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JOURNAL SCAN
Year : 2020  |  Volume : 1  |  Issue : 2  |  Page : 156-158

Hybridisation of evidence-based medicine with evidence-based management to minimise overuse and maximise quality in healthcare


Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, India

Date of Submission21-May-2020
Date of Decision15-Jun-2020
Date of Acceptance13-Oct-2020
Date of Web Publication15-Dec-2020

Correspondence Address:
Dr. Sri Aurobindo Prasad Das
Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JME.JME_66_20

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How to cite this article:
Das SA, Nundy S. Hybridisation of evidence-based medicine with evidence-based management to minimise overuse and maximise quality in healthcare. J Med Evid 2020;1:156-8

How to cite this URL:
Das SA, Nundy S. Hybridisation of evidence-based medicine with evidence-based management to minimise overuse and maximise quality in healthcare. J Med Evid [serial online] 2020 [cited 2021 Apr 13];1:156-8. Available from: http://www.journaljme.org/text.asp?2020/1/2/156/303575




  Article Information Top


Using the evidence-based medicine and evidence-based management to minimise overuse and maximise quality in healthcare: A hybrid perspective. BMJ Evid Based Med 2020;25:3-5. (Doi: 10.1136/bmjebm-2018-110957).


  Background Top


The last few decades of the 19th century stood witness to a paradigm shift in the approach and implementation of clinical decision-making by physicians. This change was a result of the effort of several individuals and groups who felt that treatments administered by doctors were largely based on assumptions, old standard-of-care practices or the beliefs of experts. They felt that these enquiries were often biased and lacked clinical reasoning. This gave birth to the concept of 'evidence-based medicine (EBM)' which revolutionised the art of decision-making in clinical management.

As described by Sackett et al., EBM is 'the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients'.[1] It aims to bring together physicians' experience, patient values and the best available scientific information to create guidelines and policies to help improve patient care. EBM relies on structured and objective quality research with sound statistics to generate data that will help in making informed clinical decision-making in the diagnosis, investigation and management of patients.[2],[3]

Over the years, the term 'evidence based' has diversified across the whole spectrum of healthcare. It is now being actively applied to medical education, health organisations and population-directed programmes. Evidence-based management (EBMgt) is such an offshoot which aims at improving managerial decisions and organisational practices using well-based medical research. It helps managers in making more informed and rational healthcare policies and helps in clinical decision-making.

Challenges faced by evidence-based practice include large volumes of data, biased evidence from drug company-funded research, inflexible treatment practices, overuse of testing, overtreatment of patients and wasted resources. At this time when there are debates over the pros and cons of evidence-based practice, the journal BMJ-EBM has published an interesting paper by Hasanpoor et al. who have proposed the use of a hybrid perspective of EBM and EBMgt to minimise overuse and to maximise quality in healthcare.

The authors have highlighted the importance of EBM and EBMgt in providing a rationale evidence-based medical service to patients with an aim at maximising benefits. However, this practice has come with a cost. They have brought forth issues which include:

  1. Overuse of testing, leading to false positives and overdiagnosis
  2. Overtreatment of these overdiagnosed conditions
  3. Adverse events due to these overtreatments
  4. Large loss of revenues (approx. 280 billion USD).


These have led healthcare providers to formulate critical strategies to decrease the overuse of health resources and optimise patient outcome. The authors recommend hybridisation of EBM and EBMgt strategies for optimal utilisation of health resources.

The hybrid framework of evidence-based medicine and evidence-based management

They propose a combination of these two components to improve knowledge and performance of the healthcare system. They feel that both models are also heavily interdependent and EBMgt can improve organisational and managerial decisions, resulting in better organisational performance. Integration will help remove obstacles in the decision-making process.

EBM relies on the 'pyramid of evidence' which is designed to weigh different levels of evidence in order to make health-related decisions. It is constituted by study designs ranging from expert opinions to systematic reviews arranged in an ascending order corresponding to increased rigor, quality and reliability of evidence [Figure 1]. As we go up the pyramid, results become more accurate with less error and bias. This also yields Grading of Recommendations Assessment, Development and Evaluation recommendations for evidence.
Figure 1: EBM pyramid. (Adapted from Wakeforest School of Medicine database; https://libguides.wakehealth.edu/EBP)

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EBMgt on the other hand sources its evidence from what has been described as the EBMgt hexagon. The healthcare managers who often depend on qualitative and quantitative scientific evidence also need to consider the other components such as information of hospitals, political social development plans, managers' professional expertise, ethical–moral evidence values and expectation of stakeholders. These six points form the six angles of a hexagon which are critical at a managerial level to generate robust data to aid in clinical decision-making.

The authors propose a linkage between the above two models, which requires both healthcare managers and physicians to work together. Both have to select the best available evidence and sources and utilise the same in decision-making following the fundamental six steps:

  • Step 1 – Asking: To translate the practical issue or problem into answerable questions
  • Step 2 – Acquiring: To systematically search for the best evidence
  • Step 3 – Appraising: To critically appraise the correctness and appropriateness of evidence
  • Step 4 – Aggregating: To weigh and pull evidence to ensure its best application
  • Step 5 – Applying: To apply the evidence in organisational and clinical decisions
  • Step 6 – Assessing: To assess the outcomes of the decisions taken.


These six phases are named 6A (asking, acquiring, appraising, aggregating, applying and assessing), and they constitute the evidence-based decision-making (EBDM) process.

They conclude that combining EBM with EBMgt can lead to effective decision-making and better healthcare to patients. This joint effort between two groups of decision makers will enhance knowledge and enable well-informed practices, leading to an improved quality of healthcare.


  Commentary Top


The concept of 'evidence-based medical practice' has revolutionised the delivery of healthcare to the patients. It has changed the decision-making mechanism of a physician into a more rationale and objective-oriented rendition. The practice has now diversified into medical education, individual health practices and also large healthcare organisations.

Commercialisation of healthcare has seen a change in the role of physician from being a primary caregiver to a more managerial role in a large health organisation. This, in turn, has led to the development of EBMgt which recognises the need for formulating organisational strategies and management practices to provide evidence-based medical services.

As already mentioned, the drawbacks of evidence-based practice include the possibility of biased data, inflexible treatment recommendations, overtesting, overdiagnosis, overtreatment and huge financial losses to health corporations. This has led to a need for a robust system to balance the advantages and disadvantages of evidence-based medical practice.

Hybridisation of EBM with EBMgt has been proposed as a way forwards towards securing this balance. This alliance between healthcare managers and physicians can help in picking the best available evidence, resulting in improvement in decision-making. This will lead to an effective, efficient and ethical delivery of medical care.

The proposed EBDM process which links both EBM and EBMgt is a promising approach aimed at decreasing overuse of health resources and improving quality. The six-phased 6A approach helps both the managers and physicians to work together, share knowledge and create a reliable approach to clinical decision-making. This framework begins right from asking the correct question to acquiring the best data for application and assessing the outcome of the intervention. This also effectively bypasses the main obstacle between EBM and EBMgt, which is a lack of communication. It helps foster a healthy relation between the two groups of decision makers.

Even though this transition between theory and practice appears very much possible, integration of EBM and EBMgt needs to be applied to large organisations. Data from high-volume healthcare centres will go a long way towards asserting the rationale of this hybridisation and its goal of improving patient care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: What it is and what it isn't. BMJ 1996;312:71-2.  Back to cited text no. 1
    
2.
Rosenberg W, Donald A. Evidence based medicine: An approach to clinical problem-solving. BMJ 1995;310:1122-6.  Back to cited text no. 2
    
3.
Trisha G. How to Read a Paper: The Basics of Evidence-Based Medicine. 4th ed. Southern Gate, United Kingdom: John Wiley & Sons; 2010. p. 1.  Back to cited text no. 3
    


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