Clinical practice based on evidence of efficacy: EBM, EBP, EBHC

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EBM, acronym for Evidence-based Medicine, is the medicine based on evidence of efficacy.

The term “evidence” represents the proof of efficacy, that is the results of the studies supporting the efficacy of a certain drug or intervention published in scientific journals. All these studies together take the name of “literature“.

EBM is a model of thought developed in the last decade of the twentieth century with the intention of addressing some problems that used to afflict and still do the clinical-health sector, including for example:

• the difficulty to carry out professional development for doctors, due to the exponential proliferation of research studies, also caused by the advent of the Internet;
• the need to make a critical assessment of the quality of studies;
• the transfer of the results of the studies to the therapeutic protocols of the health facilities;
• the rising costs of healthcare.

In 1996 the creators of the method¹ specified that in this approach clinical decisions come from the integration between the doctor’s experience and the conscientious, explicit and judicious use of the best available scientific evidence, mediated by the patient’s preferences. For an introductory reading concerning various aspects of the EBM practice please refer to this commented bibliography of 10 articles on the topic².

The model was widely followed and was gradually extended also to other sectors (eg, nursing, physical therapy, odontology) so that the word “medicine” was replaced by the term “practice” and Evidence-based Practice – EBP – started to be defined.

In short, the healthcare professional who applies this model makes use of their expertise and clinical experience to develop each time a specific treatment plan (amongst many possible) based on a reasoning that must take into account:

• the “preferences and actions of the patient”: the practitioner will have to personalize the treatment according to the needs and biological conditions of each individual patient. For example, by making an accurate medical history to decide whether the results of the medical research are transferable to the case at hand. The patient must be put at the center of the procedure while actively participating by giving consent to therapeutic decisions;
• the “clinical context”: the practitioner must know, for example, the resources of the health or insurance system accessible by the patient;
• the “best evidence”: the practitioner will have to be able to carry out a search within the literature, to make a critical assessment of the articles and other material found, and, wherever applicable, they will have to abide by the Guidelines.

For further information about scientific research in the manual-therapy field please refer to the volume edited by Francesco Cerritelli and Diego Lanaro³.

The principles of EBM have been extended also to the health care sector and framed in the EBHC, Evidence-based Health Care, from which the Guidelines describing the modality to program health care come from.In the UK the EBM Guidelines are issued as recommendations by NICE, National Institute for Care and Health Excellence, and are available on the NICE website.

All “evidence-based” systems need to be updated constantly and punctually. Health sciences have thus become a field in the making, thriving to absorb the latest findings so as to incorporate them into health policy strategies that can allow the integration of all evidence-based methodological tools with all the processes governing the health care organization, including administrative, structural, financial and professional processes.

Considered collectively, these political strategies, committed in the effort to “erogate a sustainable, responsible, patient-focused and qualitative care service”, take the name of Clinical Governance.⁴

In the UK, clinical governance is “a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”⁴

The 7 pillars of Clinical Governance are:

• • Clinical effectiveness
  • Information
  • Risk management
  • Education and training
  • Audit
  • Patient & public involvement
  • Staff management

Bibliography

1. Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence-Based Medicine: What it is and what it isn’t. BMJ 1996;312:71-2
2. Nunan D, O’Sullivan J, Heneghan C, Pluddemann A, Aronson J, Mahtani K. Ten essential papers for the practice of evidence-based medicine. Evid Based Med. 2017 Dec;22(6):202-204.
3. Cerritelli F, Lanaro D. Elementi di ricerca in osteopatia e terapie manuali. Napoli: Edises, 2018.
4. https://www.england.nhs.uk/mat-transformation/matrons-handbook/governance-patient-safety-and-quality/