Review Progress in evidence-based medicine:a quarter century on @@ Benjamin Djulbegovic,Gordon H Guyatt In response to limitations in the understanding and use of published evidence,eviden e-based medicine (EBM) iEBM's in ise lim and has inc easingl need to co of t pra dic eipncdhde placing t epractice and prefe ased medicine physiologicaland basic citute,Tam b arding the .with the fthe US 6 ave h Rudolph Virchow,Claude Bemard regarding drug efficac other countries followed soo Europe.and the Flexner report in the d a bedrock the efficacy and safety of 么 accurate observatio al data in the rk of Pi re-charles aaedreoandehsnownsheaidnoentu of scurvy in the British navy,'the focus of most of these and Archie Cochrane ()highlighted the medicine and roposed initial evidentiary Key message In 1991 one EBMstartedasamovementintheeal19gcstoealai of medicine asse ssing sed on c opmen Search strategy and selection criteria in t EBM has edical practice vidence-Based medicine/stan ubstantially to impro R "EV Apml1g2o16heewa5norestctonOnhetathte 6009 hits were ident ented the sear artides The r ers have also p g/10 -6736(163H592-www.thelancet.com Published online February 16, 2017 http://dx.doi.org/10.1016/S0140-6736(16)31592-6 1 Review Progress in evidence-based medicine: a quarter century on Benjamin Djulbegovic, Gordon H Guyatt In response to limitations in the understanding and use of published evidence, evidence-based medicine (EBM) began as a movement in the early 1990s. EBM’s initial focus was on educating clinicians in the understanding and use of published literature to optimise clinical care, including the science of systematic reviews. EBM progressed to recognise limitations of evidence alone, and has increasingly stressed the need to combine critical appraisal of the evidence with patient’s values and preferences through shared decision making. In another progress, EBM incorporated and further developed the science of producing trustworthy clinical practice guidelines pioneered by investigators in the 1980s. EBM’s enduring contributions to clinical medicine include placing the practice of medicine on a solid scientifi c basis, the development of more sophisticated hierarchies of evidence, the recognition of the crucial role of patient values and preferences in clinical decision making, and the development of the methodology for generating trustworthy recommendations. Historical origins of evidence-based medicine Since the time of Hippocrates, medicine has struggled to balance the uncontrolled experience of healers with observations obtained by rigorous investigation of claims regarding the eff ects of health interventions. During the past 300 years, demands that the practice of medicine be founded on scientifi cally trustworthy empirical evidence have become increasingly vocal. Pioneers, including Rudolph Virchow, Claude Bernard, and Louis Pasteur, championed science in medicine in Europe, and the Flexner report in the early 20th century cemented scientifi c inquiry as a bedrock of American medicine. Although one can identify attempts to obtain accurate observational data in the work of Pierre-Charles￾Alexandre Louis and John Snow in the mid-19th century, and the use of clinical trials in James Lind’s famous study of scurvy in the British navy,1 the focus of most of these innovators was on physiological and basic research as a foundation for clinical practice, rather than the empirical assessment of diagnostic testing, prognosis, and therapeutic eff ect. Indeed, it was not until 1962, with the passage of the US Food and Drug Administration Kefauver-Harris Act in the USA, that rigorous empirical testing of clinical trials in human beings was legally required to establish claims regarding drug effi cacy;2 other countries followed soon thereafter. Although these regulatory developments established the necessity for well done clinical trials demonstrating the effi cacy and safety of new pharmaceutical innovations, unsystematic, uncontrolled clinical experience and physiological reasoning maintained their dominance as drivers of clinical practice. In the 1970s and 1980s, David Sackett, David Eddy, and Archie Cochrane (among others) highlighted the need for strengthening the empirical practice of medicine and proposed initial evidentiary rules for guiding clinical decisions.3–7 In 1991, one of us (GHG) introduced the term evidence-based medicine (EBM),8 with a focus on educating front-line clinicians in assessing the credibility of research evidence, Published Online February 16, 2017 http://dx.doi.org/10.1016/ S0140-6736(16)31592-6 University of South Florida Program for Comparative Effectiveness Research, and Division of Evidence Based Medicine, Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA (Prof B Djulbegovic MD); H Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA (Prof B Djulbegovic); Tampa General Hospital, Tampa, FL, USA (Prof B Djulbegovic); and Department of Clinical Epidemiology and Biostatistics, and Department of Medicine, McMaster University, Hamilton, ON, Canada (Prof G H Guyatt MD) Correspondence to: Prof Benjamin Djulbegovic, USF Health, Program for Comparative Effectiveness Research, University of South Florida, Tampa, FL 33612, USA bdjulbeg@health.usf.edu Key messages • EBM started as a movement in the early 1990s to evaluate and in turn acquire a better empirical basis for the practice of medicine • EBM originally focused on critical appraisal, development of systematic reviews, and clinical practice guidelines • These three domains coalesced in the mid-2000s and characterise the practice of EBM today • EBM has become essential for the training of young clinicians by stressing critical thinking and the importance of statistical reasoning and continuous evaluation of medical practice • EBM has contributed substantially to improvement of the quality of research by transparently documenting the problems with existing research and subsequently developing better research standards • EBM has also improved the practice of medicine by developing methods and techniques for generating systematic reviews and clinical practice guidelines • The main challenge for EBM remains how to develop a coherent theory of decision making by relating to other decision science disciplines Search strategy and selection criteria We searched PubMed for English language articles using the following search criteria: (“Evidence-Based Medicine/ ethics”[Majr] OR “Evidence-Based Medicine/history”[Majr] OR “Evidence-Based Medicine/methods”[Majr] OR “Evidence-Based Medicine/standards”[Majr] OR “Evidence-Based Medicine/statistics and numerical data”[Majr] OR “Evidence-Based Medicine/trends”[Majr]). “Evidence-Based Medicine”[Mesh] AND (critical[All Fields] AND appraisal[All Fields]). The last search was performed on April 19, 2016 (there was no restriction on the start date). 6009 hits were identifi ed. We supplemented the search by searching our personal libraries and the references of selected articles. The reviewers have also provided useful references. We selected articles of relevance for the main sections of the paper using our own judgment