the end of the 1980s, a group at RAND showed that large proportions of procedures performed by physicians were considered inappropriate even by the standards of their own experts.[24]

### Evidence-based guidelines and policies

Main page: Medicine:Medical guideline

David M. Eddy first began to use the term 'evidence-based' in 1987 in workshops and a manual commissioned by the Council of Medical Specialty Societies to teach formal methods for designing clinical practice guidelines. The manual was eventually published by the American College of Physicians.[25][26] Eddy first published the term 'evidence-based' in March 1990, in an article in the Journal of the American Medical Association that laid out the principles of evidence-based guidelines and population-level policies, which Eddy described as "explicitly describing the available evidence that pertains to a policy and tying the policy to evidence instead of standard-of-care practices or the beliefs of experts. The pertinent evidence must be identified, described, and analyzed. The policymakers must determine whether the policy is justified by the evidence. A rationale must be written."[27] He discussed evidence-based policies in several other papers published in JAMA in the spring of 1990.[27][28] Those papers were part of a series of 28 published in JAMA between 1990 and 1997 on formal methods for designing population-level guidelines and policies.[29]

### Medical education

The term 'evidence-based medicine' was introduced slightly later, in the context of medical education. In the autumn of 1990, Gordon Guyatt used it in an unpublished description of a program at McMaster University for prospective or new medical students.[30] Guyatt and others first published the term two years later (1992) to describe a new approach to teaching the practice of medicine.[2]

In 1996, David Sackett and colleagues clarified the definition of this tributary of evidence-based medicine as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. ... [It] means integrating individual clinical expertise with the best available external clinical evidence from systematic research."[1] This branch of evidence-based medicine aims to make individual decision making more structured and objective by better reflecting the evidence from research.[31][32] Population-based data are applied to the care of an individual patient,[33] while respecting the fact that practitioners have clinical expertise reflected in effective and efficient diagnosis and thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences.[1]

Between 1993 and 2000, the Evidence-Based Medicine Working Group at McMaster University published the methods to a broad physician audience in a series of 25 "Users' Guides to the Medical Literature" in JAMA. In 1995 Rosenberg and Donald defined individual-level, evidence-based medicine as "the process of finding, appraising, and using contemporaneous research findings as the basis for medical decisions."[34] In 2010, Greenhalgh used a definition that emphasized quantitative methods: "the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision-making in the diagnosis, investigation or management of individual patients."[35][1]

The two original definitions[which?] highlight important differences in how evidence-based medicine is applied to populations versus individuals. When designing guidelines applied to large groups of people in settings with relatively little opportunity for modification by individual physicians, evidence-based policymaking emphasizes that good evidence should exist to document a test's or treatment's effectiveness.[36] In the setting of individual decision-making, practitioners can be given greater latitude in how they interpret research and combine it with their clinical judgment.[1][37] In 2005, Eddy offered an umbrella definition for the two branches of EBM: "Evidence-based medicine is a set of principles and methods intended to ensure that to the greatest extent possible, medical decisions, guidelines, and other types of policies are based on and consistent with good evidence of effectiveness and benefit."[38]

### Progress

In the area of evidence-based guidelines and policies, the explicit insistence on evidence of effectiveness was introduced by the American Cancer Society in 1980.[39] The U.S. Preventive Services Task Force (USPSTF) began issuing guidelines for preventive interventions based on evidence-based principles in 1984.[40] In 1985, the Blue Cross Blue Shield Association applied strict evidence-based criteria for covering new technologies.[41] Beginning in 1987, specialty societies such as the American College of Physicians, and voluntary health organizations such as the American Heart Association, wrote many evidence-based guidelines. In 1991, Kaiser Permanente, a managed care organization in the US, began an evidence-based guidelines program.[42] In 1991, Richard Smith wrote an editorial in the British Medical Journal and introduced the ideas of evidence-based policies in the UK.[43] In 1993, the Cochrane Collaboration created a network of 13 countries to produce systematic reviews and guidelines.[44] In 1997, the US Agency for Healthcare Research and Quality (AHRQ, then known as the Agency for Health Care Policy and Research, or AHCPR) established Evidence-based Practice Centers (EPCs) to produce evidence reports and technology assessments to support the development of guidelines.[45] In the same year, a National Guideline Clearinghouse that followed the principles of evidence-based policies was created by AHRQ, the AMA, and the American Association of Health Plans (now America's Health Insurance Plans).[46] In 1999, the National Institute for Clinical Excellence (NICE) was created in the UK.[47]

In the area of medical education, medical schools in Canada, the US, the UK, Australia, and other countries[48][49] now offer programs that teach evidence-based medicine. A 2009 study of UK programs found that more than half of UK medical schools offered some training in evidence-based medicine, although the methods and content varied considerably, and EBM teaching was restricted by lack of curriculum time, trained tutors and teaching materials.[50] Many programs have been developed to help individual physicians gain better access to evidence. For example, UpToDate was created in the early 1990s.[51] The Cochrane Collaboration began publishing evidence reviews in 1993.[42] In 1995, BMJ Publishing Group launched Clinical Evidence, a 6-monthly periodical that provided brief summaries of the current state of evidence about important clinical questions for clinicians.[52]

### Current practice

By 2000, use of the term evidence-based had extended to other levels of the health care system. An example is evidence-based health services, which seek to increase the competence of health service decision makers and the practice of evidence-based medicine at the organizational or institutional level.[53]

The multiple tributaries of evidence-based medicine share an emphasis on the importance of incorporating evidence from formal research in medical policies and decisions. However, because they differ on the extent to which they require good evidence of effectiveness before promoting a guideline or payment policy, a distinction is sometimes made between evidence-based medicine and science-based medicine, which also takes into account factors such as prior plausibility and compatibility with established science (as when medical organizations promote controversial treatments such as acupuncture).[54] Differences also exist regarding the extent to which it is feasible to incorporate individual-level information in decisions. Thus, evidence-based guidelines and policies may not readily "hybridise" with experience-based practices orientated towards ethical clinical judgement, and can lead to contradictions, contest, and unintended crises.[21] The most effective "knowledge leaders" (managers and clinical leaders) use a broad range of management knowledge in their decision making, rather than just formal evidence.[22] Evidence-based guidelines may provide the basis for governmentality in health care, and consequently play a central role in the governance of contemporary health care systems.[23]

## Methods

### Steps

The steps for designing explicit, evidence-based guidelines were described in the late 1980s: formulate the question (population, intervention, comparison intervention, outcomes, time horizon, setting); search the literature to identify studies that inform the question; interpret each study to determine precisely what it says about the question; if several studies address the question, synthesize their results (meta-analysis); summarize the evidence in evidence tables; compare the benefits, harms and costs in a balance sheet; draw a conclusion about the preferred practice; write the guideline; write the rationale for the guideline; have others review each of the previous steps; implement the guideline.[20]

For the purposes of medical education and individual-level decision making, five steps of EBM in practice were described in 1992[55] and the experience of delegates attending the 2003 Conference of Evidence-Based Health Care Teachers and Developers was summarized into five steps and published in 2005.[56] This five-step process can broadly be categorized as follows:

1. Translation of uncertainty to an answerable question; includes critical questioning, study design and levels of evidence[57]
2. Systematic retrieval of the best evidence available[58]
3. Critical appraisal of evidence for internal validity that can be broken down into aspects regarding:[33]
* Systematic errors as a result of selection bias, information bias and confounding
* Quantitative aspects of diagnosis and treatment
* The effect size and aspects regarding its precision
* Clinical importance of results
* External validity or generalizability
4. Application of results in practice[59]
5. Evaluation of performance[60]

### Evidence reviews

Systematic reviews of published research studies are a major part of the evaluation of particular treatments. The Cochrane Collaboration is one of the best-known organisations that conducts systematic reviews. Like other producers of systematic reviews, it requires authors to provide a detailed study protocol as well as a reproducible plan of their literature search and evaluations of the evidence.[61] After the best evidence is assessed, treatment is categorized as (1) likely to be beneficial, (2) likely to be harmful, or (3) without evidence to support either benefit or harm.[citation needed]

A 2007 analysis of 1,016 systematic reviews from all 50 Cochrane Collaboration Review Groups found that 44% of the reviews concluded that the intervention was likely to be beneficial, 7% concluded that the intervention was likely to be harmful, and 49% concluded that evidence did not support either benefit or harm. 96% recommended further research.[62] In 2017, a study assessed the role of systematic reviews produced by Cochrane Collaboration to inform US private payers' policymaking; it showed that although the medical policy documents of major US private payers were informed by Cochrane systematic reviews, there was still scope to encourage the further use.[63]

### Assessing the quality of evidence

Main page: Levels of evidence

Evidence-based medicine categorizes different types of clinical evidence and rates or grades them[64] according to the strength of their freedom from the various biases that beset medical research. For example, the strongest evidence for therapeutic interventions is provided by systematic review of randomized, well-blinded, placebo-controlled trials with allocation concealment and complete follow-up involving a homogeneous patient population and medical condition. In contrast, patient testimonials, case reports, and even expert opinion have little value as proof because of the placebo effect, the biases inherent in observation and reporting of cases, and difficulties in ascertaining who is an expert (however, some critics have argued that expert opinion "does not belong in the rankings of the quality of empirical evidence because it does not represent a form of empirical evidence" and continue that "expert opinion would seem to be a separate, complex type of knowledge that would not fit into hierarchies otherwise limited to empirical evidence alone.").[65]

Several organizations have developed grading systems for assessing the quality of evidence. For example, in 1989 the U.S. Preventive Services Task Force (USPSTF) put forth the following system:[66]

* Level I: Evidence obtained from at least one properly designed randomized controlled trial.
* Level II-1: Evidence obtained from well-designed controlled trials without randomization.
* Level II-2: Evidence obtained from well-designed cohort studies or case-control studies, preferably from more than one center or research group.
* Level II-3: Evidence obtained from multiple time series designs with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
* Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Another example are the Oxford CEBM Levels of Evidence published by the Centre for Evidence-Based Medicine. First released in September 2000, the Levels of Evidence provide a way to rank evidence for claims about prognosis, diagnosis, treatment benefits, treatment harms, and screening, which most grading schemes do not address. The original CEBM Levels were Evidence-Based On Call to make the process of finding evidence feasible and its results explicit. In 2011, an international team redesigned the Oxford CEBM Levels to make them more understandable and to take into account recent developments in evidence ranking schemes. The Oxford CEBM Levels of Evidence have been used by patients and clinicians, as well as by experts to develop clinical guidelines, such as recommendations for the optimal use of phototherapy and topical therapy in psoriasis[67] and guidelines for the use of the BCLC staging system for diagnosing and monitoring hepatocellular carcinoma in Canada.[68]

In 2000, a system was developed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. The GRADE system takes into account more dimensions than just the quality of medical research.[69] It requires users who are performing an assessment of the quality of evidence, usually as part of a systematic review, to consider the impact of different factors on their confidence in the results. Authors of GRADE tables assign one of four levels to evaluate the quality of evidence, on the basis of their confidence that the observed effect (a numeric value) is close to the true effect. The confidence value is based on judgments assigned in five different domains in a structured manner.[70] The GRADE working group defines 'quality of evidence' and 'strength of recommendations' based on the quality as two different concepts that are commonly confused with each other.[70]

Systematic reviews may include randomized controlled trials that have low risk of bias, or observational studies that have high risk of bias. In the case of randomized controlled trials, the quality of evidence is high but can be downgraded in five different domains.[71]

* Risk of bias: A judgment made on the basis of the chance that bias in included studies has influenced the estimate of effect.
* Imprecision: A judgment made on the basis of the chance that the observed estimate of effect could change completely.
* Indirectness: A judgment made on the basis of the differences in characteristics of how the study was conducted and how the results are actually going to be applied.
* Inconsistency: A judgment made on the basis of the variability of results across the included studies.
* Publication bias: A judgment made on the basis of the question whether all the research evidence has been taken to account.[72]

In the case of observational studies per GRADE, the quality of evidence starts off lower and may be upgraded in three domains in addition to being subject to downgrading.[71]

* Large effect: Methodologically strong studies show that the observed effect is so large that the probability of it changing completely is less likely.
* Plausible confounding would change the effect: Despite the presence of a possible confounding factor that is expected to reduce the observed effect, the effect estimate still shows significant effect.
* Dose response gradient: The intervention used becomes more effective with increasing dose. This suggests that a further increase will likely bring about more effect.

Meaning of the levels of quality of evidence as per GRADE:[70]

* High Quality Evidence: The authors are very confident that the presented estimate lies very close to the true value. In other words, the probability is very low that further research will completely change the presented conclusions.
* Moderate Quality Evidence: The authors are confident that the presented estimate lies close to the true value, but it is also possible that it may be substantially different. In other words, further research may completely change the conclusions.
* Low Quality Evidence: The authors are not confident in the effect estimate, and the true value may be substantially different. In other words, further research is likely to change the presented conclusions completely.
* Very Low Quality Evidence: The authors do not have any confidence in the estimate and it is likely that the true value is substantially different from it. In other words, new research will probably change the presented conclusions completely.

### Categories of recommendations

In guidelines and other publications, recommendation for a clinical service is classified by the balance of risk versus benefit and the level of evidence on which this information is based. The U.S. Preventive Services Task Force uses the following system:[73]

* Level A: Good scientific evidence suggests that the benefits of the clinical service substantially outweigh the potential risks. Clinicians should discuss the service with eligible patients.
* Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks. Clinicians should discuss the service with eligible patients.
* Level C: At least fair scientific evidence suggests that the clinical service provides benefits, but the balance between benefits and risks is too close for general recommendations. Clinicians need not offer it unless individual considerations apply.
* Level D: At least fair scientific evidence suggests that the risks of the clinical service outweigh potential benefits. Clinicians should not routinely offer the service to asymptomatic patients.
* Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.

GRADE guideline panelists may make strong or weak recommendations on the basis of further criteria. Some of the important criteria are the balance between desirable and undesirable effects (not considering cost), the quality of the evidence, values and preferences and costs (resource utilization).[71]

Despite the differences between systems, the purposes are the same: to guide users of clinical research information on which studies are likely to be most valid. However, the individual studies still require careful critical appraisal.[citation needed]

### Statistical measures

Evidence-based medicine attempts to express clinical benefits of tests and treatments using mathematical methods. Tools used by practitioners of evidence-based medicine include:

* Likelihood ratio

Main page: Likelihood ratios in diagnostic testing The pre-test odds of a particular diagnosis, multiplied by the likelihood ratio, determines the post-test odds. (Odds can be calculated from, and then converted to, the [more familiar] probability.) This reflects Bayes' theorem. The differences in likelihood ratio between clinical tests can be used to prioritize clinical tests according to their usefulness in a given clinical situation.

* AUC-ROC The area under the receiver operating characteristic curve (AUC-ROC) reflects the relationship between sensitivity and specificity for a given test. High-quality tests will have an AUC-ROC approaching 1, and high-quality publications about clinical tests will provide information about the AUC-ROC. Cutoff values for positive and negative tests can influence specificity and sensitivity, but they do not affect AUC-ROC.
* Number needed to treat (NNT)/Number needed to harm (NNH). NNT and NNH are ways of expressing the effectiveness and safety, respectively, of interventions in a way that is clinically meaningful. NNT is the number of people who need to be treated in order to achieve the desired outcome (e.g. survival from cancer) in one patient. For example, if a treatment increases the chance of survival by 5%, then 20 people need to be treated in order for 1 additional patient to survive because of the treatment. The concept can also be applied to diagnostic tests. For example, if 1,339 women age 50–59 need to be invited for breast cancer screening over a ten-year period in order to prevent one woman from dying of breast cancer,[74] then the NNT for being invited to breast cancer screening is 1339.

### Quality of clinical trials

Evidence-based medicine attempts to objectively evaluate the quality of clinical research by critically assessing techniques reported by researchers in their publications.

* Trial design considerations: High-quality studies have clearly defined eligibility criteria and have minimal missing data.[75][76]
* Generalizability considerations: Studies may only be applicable to narrowly defined patient populations and may not be generalizable to other clinical contexts.[75]
* Follow-up: Sufficient time for defined outcomes to occur can influence the prospective study outcomes and the statistical power of a study to detect differences between a treatment and control arm.[77]
* Power: A mathematical calculation can determine whether the number of patients is sufficient to detect a difference between treatment arms. A negative study may reflect a lack of benefit, or simply a lack of sufficient quantities of patients to detect a difference.[77][75][78]

## Limitations and criticism

There are a number of limitations and criticisms of evidence-based medicine.[79][80][81] Two widely cited categorization schemes for the various published critiques of EBM include the three-fold division of Straus and McAlister ("limitations universal to the practice of medicine, limitations unique to evidence-based medicine and misperceptions of evidence-based-medicine")[82] and the five-point categorization of Cohen, Stavri and Hersh (EBM is a poor philosophic basis for medicine, defines evidence too narrowly, is not evidence-based, is limited in usefulness when applied to individual patients, or reduces the autonomy of the doctor/patient relationship).[83]

In no particular order, some published objections include:

* Research produced by EBM, such as from randomized controlled trials (RCTs), may not be relevant for all treatment situations.[84] Research tends to focus on specific populations, but individual persons can vary substantially from population norms. Because certain population segments have been historically under-researched (due to reasons such as race, gender, age, and co-morbid diseases), evidence from RCTs may not be generalizable to those populations.[85] Thus, EBM applies to groups of people, but this should not preclude clinicians from using their personal experience in deciding how to treat each patient. One author advises that "the knowledge gained from clinical research does not directly answer the primary clinical question of what is best for the patient at hand" and suggests that evidence-based medicine should not discount the value of clinical experience.[65] Another author stated that "the practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."[1]
* The theoretical ideal of EBM (that every narrow clinical question, of which hundreds of thousands can exist, would be answered by meta-analysis and systematic reviews of multiple RCTs) faces the limitation that research (especially the RCTs themselves) is expensive; thus, in reality, for the foreseeable future, the demand for EBM will always be much higher than the supply, and the best humanity can do is to triage the application of scarce resources.
* Research can be influenced by biases such as publication bias and conflict of interest in academic publishing. For example, studies with conflicts due to industry funding are more likely to favor their product.[86][87] It has been argued that contemporary evidence based medicine is an illusion, since evidence based medicine has been corrupted by corporate interests, failed regulation, and commercialisation of academia.[88]
* Systematic Reviews methodologies are capable of bias and abuse in respect of (i) choice of inclusion criteria (ii) choice of outcome measures, comparisons and analyses (iii) the subjectivity inevitable in Risk of Bias assessments, even when codified procedures and criteria are observed.[89][90][91] An example of all these problems can be seen in a Cochrane Review,[92] as analyzed by Edmund J. Fordham, et al. in their relevant review.[89]
* A lag exists between when the RCT is conducted and when its results are published.[93]
* A lag exists between when results are published and when they are properly applied.[94]
* Hypocognition (the absence of a simple, consolidated mental framework into which new information can be placed) can hinder the application of EBM.[95]
* Values: while patient values are considered in the original definition of EBM, the importance of values is not commonly emphasized in EBM training, a potential problem under current study.[96][97][98]

A 2018 study, "Why all randomised controlled trials produce biased results", assessed the 10 most cited RCTs and argued that trials face a wide range of biases and constraints, from trials only being able to study a small set of questions amenable to randomisation and generally only being able to assess the average treatment effect of a sample, to limitations in extrapolating results to another context, among many others outlined in the study.[79]

## Application of evidence in clinical settings

Despite the emphasis on evidence-based medicine, unsafe or ineffective medical practices continue to be applied, because of patient demand for tests or treatments, because of failure to access information about the evidence, or because of the rapid pace of change in the scientific evidence.[99] For example, between 2003 and 2017, the evidence shifted on hundreds of medical practices, including whether hormone replacement therapy was safe, whether babies should be given certain vitamins, and whether antidepressant drugs are effective in people with Alzheimer's disease.[100] Even when the evidence unequivocally shows that a treatment is either not safe or not effective, it may take many years for other treatments to be adopted.[99]

There are many factors that contribute to lack of uptake or implementation of evidence-based recommendations.[101] These include lack of awareness at the individual clinician or patient (micro) level, lack of institutional support at the organisation level (meso) level or higher at the policy (macro) level.[102][103] In other cases, significant change can require a generation of physicians to retire or die and be replaced by physicians who were trained with more recent evidence.[99]

Physicians may also reject evidence that conflicts with their anecdotal experience or because of cognitive biases – for example, a vivid memory of a rare but shocking outcome (the availability heuristic), such as a patient dying after refusing treatment.[99] They may overtreat to "do something" or to address a patient's emotional needs.[99] They may worry about malpractice charges based on a discrepancy between what the patient expects and what the evidence recommends.[99] They may also overtreat or provide ineffective treatments because the treatment feels biologically plausible.[99]

It is the responsibility of those developing clinical guidelines to include an implementation plan to facilitate uptake.[104] The implementation process will include an implementation plan, analysis of the context, identifying barriers and facilitators and designing the strategies to address them.[104]

## Education

Training in evidence based medicine is offered across the continuum of medical education.[56] Educational competencies have been created for the education of health care professionals.[105][56][106]

The Berlin questionnaire and the Fresno Test[107][108] are validated instruments for assessing the effectiveness of education in evidence-based medicine.[109][110] These questionnaires have been used in diverse settings.[111][112]

A Campbell systematic review that included 24 trials examined the effectiveness of e-learning in improving evidence-based health care knowledge and practice. It was found that e-learning, compared to no learning, improves evidence-based health care knowledge and skills but not attitudes and behaviour. No difference in outcomes is present when comparing e-learning with face-to-face learning. Combining e-learning and face-to-face learning (blended learning) has a positive impact on evidence-based knowledge, skills, attitude and behavior.[113] As a form of e-learning, some medical school students engage in editing Wikipedia to increase their EBM skills,[114] and some students construct EBM materials to develop their skills in communicating medical knowledge.[115]

## See also

## References

1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 "Evidence based medicine: what it is and what it isn't". BMJ 312 (7023): 71–72. January 1996. doi:10.1136/bmj.312.7023.71. PMID 8555924.
2. ↑ 2.0 2.1 Evidence-Based Medicine Working Group (November 1992). "Evidence-based medicine. A new approach to teaching the practice of medicine". JAMA 268 (17): 2420–2425. doi:10.1001/JAMA.1992.03490170092032. PMID 1404801.
3. ↑ "Evidence-Based Medicine Pyramid". Med Scholarly. https://medscholarly.com/evidence-based-medicine-pyramid/.
4. ↑ "Clinical pharmacology in the Middle Ages: principles that presage the 21st century". Clinical Pharmacology and Therapeutics 67 (5): 447–450. May 2000. doi:10.1067/mcp.2000.106465. PMID 10824622.
5. ↑ "Medieval contributions to the search for truth in clinical medicine". Perspectives in Biology and Medicine 43 (4): 530–540. 2000. doi:10.1353/pbm.2000.0037. PMID 11058989.
6. ↑ "Legacy of Avicenna and evidence-based medicine". International Journal of Cardiology 150 (3): 243–246. August 2011. doi:10.1016/j.ijcard.2010.10.019. PMID 21093081.
7. ↑ "Avicenna and evidence based medicine". Avicenna Journal of Medical Biotechnology 6 (1): 1–2. January 2014. PMID 24523951.
8. ↑ John Baptista Van Helmont (1662). Oriatrike, or Physick Refined (English translation of Ortus medicinae). https://wellcomecollection.org/works/jh9aanrn.
9. ↑ Treatise on the scurvy. Gale Ecco. 2018. ISBN 978-1-379-46980-3.
10. ↑ "Statistical research on conditions caused by calculi by Doctor Civiale. 1835". International Journal of Epidemiology 30 (6): 1246–1249. December 2001. doi:10.1093/ije/30.6.1246. PMID 11821317. http://ije.oupjournals.org/cgi/content/full/30/6/1246.
11. ↑ Guyatt GH. Evidence-Based Medicine [editorial]. ACP Journal Club 1991:A-16. (Annals of Internal Medicine; vol. 114, suppl. 2).
12. ↑ "Development of evidence-based medicine explored in oral history video, AMA, Jan 27, 2014". 27 January 2014. https://www.ama-assn.org/residents-students/residency/development-evidence-based-medicine-explored-oral-history-video.
13. ↑ "The need for evidence-based medicine". Journal of the Royal Society of Medicine 88 (11): 620–624. November 1995. doi:10.1177/014107689508801105. PMID 8544145.
14. ↑ The history of evidence-based medicine. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG). 2016. NBK390299. https://www.ncbi.nlm.nih.gov/books/NBK390299/.
15. ↑ Alvan R. Feinstein (1967). Clinical Judgement. Williams & Wilkins.
16. ↑ Cochrane A.L. (1972). Effectiveness and Efficiency: Random Reflections on Health Services. Nuffield Provincial Hospitals Trust.
17. ↑ "Small area variations in health care delivery". Science 182 (4117): 1102–1108. December 1973. doi:10.1126/science.182.4117.1102. PMID 4750608. Bibcode: 1973Sci...182.1102W.
18. ↑ "18 Probabilistic Reasoning in Clinical Medicine: Problems and Opportunities". Judgment Under Uncertainty: Heuristics and Biases. Cambridge University Press. 1982. pp. 249–267. ISBN 978-0-521-28414-1. https://books.google.com/books?id=_0H8gwj4a1MC&pg=PA249.
19. ↑ "Clinical policies and the quality of clinical practice". The New England Journal of Medicine 307 (6): 343–347. August 1982. doi:10.1056/nejm198208053070604. PMID 7088099.
20. ↑ 20.0 20.1 "Variations in physician practice: the role of uncertainty". Health Affairs 3 (2): 74–89. 1984. doi:10.1377/hlthaff.3.2.74. PMID 6469198.
21. ↑ 21.0 21.1 "The quality of medical evidence: implications for quality of care". Health Affairs 7 (1): 19–32. 1988. doi:10.1377/hlthaff.7.1.19. PMID 3360391.
22. ↑ 22.0 22.1 Feinstein AR (1985). Clinical Epidemiology: The Architecture of Clinical Research. W.B. Saunders Company. ISBN 978-0-7216-1308-6.
23. ↑ 23.0 23.1 Clinical Epidemiology: How to Do Clinical Practice Research. Lippincott Williams & Wilkins. 2006. ISBN 978-0-7817-4524-6. https://books.google.com/books?id=cuvY6TItIwgC&pg=PA59.
24. ↑ "How coronary angiography is used. Clinical determinants of appropriateness". JAMA 258 (18): 2543–2547. November 1987. doi:10.1001/jama.258.18.2543. PMID 3312657.
25. ↑ Eddy DM (1992). A Manual for Assessing Health Practices and Designing Practice Policies. American College of Physicians. ISBN 978-0-943126-18-0.
26. ↑ Institute of Medicine (1990). Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy of Sciences Press. p. 32. doi:10.17226/1626. ISBN 978-0-309-07666-1. http://www.nap.edu/openbook.php?record_id=1626&page=32.
27. ↑ 27.0 27.1 "Clinical decision making: from theory to practice. Practice policies—guidelines for methods". JAMA 263 (13): 1839–1841. April 1990. doi:10.1001/jama.263.13.1839. PMID 2313855.
28. ↑ "Clinical decision making: from theory to practice. Guidelines for policy statements: the explicit approach". JAMA 263 (16): 2239–40, 2243. April 1990. doi:10.1001/jama.1990.03440160101046. PMID 2319689.
29. ↑ Eddy DM (1996). Clinical Decision Making: From Theory to Practice. A Collection of Essays. American Medical Association. ISBN 978-0-7637-0143-7.
30. ↑ The Philosophy of Evidence-based Medicine. Wiley. 23 February 2011. p. 15. ISBN 978-1-4443-4266-6.
31. ↑ Clinical Epidemiology & Evidence-Based Medicine: Fundamental Principles of Clinical Reasoning & Research. Sage. 2001. ISBN 978-0-7619-1939-1. https://archive.org/details/clinicalepidemio0000katz.
32. ↑ Clinical Epidemiology: Principles, Methods, and Applications for Clinical Research. Jones & Bartlett Learning. 2009. ISBN 978-0-7637-5315-3.
33. ↑ 33.0 33.1 Understanding Evidence in Health Care: Using Clinical Epidemiology. South Yarra, VIC, Australia: Palgrave Macmillan. 2012. ISBN 978-1-4202-5669-7.
34. ↑ "Evidence based medicine: an approach to clinical problem-solving". BMJ 310 (6987): 1122–1126. April 1995. doi:10.1136/bmj.310.6987.1122. PMID 7742682.
35. ↑ How to Read a Paper: The Basics of Evidence-Based Medicine (4th ed.). John Wiley & Sons. 2010. p. 1. ISBN 978-1-4443-9036-0. https://archive.org/details/howtoreadpaperba00tgre.
36. ↑ "Practice policies: where do they come from?". JAMA 263 (9): 1265, 1269, 1272 passim. March 1990. doi:10.1001/jama.263.9.1265. PMID 2304243.
37. ↑ "The limits of evidence-based medicine". Respiratory Care 46 (12): 1435–1440. December 2001. PMID 11728302.
38. ↑ "Evidence-based medicine: a unified approach". Health Affairs 24 (1): 9–17. 2005. doi:10.1377/hlthaff.24.1.9. PMID 15647211.
39. ↑ "ACS report on the cancer-related health checkup". CA 30 (4): 193–240. 1980. doi:10.3322/canjclin.30.4.194. PMID 6774802.
40. ↑ "About the USPSTF". http://www.uspreventiveservicestaskforce.org/about.htm.
41. ↑ False Hope: Bone Marrow Transplantation for Breast Cancer: Bone Marrow Transplantation for Breast Cancer. Oxford University Press. 2007. pp. 183. ISBN 978-0-19-974824-2. https://books.google.com/books?id=bbcTZLRRVmoC&pg=PA183.
42. ↑ 42.0 42.1 "Transparency matters: Kaiser Permanente's National Guideline Program methodological processes". The Permanente Journal 16 (1): 55–62. 2012. doi:10.7812/tpp/11-134. PMID 22529761.
43. ↑ "Where is the wisdom...?". BMJ 303 (6806): 798–799. October 1991. doi:10.1136/bmj.303.6806.798. PMID 1932964.
44. ↑ "The Cochrane Collaboration". http://www.cochrane.org.
45. ↑ "Agency for Health Care Policy and Research". http://www.ahrq.gov/research/findings/evidence-based-reports/overview/index.html.
46. ↑ "National Guideline Clearinghouse". http://www.guideline.gov.
47. ↑ "National Institute for Health and Care Excellence". http://www.nice.org.uk.
48. ↑ "Methods of teaching medical trainees evidence-based medicine: a systematic review". Medical Education 48 (2): 124–135. February 2014. doi:10.1111/medu.12288. PMID 24528395.
49. ↑ "Evidence-based medicine training in undergraduate medical education: a review and critique of the literature published 2006–2011". Academic Medicine 88 (7): 1022–1028. July 2013. doi:10.1097/ACM.0b013e3182951959. PMID 23702528.
50. ↑ "Evidence-based medicine teaching in UK medical schools". Medical Teacher 31 (4): 332–337. April 2009. doi:10.1080/01421590802572791. PMID 19404893.
51. ↑ "UpToDate". http://www.uptodate.com/home.
52. ↑ "Clinical Evidence". http://www.clinicalevidence.bmj.com.
53. ↑ Gray, J. A. Muir (2009). Evidence-based Health Care & Public Health. Churchill Livingstone. ISBN 978-0-443-10123-6.
54. ↑ "AAFP promotes acupuncture". Science-Based Medicine. 9 October 2018. https://sciencebasedmedicine.org/aafp-promotes-acupuncture/.
55. ↑ "Critical appraisal of therapeutic interventions in the intensive care unit: human monoclonal antibody treatment in sepsis. Journal Club of the Hamilton Regional Critical Care Group". Journal of Intensive Care Medicine 7 (6): 275–282. 1992. doi:10.1177/088506669200700601. PMID 10147956.
56. ↑ 56.0 56.1 56.2 "Sicily statement on evidence-based practice". BMC Medical Education 5 (1): 1. January 2005. doi:10.1186/1472-6920-5-1. PMID 15634359.
57. ↑ "The well-built clinical question: a key to evidence-based decisions". ACP Journal Club 123 (3): A12–A13. 1995. doi:10.7326/ACPJC-1995-123-3-A12. PMID 7582737.
58. ↑ "Improving searching skills and evidence retrieval". Journal of the Royal College of Physicians of London 32 (6): 557–563. 1998. PMID 9881313.
59. ↑ "Teaching evidence-based medicine skills through a residency-developed guideline". Family Medicine 34 (9): 646–648. October 2002. PMID 12455246.
60. ↑ "Audit and feedback: effects on professional practice and healthcare outcomes". The Cochrane Database of Systematic Reviews 6 (6): CD000259. June 2012. doi:10.1002/14651858.CD000259.pub3. PMID 22696318.
61. ↑ "Evidence-based medicine and the Cochrane Collaboration". Bulletin of the NYU Hospital for Joint Diseases 67 (2): 198–205. 2009. PMID 19583554. http://www.nyuhjdbulletin.org/Permalink.aspx?permalinkId=07a150ec-2275-4bbf-9003-6ea200b62a4f.
62. ↑ "Mapping the Cochrane evidence for decision making in health care". Journal of Evaluation in Clinical Practice 13 (4): 689–692. August 2007. doi:10.1111/j.1365-2753.2007.00886.x. PMID 17683315.
63. ↑ "Role of Cochrane Reviews in informing US private payers' policies". Journal of Evidence-Based Medicine 10 (4): 293–331. November 2017. doi:10.1111/jebm.12278. PMID 29193899.
64. ↑ "EBM: Levels of Evidence". Essential Evidence Plus. http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=grade.
65. ↑ 65.0 65.1 "In defense of expert opinion". Academic Medicine 74 (11): 1187–1192. November 1999. doi:10.1097/00001888-199911000-00010. PMID 10587679.
66. ↑ U.S. Preventive Services Task Force (August 1989). Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. DIANE Publishing. pp. 24–. ISBN 978-1-56806-297-6. https://books.google.com/books?id=eQGJHgI_dR8C&pg=PR24.
67. ↑ OCEBM Levels of Evidence Working Group (May 2016). "The Oxford Levels of Evidence 2'". http://www.cebm.net/index.aspx?o=5653.
68. ↑ "Evidence-based recommendations on topical treatment and phototherapy of psoriasis: systematic review and expert opinion of a panel of dermatologists". Journal of the European Academy of Dermatology and Venereology 26 (Suppl 3): 1–10. May 2012. doi:10.1111/j.1468-3083.2012.04518.x. PMID 22512675.
69. ↑ "Welcome to the GRADE working group". http://www.gradeworkinggroup.org/.
70. ↑ 70.0 70.1 70.2 "GRADE guidelines: 3. Rating the quality of evidence". Journal of Clinical Epidemiology 64 (4): 401–406. April 2011. doi:10.1016/j.jclinepi.2010.07.015. PMID 21208779.
71. ↑ 71.0 71.1 71.2 GRADE handbook for grading quality of evidence and strength of recommendation (Version 3.2 ed.). 2009.
"GRADEPro". http://tech.cochrane.org/gradepro.
GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group. 2013. https://gdt.gradepro.org/app/handbook/handbook.html. Retrieved 3 September 2019.
72. ↑ DeVito, Nicholas J.; Goldacre, Ben (April 2019). "Catalogue of bias: publication bias". BMJ Evidence-based Medicine 24 (2): 53–54. doi:10.1136/bmjebm-2018-111107. ISSN 2515-4478. PMID 30523135.
73. ↑ "Multidisciplinary Canadian consensus recommendations for the management and treatment of hepatocellular carcinoma". Current Oncology 18 (5): 228–240. October 2011. doi:10.3747/co.v18i5.952. PMID 21980250.
74. ↑ "Patient Compliance with statins" Bandolier Review 2004
75. ↑ 75.0 75.1 75.2 Bellomo, Rinaldo; Bagshaw, Sean M. (2006). "Evidence-based medicine: classifying the evidence from clinical trials—the need to consider other dimensions". Critical Care 10 (5): 232. doi:10.1186/cc5045. ISSN 1466-609X. PMID 17029653.
76. ↑ Greeley, Christopher (December 2016). "Demystifying the Medical Literature". Academic Forensic Pathology 6 (4): 556–567. doi:10.23907/2016.055. ISSN 1925-3621. PMID 31239931.
77. ↑ 77.0 77.1 Akobeng, A. K. (August 2005). "Understanding randomised controlled trials". Archives of Disease in Childhood 90 (8): 840–844. doi:10.1136/adc.2004.058222. ISSN 1468-2044. PMID 16040885.
78. ↑ "Statistical Power". 2007. http://www.bandolier.org.uk/booth/glossary/statpow.html.
79. ↑ 79.0 79.1 "Why all randomised controlled trials produce biased results". Annals of Medicine 50 (4): 312–322. June 2018. doi:10.1080/07853890.2018.1453233. PMID 29616838.
80. ↑ "The promises and pitfalls of evidence-based medicine". Health Affairs 24 (1): 18–28. 2005. doi:10.1377/hlthaff.24.1.18. PMID 15647212.
81. ↑ "The illusion of evidence based medicine". BMJ 376: o702. March 2022. doi:10.1136/bmj.o702. PMID 35296456.
82. ↑ "Evidence-based medicine: a commentary on common criticisms". CMAJ 163 (7): 837–841. October 2000. PMID 11033714. PMC 80509. http://www.cmaj.ca/content/163/7/837.full.pdf.
83. ↑ "A categorization and analysis of the criticisms of Evidence-Based Medicine". International Journal of Medical Informatics 73 (1): 35–43. February 2004. doi:10.1016/j.ijmedinf.2003.11.002. PMID 15036077. http://skynet.ohsu.edu/~hersh/ijmi-04-ebm.pdf.
84. ↑ "Meaning and measurement: an inclusive model of evidence in health care". Journal of Evaluation in Clinical Practice 7 (2): 91–96. May 2001. doi:10.1046/j.1365-2753.2001.00279.x. PMID 11489034.
85. ↑ "Evidence based medicine and justice: a framework for looking at the impact of EBM upon vulnerable or disadvantaged groups". Journal of Medical Ethics 30 (2): 141–145. April 2004. doi:10.1136/jme.2003.007062. PMID 15082806.
86. ↑ "How evidence-based medicine is failing due to biased trials and selective publication". Journal of Evaluation in Clinical Practice 20 (6): 908–914. December 2014. doi:10.1111/jep.12147. PMID 24819404.
87. ↑ "Relationship between conflicts of interest and research results". Journal of General Internal Medicine 19 (1): 51–56. January 2004. doi:10.1111/j.1525-1497.2004.30617.x. PMID 14748860.
88. ↑ "The illusion of evidence based medicine". BMJ 376: o702. March 2022. doi:10.1136/bmj.o702. PMID 35296456.
89. ↑ 89.0 89.1 "The uses and abuses of systematic reviews". ResearchGate. October 2021. https://www.researchgate.net/publication/355132966.
90. ↑ "Publication bias in meta-analyses from the Cochrane Database of Systematic Reviews". Statistics in Medicine 34 (20): 2781–2793. September 2015. doi:10.1002/sim.6525. PMID 25988604.
91. ↑ "Uses and abuses of meta-analysis". Clinical Medicine 1 (6): 478–484. Nov–Dec 2001. doi:10.7861/clinmedicine.1-6-478. PMID 11792089.
92. ↑ "Ivermectin for preventing and treating COVID-19". The Cochrane Database of Systematic Reviews 2022 (6): CD015017. June 2022. doi:10.1002/14651858.CD015017.pub3. PMID 35726131.
93. ↑ "Case report on trial: Do you, Doctor, swear to tell the truth, the whole truth and nothing but the truth?". Journal of Medical Case Reports 5 (1): 179. May 2011. doi:10.1186/1752-1947-5-179. PMID 21569508.
94. ↑ "Knowledge Transfer in the ED: How to Get Evidence Used". Best Evidence Healthcare Blog. http://blog.bestevidencesystems.com/2013/09/30/knowledge-transfer-in-the-ed-how-to-get-evidence-used/.
95. ↑ "Hypocognition and evidence-based medicine". Internal Medicine Journal 40 (1): 80–82. January 2010. doi:10.1111/j.1445-5994.2009.02086.x. PMID 20561370.
96. ↑ "Evidence-based public health: a critical perspective" (in en). Journal of Public Health 16 (3): 169–172. 1 June 2008. doi:10.1007/s10389-007-0156-7. ISSN 0943-1853.
97. ↑ "The importance of values in evidence-based medicine". BMC Medical Ethics 16 (1): 69. October 2015. doi:10.1186/s12910-015-0063-3. PMID 26459219.
98. ↑ Essential Values-Based Practice. Cambridge University Press. March 2012. ISBN 978-0-521-53025-5. http://www.cambridge.org/gb/academic/subjects/medicine/medicine-general-interest/essential-values-based-practice-clinical-stories-linking-science-people.
99. ↑ 99.0 99.1 99.2 99.3 99.4 99.5 99.6 "When Evidence Says No, But Doctors Say Yes". ProPublica. 22 February 2017. https://www.propublica.org/article/when-evidence-says-no-but-doctors-say-yes.
100. ↑ "A comprehensive review of randomized clinical trials in three medical journals reveals 396 medical reversals". eLife 8: e45183. June 2019. doi:10.7554/eLife.45183. PMID 31182188.
101. ↑ "Translational Research: Bringing Science to the Provider Through Guideline Implementation". Dental Clinics of North America 63 (1): 129–144. January 2019. doi:10.1016/j.cden.2018.08.008. PMID 30447788.
102. ↑ "Implementation research: making better use of evidence to improve healthcare". Rheumatology 59 (8): 1799–1801. August 2020. doi:10.1093/rheumatology/keaa088. PMID 32252071.
103. ↑ "The challenges of evidence implementation: it's all about the context". JBI Database of Systematic Reviews and Implementation Reports 15 (12): 2830–2831. December 2017. doi:10.11124/JBISRIR-2017-003652. PMID 29219863. https://orca.cardiff.ac.uk/id/eprint/111395/.
104. ↑ 104.0 104.1 "Implementation of recommendations in rheumatic and musculoskeletal diseases: considerations for development and uptake". Annals of the Rheumatic Diseases 81 (10): 1344–1347. October 2022. doi:10.1136/ard-2022-223016. PMID 35961760.
105. ↑ "Core Competencies in Evidence-Based Practice for Health Professionals: Consensus Statement Based on a Systematic Review and Delphi Survey". JAMA Network Open 1 (2): e180281. June 2018. doi:10.1001/jamanetworkopen.2018.0281. PMID 30646073.
106. ↑ "Evidence-based medicine teaching requirements in the USA: taxonomy and themes". Journal of Evidence-Based Medicine 9 (2): 53–58. May 2016. doi:10.1111/jebm.12186. PMID 27310370.
107. ↑ "Do short courses in evidence based medicine improve knowledge and skills? Validation of Berlin questionnaire and before and after study of courses in evidence based medicine". BMJ 325 (7376): 1338–1341. December 2002. doi:10.1136/bmj.325.7376.1338. PMID 12468485.
108. ↑ "Validation of the Fresno test of competence in evidence based medicine". BMJ 326 (7384): 319–321. February 2003. doi:10.1136/bmj.326.7384.319. PMID 12574047.
Fresno test
109. ↑ "Instruments for evaluating education in evidence-based practice: a systematic review". JAMA 296 (9): 1116–1127. September 2006. doi:10.1001/jama.296.9.1116. PMID 16954491.
110. ↑ "Evaluating the teaching of evidence based medicine: conceptual framework". BMJ 329 (7473): 1029–1032. October 2004. doi:10.1136/bmj.329.7473.1029. PMID 15514352.
111. ↑ "Determinants of knowledge gain in evidence-based medicine short courses: an international assessment". Open Medicine 4 (1): e3–e10. 2010. doi:10.2174/1874104501004010003. PMID 21686291.
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113. ↑ "E-learning of evidence-based health care (EBHC) to increase EBHC competencies in healthcare professionals: a systematic review". Campbell Systematic Reviews 4: 1–147. 2017. doi:10.4073/csr.2017.4.
114. ↑ "Why Medical Schools Should Embrace Wikipedia: Final-Year Medical Student Contributions to Wikipedia Articles for Academic Credit at One School". Academic Medicine 92 (2): 194–200. February 2017. doi:10.1097/ACM.0000000000001381. PMID 27627633.
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## Bibliography

* Understanding evidence in health care: Using clinical epidemiology. South Yarra, VIC, Australia: Palgrave Macmillan. 2012. ISBN 978-1-4202-5669-7.
* Clinical Epidemiology: Principles, Methods, and Applications for Clinical Research. Jones & Bartlett Learning. 2009. ISBN 978-0-7637-5315-3.
* The Philosophy of Evidence-based Medicine. Wiley. 2011. ISBN 978-1-4051-9667-3. https://books.google.com/books?id=O8djbHBva5IC.
* Clinical Epidemiology & Evidence-Based Medicine: Fundamental Principles of Clinical Reasoning & Research. Sage. 2001. ISBN 978-0-7619-1939-1. https://archive.org/details/clinicalepidemio0000katz.
* Care and Cure: An Introduction To Philosophy of Medicine. University of Chicago Press. 2018. ISBN 978-0-226-59517-7. https://www.press.uchicago.edu/ucp/books/book/chicago/C/bo29193227.html.

## External links

* Evidence-Based Medicine – An Oral History, JAMA and the BMJ, 2014.
* Centre for Evidence-based Medicine at the University of Oxford.
* Evidence-Based Medicine at Curlie

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Evidence-based practice

Key terms|

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Applications|

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Clinical research and experimental design

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(EBM I to II-1)|

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Incidence, Cumulative incidence, Prevalence, Point prevalence, Period prevalence

|

Association|

Risk difference, Number needed to treat, Number needed to harm, Risk ratio, Relative risk reduction, Odds ratio, Hazard ratio

Population impact|

Attributable fraction among the exposed, Attributable fraction for the population, Preventable fraction among the unexposed, Preventable fraction for the population

Other|

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* Risk–benefit ratio
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