JAMA CLASSICS the biases as ociated with observ of the orare aron nded ians will enjoy a set of in finding all forms of corrupting the evi and guic urrent EBM think users of the medica ully diffe the p n and in of p p.Bc l Edcare (ie,Ac oks and h ing or 1s1 and ow of systems-ba REFERENCES 124 2097. EBM in the Cu lealth care environment cag 20-12 Clarke M goplsddsgsnd g bu edly tow and the R will lo peyondthcnovcdyandd nges tha 24 esZ0hneanddppoah,HeahAiwmood in ence can reali With the e and mak of the mon Progran 816 MA October 1,2008-Vel 300.No. Medical A ation.All rights reserved Downloaded from www.iama.com by quest on August 17.2010 第6页gorithms that are not transparently linked to the underlying evidence base and do not represent the results of a system￾atic and critical appraisal of that evidence. It sometimes ap￾pears as if using the term obviates the need to describe the quality of underlying evidence, the magnitude of effects, or the applicability of any of the results in the context, values, and preferences of the patients. This is particularly problematic because the EBM era has coincided with a dramatic increase in the for-profit fund￾ing of research. Researchers funded by industry interpret their results differently and in favor of the industry prod￾uct relative to not-for-profit funding.12 Problems associ￾ated with industry funding include use of inappropriate con￾trol interventions, surrogate outcomes, publication and reporting bias, and misleading descriptions and presenta￾tions of research findings—all forms of corrupting the evi￾dence base.13 Unsophisticated users of the medical litera￾ture, assuming that medical editors, peer reviewers, and topic experts have now become familiar with the tenets of EBM, may trust these corrupted research reports and advocate for their application in practice. Many medical schools and training programs, in a form of premature closure, are moving away from teaching the fundamentals of careful evidence appraisal to emphasize the implementation of evidence. The intent of this new focus is to produce high-quality, safe, and low-cost care (ie, Ac￾creditation Council for Graduate Medical Education com￾petencies of systems-based practice and improvement and practice-based learning14). However, abandoning appropri￾ate skepticism regarding the effectiveness of these inter￾ventions may lead to large investments in quality￾improvement, safety, and efficiency activities that fail to yield the expected benefits. EBM in the Current Health Care Environment: Appropriate Application EBM continues to hold substantial promise for the increas￾ing conduct of high-quality studies that address important questions using optimal study designs and large sample sizes, and the unbiased, meticulous summarization of the best evi￾dence. Achieving this goal is crucial in a world moving hur￾riedly toward molecular medicine. Clinicians and research￾ers who understand the EBM approach and tenets will look beyond the novelty and deal with the special challenges that arise from the use of information from molecular diagnos￾tic and prognostic tests and from treatments linked to these technologies. EBM remains the fundamental framework for investigators intent on conducting translational research from clinical research to clinical practice. When based on EBM principles, quality improvement sci￾ence can realize the reliable application of evidence and make health care a high-value proposition. With the emergence of the electronic medical record, many see opportunities in the use of practice-based information to make inferences re￾garding treatment effectiveness and recommendations based on these inferences. However, it is essential to remember the perils of ignoring the hierarchy of evidence and aban￾doning awareness of the biases associated with observa￾tional studies. The medical community must resist the temp￾tation to use information accrued in practice based on choice rather than chance to assess treatment efficacy among pa￾tient subgroups. At the same time, these information sources will likely prove valuable in detecting rare harms and un￾intended consequences of clinical actions.15 Reliance on easily obtained but potentially misleading evi￾dence and the increase in commercial interests to produce and interpret evidence for physicians will remain potent. The ap￾propriate application of EBM will continue to provide safe￾guards against these dangers. Clinicians will enjoy a set of in￾creasingly accessible sources of evidence, evidence summaries, and guidelines that acknowledge the most current EBM think￾ing—perhaps best captured in the GRADE system—and in particular the role of values and preferences in decision mak￾ing.Medical and health policy trainingmust continue to evolve, allowing clinicians and policy makers to successfully differ￾entiate truly evidence-based sources of information and in￾terpretation of information, from those that are not. Financial Disclosures: Dr Guyatt has acted as a consultant to UpToDate for the last 5 years; Drs Montori and Guyatt are associate editors of ACP Journal Club, and are active members of the GRADE Working Group. Both authors accept no royalties for books and honoraria for speaking on EBM as personal income, but as contributions to their respective research endeavors. REFERENCES 1. Evidence-Based Medicine Working Group. Evidence-based medicine: a new ap￾proach to teaching the practice of medicine. JAMA. 1992;268(17):2420-2425. 2. Guyatt G. Evidence-based Medicine. ACP J Club. 1991;114(suppl 2):A16. 3. Guyatt GH, Rennie D. Users’ guides to the medical literature. JAMA. 1993; 270(17):2096-2097. 4. Guyatt G, Rennie D, Meade M, Cook D. JAMA Evidence Users’ Guides to the Medical Literature. A Manual for Evidence-Based Clinical Practice. 2nd ed. Chi￾cago, IL: McGraw Hill Co; 2008. 5. Wilczynski NL, Morgan D, Haynes RB. An overview of the design and meth￾ods for retrieving high-quality studies for clinical care. BMC Med Inform Decis Mak. 2005;5:20. 6. Montori VM, Saha S, Clarke M. A call for systematic reviews. J Gen Intern Med. 2004;19(12):1240-1241. 7. Guyatt GH, Haynes RB, Jaeschke RZ, et al. Users’ Guides to the Medical Lit￾erature: XXV: evidence-based medicine: principles for applying the Users’ Guides to patient care: Evidence-Based Medicine Working Group. JAMA. 2000;284 (10):1290-1296. 8. UK Department of Health. National Health Services Constitution. http://www .dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance /DH_085814. Accessed August 21, 2008. 9. Committee on Quality of Health Care in America, Institute of Medicine. Cross￾ing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academic Press; 2001. 10. Eddy DM. Evidence-based medicine: a unified approach. Health Aff (Millwood). 2005;24(1):9-17. 11. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336 (7650):924-926. 12. Als-Nielsen B, Chen W, Gluud C, Kjaergard LL. Association of funding and conclusions in randomized drug trials: a reflection of treatment effect or adverse events? JAMA. 2003;290(7):921-928. 13. Montori V, Guyatt GH. Corruption of the evidence as threat and opportunity for evidence-based medicine. Harvard Health Policy Rev. 2007;2007(8):145- 155. 14. Accreditation Council for Graduate Medical Education. Common Program Requirements. http://www.acgme.org. Accessed April 23, 2007. 15. Avorn J. In defense of pharmacoepidemiology–embracing the yin and yang of drug research. N Engl J Med. 2007;357(22):2219-2221. JAMA CLASSICS 1816 JAMA, October 15, 2008—Vol 300, No. 15 (Reprinted) ©2008 American Medical Association. All rights reserved. Downloaded from www.jama.com by guest on August 17, 2010 第 6 页