JAMA CLASSICS nave impro hat the de ticle ison making and and the Inter vices,butalso fo aw“pusd Constit ion in Gre Medic vide ogical quality and po Evolution of EBM:GRADE pertinent results transpar artic idenc cine Work minat ture to clin ich e all of as led the EBM at to 11 ciples to manag pingEBpin 300 ped laved ing the r of ele tronic tex repre all patient-important es and the necess for sy ing an sum The Grade ch ma aragraphs. ency.precision ch summ sin the medical record and the clini ents.in erventions.and outcomes of inte al we w are still evolving Identifying.appraising.and summarizing the evi- for As th vill do more good th Med iple of M (h ence bein ra panent pre ences leg.using ng the first) n EBM and nuclear fission only atte the bes pat:bu it can be ery powerful when sed app and preferences refer not only the patients perspectives.be ased precedes many recommendations.- D2008A -Wo300.No.131815 Downloaded from www.jama.com by guest on August 17,2010 第5页 PubMed, but also from Internet search engines (eg, Google), and from commercial MEDLINE interfaces (eg, OVID). These search and retrieval interfaces have improved with the de￾velopment of “hedges,” search strategies that retrieve ar￾ticles with optimal sensitivity and precision,5 and by link￾ing the title and abstract to the full-text publications and related documents. Clinicians and other learners benefit not only from these “pull” services, but alsofrom services that electronically “push” selected evidence screened for quality, newsworthiness, and relevance to the user (eg, services produced by the McMaster Premium Literature Service [PLUS] such as the ACP Journal Club Plus). A key benefit of some of these push services is the rigorous preappraisal of evidence. For instance, the ACP Jour￾nal Club not only highlights selected articles with high meth￾odological quality and potential relevance but also offers struc￾tured abstracts that document methodological quality criteria, which allows readers to evaluate the validity of the results. In addition, these services present pertinent results transpar￾ently and offer independent commentary. The dissemination of systematic reviews of primary stud￾ies, which was gaining credibility at the time of the EBM publication1 has also helped clinicians integrate all of the best available evidence addressing a particular clinical prob￾lem.6 Systematic reviews have demonstrated the limita￾tions of basing practice on the most salient, most recent, or most popular study. The Cochrane database now includes more than 3000 systematic reviews and the Cochrane Col￾laboration has played a crucial role in advancing the sci￾ence of knowledge synthesis. Relative to traditional medical texts, a number of elec￾tronic textbooks represent a revolutionary change in gath￾ering and summarizing evidence and making recommen￾dations—a change driven largely by EBM. These resources (eg, PIER, BMJClinical Evidence, UpToDate), which make use of the preappraised resources detailed in the previous paragraphs, increasingly bring evidence explicitly and prac￾tically to the point of care. Decision support systems that embed such summaries in the medical record and the clini￾cal workflow are still evolving. Evolution of EBM: Values and Preferences Identifying, critically appraising, and summarizing the evi￾dence were initial areas of focus for EBM. As the 1992 ar￾ticle1 had hinted, however, evidence alone is not sufficient to make clinical decisions. In 2000, the Evidence-Based Medi￾cineWorking Group presented the second fundamental prin￾ciple of EBM (the hierarchy of evidence being the first): what￾ever the evidence, value and preference judgments are implicit in every clinical decision.7 A key implication of this second principle is that clinical decisions, recommendations, and practice guidelines must not only attend to the best available evidence, but also to the values and preferences of the informed patient. Values and preferences refer not only the patients’ perspectives, be￾liefs, expectations, and goals for life and health, but also the processes individuals use to consider the available options and their relative benefits, harms, costs, and inconve￾niences. Since 1992, much work in the fields of shared de￾cision making and of patient decision support technolo￾gies (ie, decision aids), the evolution of the patient rights movement, and the Internet-enabled democratization of tech￾nical information have changed the landscape substan￾tially. Recently, the first National Health Service Constitu￾tion in Great Britain suggests that patient participation in decision making is a patient’s right8 ; in the United States, the Institute of Medicine designated evidence-based patient￾centered health care delivery as a key feature of high￾quality medical care.9 Evolution of EBM: GRADE The pioneering work of Eddy10 in strengthening the evi￾dence base of clinical practice guidelines preceded the EBM article.1 The Evidence-Based Medicine Working Group ini￾tially focused on the relationship between individual clini￾cians and the application of the original literature to clini￾cal care. Recognition of the importance of preappraised resources and guidelines has led the EBM movement to a greater focus on the methodology of applying EBM prin￾ciples to management recommendations. The Grades of Recommendation Assessment, Develop￾ment and Evaluation Working Group (GRADE) has devel￾oped a framework for the formulation of treatment recom￾mendations that is based on the contemporary principles of EBM.11 The GRADE process highlights the importance of clear specification of the question with identification of all patient-important outcomes and the necessity for sys￾tematic summaries of all the best evidence to guide recom￾mendations. The GRADE process includes an important evo￾lution in EBM: the definition of quality of evidence and the components that determine quality (including study de￾sign and study limitations, consistency, precision, and the extent to which the evidence directly applies to the pa￾tients, interventions, and outcomes of interest). The GRADE framework requires the specification of values and prefer￾ences in making recommendations and demands attention to circumstances (and resources for competing priorities) in deciding how confident one is that following a recom￾mendation will do more good than harm. This system pro￾duces either strong recommendations (ideal targets for qual￾ity improvement efforts) or weak ones (ideal targets for careful incorporation of patient preferences [eg, using de￾cision aids in practice]). EBM and the Current Health Care Context: Misuses of EBM An analogy can be made between EBM and nuclear fission: it can be very powerful when used appropriately and dan￾gerous when used inappropriately. The term evidence￾based precedes many recommendations, guidelines, and al￾JAMA CLASSICS ©2008 American Medical Association. All rights reserved. (Reprinted) JAMA, October 15, 2008—Vol 300, No. 15 1815 Downloaded from www.jama.com by guest on August 17, 2010 第 5 页