Talk:Evidence-based medicine/Draft: Difference between revisions

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== Too many sections? ==
I'm sure this article is excellent, but, without reading it, I wonder if we could sensibly and usefully reduce the number of headings?  This tends to interrupt the flow of the article.  Actually, so many headings actually makes it hard for a "flow," or a narrative, to develop in the first place.  Please see [[CZ:Article mechanics|Article Mechanics]] on this; the longer version goes into this in some detail. --[[User:Larry Sanger|Larry Sanger]] 22:03, 21 February 2008 (CST)


Hey, this page needs to be archived!  It's getting very long! --[[User:Larry Sanger|Larry Sanger]] 22:03, 21 February 2008 (CST)
::Okay, I archived for a fresh new outlook. --[[User:D. Matt Innis|D. Matt Innis]] 11:58, 12 March 2008 (CDT)
:I cut out some stuff. Also, does anybody mind if I cut out the section "Why do we need EBM"? I do not see that it adds much to the text in the introduction. Also, it contains no references. - [[User:Robert Badgett|Robert Badgett]] 22:14, 21 February 2008 (CST)


I will be gad to help author here, and would like to go over a plan for the article. I think that, as this article covers a a special sort of medical field that we should discuss "audience". Please, fellow editors, argue with any of these points if they differ from your understanding. Evidence based medicine is certainly all about clinical care of patients- but, unlike an article on dermatology, say, it really is about a way of thinking about medicine, an approach. Reading what is written so far- it is really meaty and presents that approach, but, in my mind suffers from 2 faults, one is that there is too much technical language without explanation, and (2) the history of medicine (in a way) has to be presented so that the naive reader understands that actually, "regualar medicine" is ''not'' evidenced based. I tyhink also, that including some real examples of changes in clinical practice that are based on evidence based medicine, may be helpful. I am going to add some of this and am open to discussion, especially from Supten. [[User:Nancy Sculerati|Nancy Sculerati]] 09:35, 15 May 2007 (CDT)
Agree it can be cut.[[User:Gareth Leng|Gareth Leng]] 11:46, 12 March 2008 (CDT)
Can we cut out the sentences like "For more information, see: Clinical practice guideline" and instead a) link the phrase at first appearance and b) add to the related articles subpage?[[User:Gareth Leng|Gareth Leng]] 11:48, 12 March 2008 (CDT)


== References-with notes ==
===Responses to too many sections===
I agree succinct is nice; however, I find that WikiPedia can be hard to follow when a topic is scattered over several pages. I am not as bothered by the length. In part because I do not see further sections that can easily be lopped off and put in their own pages. Maybe the metric section could be moved to a statistics article. We have already separate pages for [[Teaching evidence-based medicine]] and [[Evidence-based individual decision making]]. Should these have been subpages?? I suggest leaving clinical practice guidelines represented in the TOC so the concept is not lost.
# As nobody complained about my suggestion Feb 21 to delete the "Why do we need EBM", I have done so.
# In the sections "Methods proposed for assessing validity" and "Criticisms of EBM" I made the subsections not appear in the TOC.
# I moved publication bias content to article of that name.
# I removed the section heading "Methods proposed for assessing validity" but left the content. This content should be merged with the later occurring section titled "Levels of evidence".
- Bob - [[User:Robert Badgett|Robert Badgett]] 15:48, 12 March 2008 (CDT)


O'Malley P. Order no harm: evidence-based methods to reduce prescribing errors for the clinical nurse specialist. [Review] [17 refs] [Journal Article. Review] Clinical Nurse Specialist. 21(2):68-70, 2007 Mar-Apr. UI: 17308440 Classed under evidenced based medicine by Ovid (Medline) , his article reviews actual sources of medication errors.
I think there is more that can be done. Question: ok if I move most of informatics content to the existing article of that name?


Doumit G. Gattellari M. Grimshaw J. O'Brien MA. Local opinion leaders: effects on professional practice and health care outcomes.[update of Cochrane Database Syst Rev. 2000;(2):CD000125; PMID: 10796491]. [Review] [54 refs] [Journal Article. Review] Cochrane Database of Systematic Reviews. (1):CD000125, 2007. UI: 17253445


Lorenz LB. Wild RA. Polycystic ovarian syndrome: an evidence-based approach to evaluation and management of diabetes and cardiovascular risks for today's clinician. [Review] [60 refs] [Journal Article. Review] Clinical Obstetrics & Gynecology. 50(1):226-43, 2007 Mar.
==Approval?==
UI: 17304038
I've gone through this with a copyedit run and made some minor adjustments to lose some subsections and compress some bits of text on the page.


Jordan A. McDonagh JE. Transition: getting it right for young people. [Review] [29 refs] [Journal Article. Review] Clinical Medicine. 6(5):497-500, 2006 Sep-Oct.  
In my view, this is a very scholarly, comprehensive and useful guide to EBM, and a good gateway to many related articles.  
UI: 17080900


Thanigaraj S. Wollmuth JR. Zajarias A. Chemmalakuzhy J. Lasala JM. From randomized trials to routine clinical practice: an evidence-based approach for the use of drug-eluting stents. [Review] [48 refs] [Journal Article. Review] Coronary Artery Disease. 17(8):673-9, 2006 Dec.  
I think the last section should go because it seems not really in tune with the article scope as its developed - but should be moved somewhere; the point is a good one, but is overweighted by the (very nice but tangential) image.
UI: 17119375


Stanley K. Design of randomized controlled trials. [Review] [9 refs] [Journal Article. Review] Circulation. 115(9):1164-9, 2007 Mar 6.  
Please see if my edits are good with you Bob, and delete the last section if you agree, and I'm ready to propose approval. I think I've only copy edited here.[[User:Gareth Leng|Gareth Leng]] 17:53, 15 January 2009 (UTC)
UI: 17339574
: Regarding the complexity science question. What about just reducing the image (as I have done) or removing the image (which might be better and is ok with me)? If the image stays, its caption could be more succinct than I have done. By the way, the Hume statue is a great addition that you or someone did a while back. Otherwise all looks ok. - [[User:Robert Badgett|Robert Badgett]] 18:10, 15 January 2009 (UTC)


== Sectioning ==
==Snag?==
Are there perhaps more sections than are useful here? [[CZ:Article Mechanics]] recommends against many relatively short sections in favor of relatively few, longer sections.  But I don't think we have any very hard-and-fast rules about this.
I edited the metadata template to flag To Approve but it hasn't registered - help anyone?[[User:Gareth Leng|Gareth Leng]] 10:49, 16 January 2009 (UTC)


Glad to see you here, Dr. Badgett! --[[User:Larry Sanger|Larry Sanger]] 22:01, 23 October 2007 (CDT)
:Got it, you must have deleted a "|" when you put your name in. [[User:D. Matt Innis|D. Matt Innis]] 14:31, 16 January 2009 (UTC)


:Thanks - [[User:Robert Badgett|Robert Badgett]] 22:37, 31 October 2007 (CDT)
::Anyone know if there is a way to add metadata in a more user friendly manner?  I think that would help a lot, especially with newbies who get intimidated by the metadata template issues. Possibly Howard could dust off the programming side of his brain.  Or we could recruit someone who needs a project for their computer programming course? Or science fair. As for the article, it looks good. [[User:Chris Day|Chris Day]] 15:00, 16 January 2009 (UTC)


== 'Main' template not working ==
:::Interesting that you mention that, Chris. I have a couple of unfunded potential projects, one in intelligent systems for both optimization and administration of drug prescribing, and another for process control of hydroponic cultivation of culinary herbs (I might have a question or two for you on botanical sensors). My last substantial programming was ten years or so ago, much of it real-time router code, and mostly in C. Somewhat later, I did some prototypes in Perl.
I added a new call to the main template, and now all three calls are not displaying correctly. - [[User:Robert Badgett|Robert Badgett]] 22:37, 31 October 2007 (CDT)


== Misuses of EBM ==
:::It is clear that I am going to have to learn some more current languages, much more Web integrated, as well as things that I can use with open source process control. Just at the moment, I've ben trying to decide on the priority of language skill to acquire. So, if you could tell me (email or here) what is used in MediaWiki and any tools, that would be a significant help to my planning. Not promising to deliver code yet, and I usually do design before coding; I am affected but not fully convinced by the [[Agile Programming]] manifesto. Nevertheless, I need to do some study anyway. My desktop environment is Windows, but I can certainly put server-appropriate Linux on a server here. [[User:Howard C. Berkowitz|Howard C. Berkowitz]] 15:41, 16 January 2009 (UTC)
The article ignores the misuses of EBM in the real world.
Very few of the methods actually used in medicine have ever been validated by independent prospective randomized double-blind studies, or are likely to be.
The main use of EBM is by HMOs and other prepaid managed care organizations, as an excuse to refuse to pay for expensive studies or treatments, while happily paying for inexpensive, untested, unproven treatments, such as herbal and other "alternative" medicines.
I do not think this misuse of EBM should be ignored in this otherwise wholly laudatory article.
[[User:Harvey Frey|Harvey Frey]] 17:20, 12 November 2007 (CST)
: Hi!
: The use of the "there is no evidence that" is becoming a little too frequent in clinical medicine. I suggest these two articles for inclusion; unfortunately I cannot access them (full text) right now.
: J Med Ethics 2004;30:141-145 Evidence based medicine and justice: a framework for looking at the impact of EBM upon vulnerable or disadvantaged groups. W A Rogers
:  S I Saarni and H A Gylling Evidence based medicine guidelines: a solution to rationing or politics disguised as science?
: J. Med. Ethics, Apr 2004; 30: 171 - 175.  
: May I summarize the two abstracts in the Criticisms section?
: [[User:Pierre-Alain Gouanvic|Pierre-Alain Gouanvic]] 23:34, 12 November 2007 (CST)


== Problem with the references ==
== APPROVED [http://en.citizendium.org/wiki?title=Evidence-based_medicine&oldid=100440219 Version 1.0] ==
Somewhere around the 50th reference, there is a bug. Can someone fix this?
[[User:Pierre-Alain Gouanvic|Pierre-Alain Gouanvic]] 23:47, 12 November 2007 (CST)
: Great! [[User:Pierre-Alain Gouanvic|Pierre-Alain Gouanvic]] 13:50, 13 November 2007 (CST)


==Criticisms that may be incorporated into the Section==
Congratulations on approval of [http://en.citizendium.org/wiki?title=Evidence-based_medicine&oldid=100440219 this version]. [[User:D. Matt Innis|D. Matt Innis]] 02:15, 27 January 2009 (UTC)


I think more needs to be added about the sources of much so-called EBM, from sources interested in minimizing expenses of government health plans, like the Cochrane group, or through medical auditors interested primarily in maximizing profits of private HMOs, like Milliman & Robertson.
<div class="usermessage plainlinks">Discussion for [http://en.citizendium.org/wiki?title=Evidence-based_medicine&oldid=100440219 Version 1.0] stopped here. Please continue further discussion under this break. </div>
There also needs to be a fair admission of how little of accepted
----
medical practice has actually been validated by 'gold-standard' studies.  
When should a procedure be denied based on lack of EBM support?
And, to what extent are surrogate measures acceptable when, say,
survival data is unavailable? For instance in Radiation Oncology (my own specialty) if you know that higher radiation doses kill more cancer cells, and high doses are usually limited by doses to surrounding tissues, and if you can show that some new technique gives less dose to surrounding tissues this allowing higher doses to cancers, is it irrational to take that as evidence that the new technique
is superior? Must an HMO insist on a prospective randomized double-blind
study using 20 year survival as an endpoint before allowing use of the new technique?
The other issue is the extent to which 'cost' should be involved in EBM
studies, and if it IS allowed, what should be the conversion factor between dollars and years of life, or dollars and years of pain-free life. Should we EVER do a coronary bypass operation, given that the same number of dollars could save thousands of lives if spent on malaria prevention instead? But, WOULD the dollars saved be spent on malaria prevention, or would it go to executive perks and stockholder dividends? One doctor in California recently received almost a billion dollars selling his share of an HMO. Those were dollars not spent on medical care, often justified by calling some procedure "not medically necessary", or "investigational"!
And, what weight should be given to the EBM "guidelines"? Should they be
used to overrule the decision of the primary doctor on the case? If so, who takes responsibility for adverse results? The clerk who countermanded a doctor's order based on an M&R cookbook? [[User:Harvey Frey|Harvey Frey]]


:I think these are all legitimate issues. What we have so far is a pretty mainstream article, your stuff would help. Much of this could be added to the 'criticisms' section, which is currently sparse. Some of what you suggest might be better on the clinical guidelines page. [[User:Robert Badgett|Robert Badgett]]
== Toward Approval of version 1.1 ==


::Here's another example: http://www.careguidelines.com/ An entirely PROPRIETARY set of "EBM Guidelines" from Milliman, originally a hospital accounting firm, based on no known public peer review, widely sold to managed care organizations in the US, for the express purpose of controlling cost. And, of course they come with disclaimers, to avoid liability if anyone is injured by one of their clients using them. I do remember a case in California a few years ago when they figured prominently when a hospital prematurely discharged a woman post-delivery, based on these guidelines. Unfortunately, it wasn't an reported appellate case, so I'm having trouble finding it now. [[User:Harvey Frey|Harvey Frey]]
I notice that the version number ToApprove points to the current Approved version.  I assume it should point to this [http://en.citizendium.org/wiki?title=Evidence-based_medicine/Draft&oldid=100499186 version] that includes [http://en.citizendium.org/wiki?title=Evidence-based_medicine%2FDraft&diff=100499186&oldid=100440214 these edits] that are Robert's.  That means that this would be a three editor approval and everything looks okay for that tomorrow. If there is any objection or if I have made the wrong assumption, please let me know here before tomorrow. Thanks, [[User:D. Matt Innis|D. Matt Innis]] 02:43, 1 July 2009 (UTC)


:::Interesting. I cannot find their guidelines to assess their methods, but from your description, it sounds like they hijacked the label evidence-based. [[User:Robert Badgett|Robert Badgett]]
== APPROVED [http://en.citizendium.org/wiki?title=Evidence-based_medicine/Draft&oldid=100499186 Version 1.1] ==


: If I understood you well, the example you provide from oncology:
<div class="usermessage plainlinks">Discussion for [http://en.citizendium.org/wiki?title=Evidence-based_medicine/Draft&oldid=100499186 Version 1.1] stopped here. Please continue further discussion under this break. </div>
:''For instance in Radiation Oncology (my own specialty) if you know that higher radiation doses kill more cancer cells, and high doses are usually limited by doses to surrounding tissues, and if you can show that some new technique gives less dose to surrounding tissues this allowing higher doses to cancers, is it irrational to take that as evidence that the new technique is superior?''
----
: is an illustration of the difficulty of using causal inferences and, for that matter, common sense, in the framework of EBM. I unearthed something like a little gem, which could be useful in defining EBM from the practicioner's and patient's point of view (I'm not saying that this article is "one of its kind" though): Critique of (im)pure reason: evidence-based medicine and common sense <ref name="pmid15189382">{{cite journal |author=Michelson J |title=Critique of (im)pure reason: evidence-based medicine and common sense |journal=Journal of evaluation in clinical practice |volume=10 |issue=2 |pages=157–61 |year=2004 |pmid=15189382 |doi=10.1111/j.1365-2753.2003.00478.x}}</ref>
:''While the goal of evidence-based medicine (EBM) is certainly laudable, it is completely based on the proposition that 'truth' can be gleaned exclusively from statistical studies. In many instances, the complexity of human physiology and pathophysiology makes this a reasonable, if not necessary, assumption. However, there are two additional large classes of medical 'events' that are not well served by this paradigm: those that are based on physically required causality, and those that are so obvious (to the casual observer) that no self-respecting study will ever be undertaken (let alone published). Frequently, cause-and-effect relationships are so evident that they fall into both categories, and are best dealt with by the judicious use of common sense. Unfortunately, the use of common sense is not encouraged in the EBM literature, as it is felt to be diametrically opposed to the very notion of EBM. As is more fully discussed in the manuscript, this active disregard for common sense leaves us at a great disadvantage in the practical practice of medicine.''
: I believe that this criticism is important because it brings in bright light the relationship between EBM and fundamental research: the latter deals with complex-cause-and-effect relationships, the former with specific effects, out of the black box of human physiology. [[User:Pierre-Alain Gouanvic|Pierre-Alain Gouanvic]] 12:05, 14 November 2007 (CST)


==Some problems==
== Reference needs fixing ==
"Evidence-based medicine seeks to promote practices that has been shown, through the scientific method to have validity by empiric proof."
This needs re-thinking; I think that what is meant here is "promoting practices the effectiveness of which has been supported by stringent statistical analysis of the results of carefully controlled clinical studies."


Evidence-based medicine is not science-based medicine. Science-based medicine works from a fundamental understanding of basic mechanisms to generate a rationally designed intervention strategy. Not all medical interventions are actually based in science in this sense (and some would say that relatively few are). More commonly, they are based empirically on experience of what actually works, and the scientific rationale or explanation comes later (if at all).
In http://en.citizendium.org/wiki/Evidence-based_medicine/Draft#Acquisition_of_evidence, a reference needs fixing. Not evident how to do it.  [[User:Anthony.Sebastian|Anthony.Sebastian]] 03:21, 1 October 2009 (UTC)
:Thanks for finding that, it was pretty ugly but is now fixed. [[User:Robert Badgett|Robert Badgett]] 03:34, 1 October 2009 (UTC)


Most importantly here though, the scientific method would test the ''explanations'' for the effectiveness of particular treatments by hypothesis-based experimental testing. Whether this has been done or not would not really influence the decision to use a particular intervemntion or not.[[User:Gareth Leng|Gareth Leng]] 03:55, 14 November 2007 (CST)
== approval ==


Now that there are three editors on board for reapproval (thanks guys), there is much less reason to wait another month before approval.  If you'd like to move the target date sooner, you should feel free. --Joe ([[User:Approvals Manager|Approvals Manager]]) 12:47, 1 October 2009 (UTC)


I haven't checked the references, only put them into what I think is style consistent within the article and consistent with Biology work group style; I've shorten author lists to et al. when there are more than 2 authors and omitted issue numbers as redundant, generally to try to keep the list concise for printing. My general feeling is that it seems over-referenced - I'd be wary of this as a large current reference list becomes outdated fast, a smaller list of elite core references has a longer shelf life. The size is also a burden for verification.
However it's a very nicely written very helpful article. I'd just return to the use of the word "proof" which I'd strongly urge that you avoid. Scientists would rarely consider anything to be proved; the evidence might be strong enough to accept a conclusion (provisionally), but if a conclusion rests on statistics then there is always a margin for error.[[User:Gareth Leng|Gareth Leng]] 06:51, 14 November 2007 (CST)


== required fixes, self approval? ==
==APPROVED Version 2.0==  
Several things need fixing prior to approval. The article needs to be consistant, ie "evidence-based" vs "evidence based" oocurs in the article, as well as minor typos.  At least two sections are completely empty somewhere near the bottom, including the "Apply" and "Assess" sections.  They need to be removed or expanded.  Finally, the nominating editor appears to have created and written on this page. I suggest removal of nomination, a careful read and editing, and then re-nomination [[User:David E. Volk|David E. Volk]] 09:18, 14 November 2007 (CST)


== Studies of effectiveness section ==
<div class="usermessage plainlinks">Discussion for [http://en.citizendium.org/wiki?title=Evidence-based_medicine/Draft&oldid=100578938 Version 2.0] stopped here. Please continue further discussion under this break. </div>
The last sentence in this paragraph is not a sentence. I can't figure out what was meant. I inserted EBM in a few sentences where it seemed to be missing.  [[User:David E. Volk|David E. Volk]] 10:15, 14 November 2007 (CST)


==Is this ready for approval?==
===New version 2 has an error in a section heading===
Several section were blank.  i added text from related articles to give an overview but we can't have an approved aricles with blank sections.  Also it seems incomplete in places.  Particularly, There are four cases of one sub section in a hierarchy.  This seems to imply there is another sub section that could be added.  If not then the subsection seems unnecessary.  For example;
The error:
:7 Incorporating evidence into clinical care
::7.1 Medical informatics
::7.2  ?
:8.3 Clinical reasoning
::8.3.1 Improving clinical care
::8.3.2  ?
:9.4 Apply
::9.4.1 Clinical reasoning
::9.4.2  ?
:10.3 Epistemology
::10.3.1 Complexity theory
::10.3.2  ?


In all these cases it seems like there should either be another subsection or that the x.x.1 sub heading is not required. I dpn't know enough about the topic to know what the ? might be. [[User:Chris Day|Chris Day]] [[User talk:Chris Day|(talk)]] 22:44, 14 November 2007 (CST)
<nowiki>===Acquisition of evidence=== </nowiki>


...harms the contents menu. Should I start approval for another version? The draft does not have that error and has a number of new changes as well. The frequent approvals are very awkward.  [[User:Robert Badgett|Robert Badgett]] 19:18, 2 November 2009 (UTC)


==What does this mean?==
:Well, I can correct that, since you're an editor telling me to do a minor typo fix.  What should it be? <nowiki>==Acquisition of evidence==</nowiki>? [[User:Hayford Peirce|Hayford Peirce]] 19:52, 2 November 2009 (UTC)
I was trying to edit the second paragraph in the first section but came to the conclusion that i did not really know what it means.
::"''Evidence-based medicine seeks to promote practices that have been shown, through the [[scientific method]] to have validity by empiric proof. As such, it currently encompasses only a few of the actual practices in clinical medicine and surgery.  More often, recommendations are made on the basis of best evidence that are reasonable, but not proven. Evidence-based medicine is also a philosophy, however, that seeks to validate practices by finding proof.''"


The first sentence I would change to:
::The number of '='s is ok, but I believe there is a space accidentally placed before the first '='. - [[User:Robert Badgett|Robert Badgett]] 20:03, 2 November 2009 (UTC)
::"''Evidence-based medicine seeks to promote practices that have been shown to have validity using the [[scientific method]].''"


The second sentence reads I'm unsure what the point is. Is the implication that the actual practices in clinical medicine and surgery do not follow the scientific method? Is so, does this even need to be said, this is redundant with the first paragraph.
:::Yes. I just fixed it. [[User:Hayford Peirce|Hayford Peirce]] 20:33, 2 November 2009 (UTC)
::::Thanks - [[User:Robert Badgett|Robert Badgett]] 20:34, 2 November 2009 (UTC)


The third sentence seems redundant with the first sentence.  It says the same as "promote practices that have been shown to have validity using the [[scientific method]]"
==See also section==
 
Ok to delete the EHR, EMR, and Clinical Data warehouse links? - [[User:Robert Badgett|Robert Badgett]] 20:29, 9 February 2010 (UTC)
The last paragraph relating to phiolosophy loses me. Phiolosophy and EBM seem to be the opposite of each other but this sentence seems to be saying they are both? i find this very confusing. I hope these comments are useful. [[User:Chris Day|Chris Day]] [[User talk:Chris Day|(talk)]] 23:16, 14 November 2007 (CST)
:It looks like there's some redundancy in it, from an outsider point of view.  Even when it says that "Evidence-based medicine is also a philosophy, however, that seeks to validate practices by finding proof", it seems to read that A is something that relies on B, but A also seeks to prove B but I would not use the word "philosophy" but rather restate it as "Part of the ultimate goal of evidence-based medicine is to validate practices by establishing proof of the results." --[[User:Robert W King|Robert W King]] 23:41, 14 November 2007 (CST)
 
Isn't that exactly the same as the first sentence in the paragraph? Here I slightly reworded it and you'll see what I mean.
::"''Part of the ultimate goal of evidence-based medicine is to validate practices by using the scientic method.''"
 
It seems to me that the whole paragraph distills down to the first sentence:
 
::"''Evidence-based medicine seeks to promote practices that have been shown to have validity using the [[scientific method]].''"
 
[[User:Chris Day|Chris Day]] [[User talk:Chris Day|(talk)]] 23:50, 14 November 2007 (CST)
:::If the rest of the paragraph is superfulous because of redundancy, I'd probably just remove the errant content! --[[User:Robert W King|Robert W King]] 00:24, 15 November 2007 (CST)
::::That's what i have done.  Let's see what the health editors think.  [[User:Chris Day|Chris Day]] [[User talk:Chris Day|(talk)]] 00:35, 15 November 2007 (CST)
 
==Industry and publication bias==
Reading this again, it struck me that an important part of meta-analysis and appraisal is neglected. Most studies where they are misleading are I think misleading because of flaws in design or conduct or analysis. I don't know that I've ever seen a study where legitimate criticisms can't be raised, that might affect the interpretation. A good meta-analysis grades the quality of the trials, weighting the outcomes by quality, and I think attempts to come to a global recommendation on the basis that while individual trials might be imperfect for different reasons, when collectively they come to a common conclusion that conclusion is probably reliable.
 
The issue of publication bias works two ways. First, negative or inconclusive results are less likely to be reported. Second, positive results may be more likely to be reported ''when they are confirmatory of already published findings'' even when the quality of the trial is poor.
 
Overall, industry-sponsored trials are given a rough ride here. It should be remembered I think that, without industry sponsorship, there would be far fewer trials in the first place. The quality of studies very much depends on the integrity and competence of the academic or clinical scientists conducting them. We as academics can't blame industry for our own shortcomings. I do think that the major pharmaceutical companies try to find academic partners whose integrity and competence are unimpeachable; it's very much in their interests to do so, whatever the outcome of the trials. 
 
[[User:Gareth Leng|Gareth Leng]] 03:59, 16 November 2007 (CST)
 
There are many "jargon terms" introduced here e.g.
Relative risk ratio
Relative risk reduction
Absolute measures
Absolute risk reduction
Number needed to treat
Number needed to screen
Number needed to harm
 
I wonder if it would be sensible to add a glossary as a subpage that gave definitions of these? Or is there some other solution? Perhaps there's a case for making a stub for each of these, with a brief definition and an external link.[[User:Gareth Leng|Gareth Leng]] 07:17, 16 November 2007 (CST)
 
:I like the glossary idea on subpages.  It goes along with the definitions template that Larry created as well. --[[User:D. Matt Innis|Matt Innis]] [[User talk:D. Matt Innis|(Talk)]] 07:56, 16 November 2007 (CST)
 
== Delayed approval ==
 
Although this article is outside of my sphere of competence, I recomment delaying the approval for at least 7 days, so that changes can be made. There are too many comments here from senior scientists, which may not be taken into account if the approval occurs
as scheduled. Please indicate your support or opposition for my proposal of a short delay. --[[User:Martin Baldwin-Edwards|Martin Baldwin-Edwards]] 08:40, 16 November 2007 (CST)
 
I think 7 days may not be enough unless we are able to fill in the blank spaces toward the bottom and clean up the criticism section.  I have added the [[Healing Arts|Healing Arts Workgroup]] as this article affects them as well. --[[User:D. Matt Innis|Matt Innis]] [[User talk:D. Matt Innis|(Talk)]] 07:46, 16 November 2007 (CST)
 
I agree that some delay is sensible. I added a stub for [[Odds ratio]] as an example for my comment above, sadly I noticed too late that this is a term omitted (dooh)[[User:Gareth Leng|Gareth Leng]] 08:49, 16 November 2007 (CST)
 
:Notice what I did with odds ratio.  You put the name in the r template like this <nowiki>{{r|odds ratio}}</nowiki> and then click on the little 'e' and put in the defintiion.  The it shows up anywhere we put that on any page about odds ratio. --[[User:D. Matt Innis|Matt Innis]] [[User talk:D. Matt Innis|(Talk)]] 08:31, 16 November 2007 (CST) Thanks[[User:Gareth Leng|Gareth Leng]] 09:35, 16 November 2007 (CST)
 
==Cut this?==
I cut this short section. It is in the criticism section, and I couldn't identify in what respect there is any criticism. I guess I think that this may be interesting but is probably only tangential to the article?
====Complexity theory====
Complexity theory is proposed as further explaining the nature of medical knowledge.<ref name="isbn1-85775-724-6">{{cite book |author=Sweeney, Kieran  |title=Complexity in Primary Care: Understanding Its Value |publisher=Radcliffe Medical Press |location=Abingdon |year=2006 |pages= |isbn=1-85775-724-6 |oclc= |doi=}}[http://www.acpjc.org/Content/147/3/issue/ACPJC-2007-147-3-A11.htm Review]</ref><ref name="isbn1-85775-855-2">{{cite book |author=Holt, Tim A | title=Complexity for Clinicians |publisher=Radcliffe Medical Press |location=Abingdon |year=2004 |pages= |isbn=1-85775-855-2 |oclc= |doi=}} [http://www.mja.com.au/public/bookroom/2007/zwar/zwar.html Review], [http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1463117 ACP Journal Club Review]</ref>
 
[[User:Gareth Leng|Gareth Leng]] 09:35, 16 November 2007 (CST)
 
:Restored, renamed, and expanded this section with context. See what you think. - [[User:Robert Badgett|Robert Badgett]] 08:57, 16 November 2007 (CST)
 
::Complexity theory needs to be defined or explained. --[[User:D. Matt Innis|Matt Innis]] [[User talk:D. Matt Innis|(Talk)]] 09:06, 16 November 2007 (CST)
 
:::Liked what you did Robert; also agree with Matt - maybe though it's just again that Complexity theory needs a stub rather than a definition here.[[User:Gareth Leng|Gareth Leng]] 11:54, 16 November 2007 (CST)
 
::::That might work, depending on how you do it, but I like having at least some clarity here and then they can click on the link for more, especially on those more scientific terms that their meanings cannot be easily inferred by the average reader. --D. Matt Innis 11:44, 16 November 2007 (CST)
 
==??==
"were more likely to adopt COX-2 drugs before the drugs were recalled by the FDA"
 
well yes, they would be wouldn't they? But were they recalled by the FDA?[[User:Gareth Leng|Gareth Leng]] 08:54, 16 November 2007 (CST)
 
==Quality of references==
I have started to do some checking of the references. I looked at this
"A randomized controlled trial supports the efficiency of this approach.[7]"
which is a reference used 3 times. This is a study of 32 medical students assigned to one of 2 search protocols. Frankly it has statistical weaknesses; most obviously the analysis is based on the numbers of answers to questions not on the individual performances; as the individuals are independent but their answers are obviously not, this seems inappropriate. I don't mean to rubbish this small trial, only to say that I think, especially in this article, we should set the bar for citing studies as evidence at an appropriately high level - i.e. at a level appropriate for the topic. Using small or poorly controlled studies as evidence to support conclusions about EBM is surely not what we want to do?  I really would recommend trimming the references in the article down to a sustainable core of unimpeachably strong studies.[[User:Gareth Leng|Gareth Leng]]
 
Agreed.  Considering we have the expertise here, we don't need to reference things that are reasonably understandable unless there is a conflict or questionable synthesis of the information. --[[User:D. Matt Innis|Matt Innis]] [[User talk:D. Matt Innis|(Talk)]] 09:47, 16 November 2007 (CST)
 
==alt med==
I added a blurb about alt med being evaluted using EBM as well.  Feel free to clarify or clean it up.  I think it is important that this method might be the way to evaluate the claims made by techniques that are subject to bias. --[[User:D. Matt Innis|Matt Innis]] [[User talk:D. Matt Innis|(Talk)]] 09:40, 16 November 2007 (CST)
 
== COx-2 drugs = COX-2 inhibitors? ==
Robert, can you rephrase  COX-2 "drugs"  to be more descriptive?
 
== Server timing ==
 
In case anyone is wondering, the timing of the server is way off and clocks are not valid, so the order of edits in the history do not necessarily follow when they were actually made, i.e. Gareth's last edit was actually made before mine, but shows an hour later. --[[User:D. Matt Innis|Matt Innis]] [[User talk:D. Matt Innis|(Talk)]] 09:42, 16 November 2007 (CST)
 
== file drawer ==
 
This sentence:
*In performing a meta-analyses, a file drawer[15] or a funnel plot analysis[16][17] may help detect underlying publication bias among the studies in the meta-analysis [http://en.citizendium.org/wiki/Evidence-based_medicine#Publication_bias].
sure could use a quick explanation of file drawer and funnel plot.
--D. Matt Innis 10:25, 16 November 2007 (CST)
 
==Really ready for approval?==
I just [http://en.citizendium.org/wiki?title=Evidence-based_medicine&diff=100217773&oldid=100217671 corrected] a grammar error in the intro. It looked like something had been deleted and left a dangling ''and''.  Also the very last paragraph in the intro is th following.
::"Evidence-Based Health Care'' or ''evidence-based practice'' extends the concept of EBM to all health professions, including purchasing and management [http://www.cebm.net/glossary.asp]."
Here the references cited does not seem to give any information with regard to purchasing and management and ''evidence-based practice''. If it does it is not obvious to me as a layperson. Also, this reference does not use the <nowiki><ref></ref></nowiki> format. I know these are minor issues but if these are in the intro what is the rest of the article like? [[User:Chris Day|Chris Day]] [[User talk:Chris Day|(talk)]] 17:38, 17 November 2007 (CST)

Latest revision as of 16:02, 5 March 2024

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 Definition:  The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. [d] [e]
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Too many sections?

I'm sure this article is excellent, but, without reading it, I wonder if we could sensibly and usefully reduce the number of headings? This tends to interrupt the flow of the article. Actually, so many headings actually makes it hard for a "flow," or a narrative, to develop in the first place. Please see Article Mechanics on this; the longer version goes into this in some detail. --Larry Sanger 22:03, 21 February 2008 (CST)

Hey, this page needs to be archived! It's getting very long! --Larry Sanger 22:03, 21 February 2008 (CST)

Okay, I archived for a fresh new outlook. --D. Matt Innis 11:58, 12 March 2008 (CDT)
I cut out some stuff. Also, does anybody mind if I cut out the section "Why do we need EBM"? I do not see that it adds much to the text in the introduction. Also, it contains no references. - Robert Badgett 22:14, 21 February 2008 (CST)

Agree it can be cut.Gareth Leng 11:46, 12 March 2008 (CDT) Can we cut out the sentences like "For more information, see: Clinical practice guideline" and instead a) link the phrase at first appearance and b) add to the related articles subpage?Gareth Leng 11:48, 12 March 2008 (CDT)

Responses to too many sections

I agree succinct is nice; however, I find that WikiPedia can be hard to follow when a topic is scattered over several pages. I am not as bothered by the length. In part because I do not see further sections that can easily be lopped off and put in their own pages. Maybe the metric section could be moved to a statistics article. We have already separate pages for Teaching evidence-based medicine and Evidence-based individual decision making. Should these have been subpages?? I suggest leaving clinical practice guidelines represented in the TOC so the concept is not lost.

  1. As nobody complained about my suggestion Feb 21 to delete the "Why do we need EBM", I have done so.
  2. In the sections "Methods proposed for assessing validity" and "Criticisms of EBM" I made the subsections not appear in the TOC.
  3. I moved publication bias content to article of that name.
  4. I removed the section heading "Methods proposed for assessing validity" but left the content. This content should be merged with the later occurring section titled "Levels of evidence".

- Bob - Robert Badgett 15:48, 12 March 2008 (CDT)

I think there is more that can be done. Question: ok if I move most of informatics content to the existing article of that name?


Approval?

I've gone through this with a copyedit run and made some minor adjustments to lose some subsections and compress some bits of text on the page.

In my view, this is a very scholarly, comprehensive and useful guide to EBM, and a good gateway to many related articles.

I think the last section should go because it seems not really in tune with the article scope as its developed - but should be moved somewhere; the point is a good one, but is overweighted by the (very nice but tangential) image.

Please see if my edits are good with you Bob, and delete the last section if you agree, and I'm ready to propose approval. I think I've only copy edited here.Gareth Leng 17:53, 15 January 2009 (UTC)

Regarding the complexity science question. What about just reducing the image (as I have done) or removing the image (which might be better and is ok with me)? If the image stays, its caption could be more succinct than I have done. By the way, the Hume statue is a great addition that you or someone did a while back. Otherwise all looks ok. - Robert Badgett 18:10, 15 January 2009 (UTC)

Snag?

I edited the metadata template to flag To Approve but it hasn't registered - help anyone?Gareth Leng 10:49, 16 January 2009 (UTC)

Got it, you must have deleted a "|" when you put your name in. D. Matt Innis 14:31, 16 January 2009 (UTC)
Anyone know if there is a way to add metadata in a more user friendly manner? I think that would help a lot, especially with newbies who get intimidated by the metadata template issues. Possibly Howard could dust off the programming side of his brain. Or we could recruit someone who needs a project for their computer programming course? Or science fair. As for the article, it looks good. Chris Day 15:00, 16 January 2009 (UTC)
Interesting that you mention that, Chris. I have a couple of unfunded potential projects, one in intelligent systems for both optimization and administration of drug prescribing, and another for process control of hydroponic cultivation of culinary herbs (I might have a question or two for you on botanical sensors). My last substantial programming was ten years or so ago, much of it real-time router code, and mostly in C. Somewhat later, I did some prototypes in Perl.
It is clear that I am going to have to learn some more current languages, much more Web integrated, as well as things that I can use with open source process control. Just at the moment, I've ben trying to decide on the priority of language skill to acquire. So, if you could tell me (email or here) what is used in MediaWiki and any tools, that would be a significant help to my planning. Not promising to deliver code yet, and I usually do design before coding; I am affected but not fully convinced by the Agile Programming manifesto. Nevertheless, I need to do some study anyway. My desktop environment is Windows, but I can certainly put server-appropriate Linux on a server here. Howard C. Berkowitz 15:41, 16 January 2009 (UTC)

APPROVED Version 1.0

Congratulations on approval of this version. D. Matt Innis 02:15, 27 January 2009 (UTC)

Discussion for Version 1.0 stopped here. Please continue further discussion under this break.

Toward Approval of version 1.1

I notice that the version number ToApprove points to the current Approved version. I assume it should point to this version that includes these edits that are Robert's. That means that this would be a three editor approval and everything looks okay for that tomorrow. If there is any objection or if I have made the wrong assumption, please let me know here before tomorrow. Thanks, D. Matt Innis 02:43, 1 July 2009 (UTC)

APPROVED Version 1.1

Discussion for Version 1.1 stopped here. Please continue further discussion under this break.

Reference needs fixing

In http://en.citizendium.org/wiki/Evidence-based_medicine/Draft#Acquisition_of_evidence, a reference needs fixing. Not evident how to do it. Anthony.Sebastian 03:21, 1 October 2009 (UTC)

Thanks for finding that, it was pretty ugly but is now fixed. Robert Badgett 03:34, 1 October 2009 (UTC)

approval

Now that there are three editors on board for reapproval (thanks guys), there is much less reason to wait another month before approval. If you'd like to move the target date sooner, you should feel free. --Joe (Approvals Manager) 12:47, 1 October 2009 (UTC)


APPROVED Version 2.0

Discussion for Version 2.0 stopped here. Please continue further discussion under this break.

New version 2 has an error in a section heading

The error:

===Acquisition of evidence===

...harms the contents menu. Should I start approval for another version? The draft does not have that error and has a number of new changes as well. The frequent approvals are very awkward. Robert Badgett 19:18, 2 November 2009 (UTC)

Well, I can correct that, since you're an editor telling me to do a minor typo fix. What should it be? ==Acquisition of evidence==? Hayford Peirce 19:52, 2 November 2009 (UTC)
The number of '='s is ok, but I believe there is a space accidentally placed before the first '='. - Robert Badgett 20:03, 2 November 2009 (UTC)
Yes. I just fixed it. Hayford Peirce 20:33, 2 November 2009 (UTC)
Thanks - Robert Badgett 20:34, 2 November 2009 (UTC)

See also section

Ok to delete the EHR, EMR, and Clinical Data warehouse links? - Robert Badgett 20:29, 9 February 2010 (UTC)

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