Evidence-based decision-making

Vino Tito V Kurien; Suhana Shamsuddeen; MC Mahitha; Diya S Rasheed

doi:10.4103/jhnps.jhnps_5_22

REVIEW ARTICLE

Year : 2022 | Volume : 10 | Issue : 1 | Page : 48-52

Evidence-based decision-making

Vino Tito V Kurien¹, Suhana Shamsuddeen², MC Mahitha³, Diya S Rasheed⁴
¹ Department of Periodontology, Saraswati-Dhanwantari Dental College and Hospital, Parbhani, Maharashtra, India
² Department of Periodontology, Krishnadevaraya Dental College, Bengaluru, Karnataka, India
³ Department of Community Medicine, Government Medical College, Aurangabad, Maharashtra, India
⁴ Department of Neurosurgery, Rajagiri Hospital, Aluva, Kerala, India

Date of Submission	28-Jan-2022
Date of Decision	31-Mar-2022
Date of Acceptance	01-Apr-2022
Date of Web Publication	23-Jun-2022

Correspondence Address:
Suhana Shamsuddeen
Department of Periodontology, Krishnadevaraya Dental College, Bengaluru, Karnataka
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jhnps.jhnps_5_22

Abstract

Evidence-based decision-making (EBDM) entails the explicit, conscientious, and prudent evaluation of the best available information in making medical decisions. The process of EBDM involves learning the latest approaches and gaining new skills such as how to ask excellent clinical questions, carrying out a computerized search, critically evaluating the evidence, utilizing the findings in clinical settings, and analyzing the process. This method acknowledges that it is difficult for the practitioners to be totally up to date on all illnesses, treatments, materials, or products accessible. As a result, EBDM provides a method for filling in these knowledge gaps to give the best possible care. The basic goal of evidence-based practice is to improve health-care quality. It assists to arrive at a clinical decision on the basis of the latest and advanced research and the best possible evidence. Facilitating EBDM that leads to better patient outcomes, smarter research planning, better products, and improved policy formulation is critical and timely. This article gives an insight into EBDM and various levels of evidence.

Keywords: Decision-making, evidence-based, PICO

How to cite this article:
V Kurien VT, Shamsuddeen S, Mahitha M C, Rasheed DS. Evidence-based decision-making. J Head Neck Physicians Surg 2022;10:48-52

How to cite this URL:
V Kurien VT, Shamsuddeen S, Mahitha M C, Rasheed DS. Evidence-based decision-making. J Head Neck Physicians Surg [serial online] 2022 [cited 2023 Jun 4];10:48-52. Available from: https://www.jhnps.org/text.asp?2022/10/1/48/347990

Introduction

There has been a tremendous development in the implementation of scientific research evidence in the clinical practice. The evidence-based practice, which was initially introduced in medicine, ensures better health-care quality and attempts to reduce the void between research and practice.^[1] One of the most remarkable contributions of the evidence-based approach was the enhanced quality of the review process through systematic reviews (SRs). A wide range of resources is available for the clinicians to access information relevant to routine clinical practice. Therefore, clinicians should have the skills to assess the information they hear or read.^[2]

This article highlights the need for evidence, various levels of evidence, and the process involved in evidence-based decision-making (EBDM) to assist the clinician.

What is Evidence And What is the Need for Evidence?

Evidence has been defined in its broadest context as facts and circumstances that support or refute a belief or statement or indicate if something is true or acceptable. The concept of evidence has a great impact on our knowledge and understanding. The practitioner explores numerous research studies taking into consideration the clinical question, the intervention type, and area of specific interest.

The era in which we practice medicine has transformed at a tremendous rate. The patient–practitioner relationship has evolved drastically. Nowadays, patients also contribute in the decision-making process, which has been aided by incredible technological breakthroughs.^[3]

Lecturers, books, and even journal articles at times were once the key sources of information. Over the years, the methods by which we obtain the information have evolved. Web-based courses and training, as well as computer-based interactive learning, are becoming more popular. Nowadays, evidence-based medicine (EBM) has become essential to delivering the best-known treatment to patients.^[4],[5]

Evidence-Based Medicine

EBM is also known as evidence-based practice. It has been in use from the late 19^th century (Guyatt). EBM is “thorough, accurate, and appropriate application of best available evidence to treat patients while taking into account clinical knowledge and preferences of the patient to enhance the well-being.” (Sackett).

In EBM, the detection and treatment of diseases should be driven by systematic research. It has evolved over the years to include the best available scientific evidence, clinical skills, and patients' personal preferences and clinical practice.^[6]

Three essential concepts guide the implementation of EBM:

Good health care depends on objective data:

There is a requirement for good relevant clinical knowledge
New research changes health care
Lifelong learning is essential.

Levels of evidence:^[7]

Some evidence is more stronger and reliable than others
The most strongest evidence should be selected
The hierarchy of evidence on which a clinical decision was based should be understood.

Scientific data alone is insufficient:

Scientific data alone is insufficient for clinical decision-making or for patient recommendation
Scientific data must always be combined with clinical reasoning.^[8]

Levels of Evidence

In the health sector, the researchers and doctors rely on scientific literature for obtaining the primary source of information. However, the scientific worth of various publications may differ greatly in terms of quality which may cause considerable confusion and reduce the benefits to the users.

The scientific research is classified into three groups:

Preclinical studies (in vitro and in vivo studies)
Primary clinical research
Secondary clinical research.

Various studies that belong to primary clinical research are:

Case report/case series
Cross-sectional survey
Case–control study
Cohort study
Randomized controlled clinical trial.

Various studies that belong to secondary clinical research are:

Narrative review
SRs
Clinical guidelines.

Randomized controlled trials (RCT) and prospective controlled trials occupy the highest level of evidence in the hierarchy of study designs along with meta-analyses or SRs [Figure 1]. Even though SRs occupy the topmost level in the hierarchy of evidence, they are crucial for the validation of clinical trials. Uncontrolled research investigations such as case series and case reports occupy the lower level in the hierarchy of evidence along with retrospective studies.^[9]

Figure 1: Hierarchy of evidence

Click here to view

As we step up the pyramid, there is lesser number of literatures available, however, their significance in answering clinical concerns improves.^[10]

Another tool for analyzing the strength of evidence and validity of the findings in SRs and clinical practice guidelines is GRADE.^[11]

G-Grading of
R-Recommendations
A-Assessment
D-Development and
E-Evaluation.

Determining the Level of Evidence

Various research investigations are well-preferred to arrive at an answer of various types of clinical problems. Finding a SR or meta-analysis is not always easy. In such scenarios, we must work our way down the hierarchy of evidence to the next greatest level of evidence. Cohort or case-controlled designs that are well-executed can occasionally give more evidence than poorly done RCT.^[12]

There are four categories of clinical questions:

The best-suited study design for “Diagnosis” type of questions are cross-sectional or prospective, blinded comparison to the gold standard
The evidence for “Therapy” type of question can be obtained from RCT followed by cohort study, case–control, and case series
The best-suited study design for “Prognosis” and “Harm/etiology” category of questions is cohort study followed by case–control and case series.

The best evidence that we should search varies based on the category of question.^[13]

The most universally recognized tool for determining the quality of research studies, evidence, and the type of study design is ”Impact Factor” of the journal. It denotes the average citations a published article receives in a particular indexed journal.

The calculation of impact factor for a specific year is as follows:

The greater the number of citations a journal receives, the greater its impact on the scientific community.^[14],[15]

Based on the citations received by the researcher's article and the prestige of the citing journals, various bibliometric indexes have been introduced. The Hirsch index is commonly used, and it calculates how many articles a researcher has written that have received at least an equivalent amount of citations.^[16]

Searching Evidence

The process of seeking for evidence to arrive at clinical decisions begins with the formulation of the question. There are three basic approaches for gathering evidence:

Determining keywords and (Medical Subject Headings) phrases
Identifying secondary sources
Looking for primary sources.

Searching “search terms” and secondary sources:

Parts of the PICO question should be referenced in the search words.^[17]

Journals are indexed in a variety of databases. The evidence can be collected from various databases. Some of the databases are:

The Cochrane Database of SRs
Database of Abstracts of Reviews of Effects. Cochrane collaboration website provides access to these databases
PubMed which incorporates MEDLINE
The Cumulative Index to Nursing and Allied Health Literature.^[18]

Evidence-Based Decision-Making

Evidence has a significant role in arriving at a clinical decision. Being up to date with the latest research, however, is particularly challenging due to the large number of research articles and publications. We rely on these clinical studies to evaluate the effectiveness of treatment regimens, laboratory tests, and newer technologies; therefore, knowing how to discover scientific evidence is crucial for clinical practice. The utilization of research evidence cannot be replaced by clinical knowledge or the patient's input; rather, it provides a new viewpoint to the decision-making process, which is also analyzed in respect to the patient's clinical situation.^[6]

Research Practice Gaps

Health care has three types of dilemmas related to research and clinical practice:

The three categories of problems related to health-care interventions are:

Overuse – in certain situations where health-care interventions are not very effective
Underuse – when health-care interventions are useful but not used properly
Misuse – when the use of health-care interventions has ambiguity and therefore has a wide variation in their use.

For a successful EBDM, these voids should be minimized.^[19]

Principles of Evidence-Based Decision-Making

The traditional way of clinical problem-solving is different from problem-solving based on evidence. These two concepts vary in their methods of clinical reasoning. The clinical reasoning process varies in the two approaches. Traditionally, solving clinical problems relied heavily on subjective reasoning based mostly on individual experience, intuition, expert opinion, and knowledge from colleagues and textbooks. EBDM is a formalized process that allows the physician to find the latest scientific evidence that can be promptly implemented into clinical practice.

Evidence alone is not sufficient to make correct clinical decisions. Without due consideration for a clinician's individual expertise and patients' inputs or circumstances, it would be unwise to blindly follow search results of best evidence. The process of EBDM is based on a few main principles or components that are well-integrated in its flow, allowing for the successful addition of the best scientific evidence as an important dimension to traditional clinical decisions.^[9]

Process of Evidence-Based Decision-Making

The initial step in any research project is to frame a clinical question that can be answered. This is critical because the more specific and precise the review question, the more likely the review will yield accurate findings.

The process of EBDM includes five steps:

Using the PICO approach to convert the information requirements/problems into an answerable clinical question.

A patient's question or an issue is the first step of this process. A well-crafted question should consist of four sections. It is known as PICO which stands for:

P-Patient problem or population
I-Intervention
C-Comparison
O-Outcomes.

Conducting the most efficient automated search possible to arrive at an appropriate evidence to answer the question
Critical evaluation of authenticity and effectiveness of the obtained evidence
To use the outcome of the evidence in medical practice
Process and overall performance evaluation.^[20],[21]

The process involved in EBDM can be summarized in five steps. It is also represented as 5As:

ASK a clinical question which can be answered
AQUIRE the most significant evidence to answer the question
APPRAISE the obtained evidence for authenticity, significance, and implications
APPLY the obtained evidence along with critical expertise and patient's needs
ASSESS the effectiveness of the preceding four steps and look for ways to improve on them.^[22]

Shared Decision-Making

A combined approach by both the practitioners and the patients to work together to contribute to health-care decision-making is known as “Shared decision-making.” Both the doctors and patients are believed to have substantial data to contribute to the decision-making. Clinicians have access to the latest and accurate information on the diagnosis, disease progression, therapeutic alternatives, and knowledge on the clinical outcomes and side effects based on evidence. Patients have their own treatment choices and objectives.^[23]

Shared decision-making emphasizes on patient-centered care and plays a major role for enhanced health-care quality. Incorporating shared decision-making in health care will involve a variety of approaches as well as a cultural shift among professionals, their organizations, and patients. Increased awareness at all levels of society is the first step toward this transformation.^[24]

Future Directions – Addendum in Curriculum, Continuing Medical Education, and Webinars

Evidence-based practice necessitates the clinicians to question and analyze on what they are doing, especially in these times where they are expected to be up to date with new approaches and advancements. It is necessary to assess the information and determine its authenticity. Practitioners can handle the challenges of continuing to deliver quality treatment in a highly competitive environment by framing a clinical question, conducting an intensive literature search, analyzing the literature, and implementing it to patient care wherever it is appropriate. It also makes it possible to justify the treatment decisions, particularly when there is a complaint or a medicolegal issue.^[3]

At present, one of the most significant domains in medical education is the skill of evidence critical appraisal. The more training a clinician has in EBM, the less likely they are to make biased clinical decisions. They would also have a better ability to maintain their clinical expertise up to date.^[25]

The faculties in the colleges should make sure that their students have EBDM skills and an environment should be created where the students can learn individually. The staff members have a vital role in successfully bringing about changes in the classrooms and clinics. EBDMS should be incorporated into the training curriculum and reinforced every time students deliver patient care.^[26]

Evidence-based continuing medical education (CME) will include significant practice recommendations that are supported by approved evidence-based sources in which all trials on the topic have been systematically identified, assessed, and summarized according to the established criteria. CME and webinar program for health-care professionals includes acquiring evidence-based health-care knowledge and skills. Using an EBM approach to CME and webinars, gaps in clinical research can be identified and stimulate further research in areas lacking adequate evidence.^[27]

Conclusion

EBDM has become quite popular in recent years. It has become a part of routine clinical practice. As a result, clinicians must be aware of the relevance of six critical thinking, detailed research process, and the application of evidence in clinical practice. As a new research develops, the clinicians must be updated about the latest treatment options, methodology, and rationale. EBDM can be used in clinical practice if we follow a systematic method. In modern medicine, it is important to apply evidence obtained from scientific research in our routine clinical practice. Hence, this approach forms the heart of the transition toward an evidence-driven practice. Insufficient time, resources, and ability are highlighted as the barriers to the application of findings from the studies into clinical practice.

The method of EBDM making requires time to learn and practice. However, if mastered, it aids in the successful translation of results from the best available scientific research into clinical practice by equipping health-care workers with the necessary skill sets to make competent clinical judgments. We firmly believe that these tactics can help clinicians on the front lines and public health decision-makers build critical thinking skills. The practitioners can also analyze evidence critically even during the most dire public health crisis and uphold our oath as physicians: First, do no harm.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

Not applicable.

Informed consent

Not applicable.

References

1.	Brignardello-Petersen R, Carrasco-Labra A, Glick M, Guyatt GH, Azarpazhooh A. A practical approach to evidence-based dentistry. J Am Dent Assoc 2014;145:1105-7.
2.	Masic I, Miokovic M, Muhamedagic B. Evidence based medicine – New approaches and challenges. Acta Inform Med 2008;16:219-25.
3.	Mohindra K, Nirola A. Evidence-based dentistry: Future aspects. J Int Clin Dent Res Organ 2017;9:45-9. [Full text]
4.	Anderson JD. The question. Dent Clin North Am 2002;46:11-9.
5.	Coulter ID. Evidence-based dentistry and health services research: Is one possible without the other? J Dent Educ 2001;65:714-24.
6.	Evidence-Based Medicine Working Group. Evidencebased medicine. A new approach to teaching the practice of medicine. JAMA 1992;268:2420-5.
7.	Fontelo P, Liu F. A review of recent publication trends from top publishing counties. Syst Rev 2018;7:147.
8.	Fossum M, Herbst K, Harper L, Castagnetti M, Beckers G, Bagli D, et al. Evidence-based medicine 1: Background. J Pediatr Urol 2019;15:78-9.
9.	Del Fabbro M, Corbella S, Taschieri S. Principles of evidence based decision making. In: Evidence-Based Decision Making in Dentistry. Switzerland: Springer International Publishing; 2017. p. 7-18.
10.	Forrest JL, Miller SA. Evidence-based decision making in action: Part 2 – Evaluating and applying the clinical evidence. J Contemp Dent Pract 2003;4:42-52.
11.	Goldet G, Howick J. Understanding GRADE: An introduction. J Evid Based Med 2013;6:50-4.
12.	Durr-E-Sadaf. How to apply evidence-based principles in clinical dentistry. J Multidiscip Healthc 2019;12:131-6.
13.	Mithun Pai BH, Rajesh G, Shenoy R. Research design hierarchy: Strength of evidence in evidence-based dentistry. J Interdiscip Dent 2012;2:158-63.
14.	Garfield E. The history and meaning of the journal impact factor. JAMA 2006;295:90-3.
15.	Garfield E. Journal impact factor: A brief review. CMAJ 1999;161:979-80.
16.	Hirsch JE. An index to quantify an individual's scientific research output. Proc Natl Acad Sci U S A 2005;102:16569-72.
17.	Cronin P. Evidence-based radiology: Step 3 – Primary literature validity (critical appraisal). Semin Roentgenol 2009;44:153-7.
18.	Kelly AM. Evidence-based radiology: Step 2 – Searching the literature (search). Semin Roentgenol 2009;44:147-52.
19.	Walshe K, Rundall TG. Evidence-based management: From theory to practice in health care. Milbank Q 2001;79:429-57, IV-V.
20.	Sackett D, Richardson W, Rosenberg W, Haynes R. Evidence-based medicine: How to practice and teach EBM. New York: Churchill Livingstone, 1997.
21.	Forrest JL, Miller SA. Evidence-based decision making in action: Part 1 – Finding the best clinical evidence. J Contemp Dent Pract 2002;3:10-26.
22.	Akobeng AK. Principles of evidence based medicine. Arch Dis Child 2005;90:837-40.
23.	Adams JR, Drake RE. Shared decision-making and evidencebased practices. Community Ment Health J 2006;42:87-105.
24.	Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Patient Educ Couns 2006;60:301-12.
25.	Maggio LA, Tannery NH, Chen HC, ten Cate O, O'Brien B. Evidence-based medicine training in undergraduate medical education: A review and critique of the literature published 2006-2011. Acad Med 2013;88:1022-8.
26.	Forrest JL. Treatment plan for integrating evidence-based decision making into dental education. J Evid Based Dent Pract 2006;6:72-8.
27.	Bindawas SM. Evidence-based health care continuing education seminars improve academic staff knowledge and attitudes in Saudi Arabia. Pak J Med Sci 2013;29:703-9 .