{{Short description|Illness diagnosis, treatment and prevention based on data collection and analysis}} {{redirect|Science-based medicine|the website|Science-Based Medicine{{!}}''Science-Based Medicine''}} {{Use dmy dates|date=March 2022}} {{Evidence-based practices}}
'''Evidence-based medicine''' ('''EBM'''), sometimes known within healthcare as '''evidence-based practice''' ('''EBP'''),<ref>{{cite book |last1=Abela |first1=Stefan |title=Leadership and Management in Healthcare |date=13 January 2023 |publisher=Springer Nature |isbn=978-3-031-21024-2 |language=en |chapter=Evidence-Based Practice in the NHS |quote=Evidence-based practice (EBP) sometimes referred to as evidence-based medicine (EBM) is an approach to practice which allows clinicians to optimise their decisions using evidence}}</ref> is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research."<ref name=sackett2 /> The aim of EBM is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management. <ref>{{cite journal | title=Methodology series of ESAIC guidelines: standards in guidelines production |journal=European Journal of Anaesthesiology |date = March 2026 | doi=10.1097/EJA.0000000000002341 |access-date=15 May 2026 |url=https://journals.lww.com/ejanaesthesiology/fulltext/2026/03000/methodology_series_of_esaic_guidelines__standards.2.aspx }}</ref> The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians about individual patients.<ref name="Guyatt">{{cite journal | title = Evidence-based medicine. A new approach to teaching the practice of medicine | journal = JAMA | volume = 268 | issue = 17 | pages = 2420–2425 | date = November 1992 | pmid = 1404801 | doi = 10.1001/JAMA.1992.03490170092032 | citeseerx = 10.1.1.684.3783 | author1 = Evidence-Based Medicine Working Group | bibcode = 1992JAMA..268.2420G }}</ref>
The EBM Pyramid is a tool that helps in visualizing the hierarchy of evidence in medicine, from least authoritative, like expert opinions, to most authoritative, like systematic reviews.<ref>{{Cite web |title=Evidence-Based Medicine Pyramid |work=Med Scholarly |url=https://medscholarly.com/evidence-based-medicine-pyramid/ |archive-url=https://web.archive.org/web/20231203231356/https://medscholarly.com/evidence-based-medicine-pyramid/ |access-date=2023-09-28|archive-date=2023-12-03}}</ref>
Adoption of evidence-based medicine is necessary in a human rights-based approach to public health and a precondition for accessing the right to health.<ref>{{Cite book |last1=Beracochea |first1=Elvira |url=https://books.google.com/books?id=u1fCn5X1apgC&pg=PA202 |title=Rights-Based Approaches to Public Health |last2=Weinstein |first2=Corey |last3=Evans |first3=Dabney |date=2010-11-01 |publisher=Springer Publishing Company |isbn=978-0-8261-0570-7 |pages=202, 209 |language=en |quote=People cannot be healthy when governments do not respect universal human rights and implement evidence-based health policies that would realize the rights of their citizens....Respecting human rights implies the need to provide effective and evidence-based strategies.}}</ref>
== Background, history, and definition == Medicine has a long history of scientific inquiry into the prevention, diagnosis, and treatment of human disease.<ref>{{cite journal | vauthors = Brater DC, Daly WJ | title = Clinical pharmacology in the Middle Ages: principles that presage the 21st century | journal = Clinical Pharmacology and Therapeutics | volume = 67 | issue = 5 | pages = 447–450 | date = May 2000 | pmid = 10824622 | doi = 10.1067/mcp.2000.106465 | s2cid = 45980791 }}</ref><ref name="pmid11058989">{{cite journal | vauthors = Daly WJ, Brater DC | title = Medieval contributions to the search for truth in clinical medicine | journal = Perspectives in Biology and Medicine | volume = 43 | issue = 4 | pages = 530–540 | year = 2000 | pmid = 11058989 | doi = 10.1353/pbm.2000.0037 | s2cid = 30485275 }}</ref> In the 11th century AD, Avicenna, a Persian physician and philosopher, developed an approach to EBM that was mostly similar to current ideas and practises.<ref>{{cite journal | vauthors = Shoja MM, Rashidi MR, Tubbs RS, Etemadi J, Abbasnejad F, Agutter PS | title = Legacy of Avicenna and evidence-based medicine | journal = International Journal of Cardiology | volume = 150 | issue = 3 | pages = 243–246 | date = August 2011 | pmid = 21093081 | doi = 10.1016/j.ijcard.2010.10.019 }}</ref><ref>{{cite journal | vauthors = Akhondzadeh S | title = Avicenna and evidence based medicine | journal = Avicenna Journal of Medical Biotechnology | volume = 6 | issue = 1 | pages = 1–2 | date = January 2014 | pmid = 24523951 | pmc = 3895573 }}</ref>
The concept of a controlled clinical trial was first described in 1662 by Jan Baptist van Helmont in reference to the practice of bloodletting.<ref>{{cite book |author=John Baptista Van Helmont |title=Oriatrike, or Physick Refined (English translation of Ortus medicinae) |year=1662 |translator=John Chandler |url=https://wellcomecollection.org/works/jh9aanrn}}</ref> Wrote Van Helmont:{{Citation needed|date=March 2025}} {{Blockquote |text=Let us take out of the Hospitals, out of the Camps, or from elsewhere, 200, or 500 poor People, that have fevers or Pleuritis. Let us divide them in Halfes, let us cast lots, that one halfe of them may fall to my share, and the others to yours; I will cure them without blood-letting and sensible evacuation; but you do, as ye know ... we shall see how many Funerals both of us shall have... }}
The first published report describing the conduct and results of a controlled clinical trial was by James Lind, a Scottish naval surgeon who conducted research on scurvy during his time aboard HMS ''Salisbury'' in the Channel Fleet, while patrolling the Bay of Biscay. Lind divided the sailors participating in his experiment into six groups, so that the effects of various treatments could be fairly compared. Lind found improvement in symptoms and signs of scurvy among the group of men treated with lemons or oranges. He published a treatise describing the results of this experiment in 1753.<ref>{{cite book | vauthors = Lind J |title=Treatise on the scurvy|publisher=Gale Ecco |location=|year=2018 |isbn=978-1-379-46980-3}}</ref>
An early critique of statistical methods in medicine was published in 1835, in Comtes Rendus de l'Académie des Sciences, Paris, by a man referred to as "Mr Civiale".<ref>{{cite journal | vauthors = | title = Statistical research on conditions caused by calculi by Doctor Civiale. 1835 | journal = International Journal of Epidemiology | volume = 30 | issue = 6 | pages = 1246–1249 | date = December 2001 | pmid = 11821317 | doi = 10.1093/ije/30.6.1246 | url = http://ije.oupjournals.org/cgi/content/full/30/6/1246 | orig-date = 1835 | doi-access = free | archive-url = https://web.archive.org/web/20050429042527/http://ije.oupjournals.org/cgi/content/full/30/6/1246 | archive-date = 29 April 2005 | url-access = subscription }}</ref>
In 1990, Gordon Guyatt, then a young internal medicine residency coordinator at McMaster University, introduced a teaching method he initially termed "Scientific Medicine." This approach emphasized applying critical appraisal techniques directly to bedside clinical decision-making, building on the work of his mentor, David Sackett. However, the concept met resistance from colleagues, as it implied that existing clinical practices lacked scientific rigor, even though this was likely true. To address this, Guyatt rebranded the approach as "Evidence-Based Medicine", a term first formally introduced in a 1991 editorial in the ACP Journal Club. Although the name was coined in 1991, it took several years after and a concerted efforts of many other teams to define the foundations of this method.<ref>{{cite journal |last1=Sur |first1=RL |last2=Dahm |first2=P |title=History of evidence-based medicine. |journal=Indian Journal of Urology |date=October 2011 |volume=27 |issue=4 |pages=487–9 |doi=10.4103/0970-1591.91438 |doi-access=free |pmid=22279315|pmc=3263217 }}</ref><ref>Guyatt GH. Evidence-Based Medicine [editorial]. ACP Journal Club 1991:A-16. (Annals of Internal Medicine; vol. 114, suppl. 2).</ref><ref>{{cite web|url=https://www.ama-assn.org/residents-students/residency/development-evidence-based-medicine-explored-oral-history-video |title= Development of evidence-based medicine explored in oral history video, AMA, Jan 27, 2014|date= 27 January 2014}}</ref><ref>{{cite journal | vauthors = Sackett DL, Rosenberg WM | title = The need for evidence-based medicine | journal = Journal of the Royal Society of Medicine | volume = 88 | issue = 11 | pages = 620–624 | date = November 1995 | pmid = 8544145 | pmc = 1295384 | doi = 10.1177/014107689508801105 }}</ref><ref>{{cite book |location=Cologne, Germany |publisher=Institute for Quality and Efficiency in Health Care (IQWiG) |date=2016 |title=The history of evidence-based medicine |url=https://www.ncbi.nlm.nih.gov/books/NBK390299/ |id=NBK390299}}</ref>
Although more popular in medicine, the concept of "evidence-based" is spreading to other disciplines, such as the humanities, and to languages other than English, albeit at a slower pace.<ref>{{cite journal |last1=Watine |first1=J |title=Translations of the "Evidence-Based Medicine" concept in different languages: is it time for international standardisation? |journal=Clinical Chemistry and Laboratory Medicine |date=September 2010 |volume=48 |issue=9 |pages=1227–8 |doi=10.1515/CCLM.2010.266 |pmid=20618091}}</ref>
=== Clinical decision-making === Alvan Feinstein's publication of ''Clinical Judgment'' in 1967 focused attention on the role of clinical reasoning and identified biases that can affect it.<ref name="feinstein">{{cite book |author=Alvan R. Feinstein |title=Clinical Judgement |year=1967 |publisher=Williams & Wilkins}}</ref> In 1972, Archie Cochrane published ''Effectiveness and Efficiency'', which described the lack of controlled trials supporting many practices that had previously been assumed to be effective.<ref name="cochraneal">{{cite book |author=Cochrane A.L. |author-link= Archie Cochrane |title=Effectiveness and Efficiency: Random Reflections on Health Services |year=1972 |publisher=Nuffield Provincial Hospitals Trust}}</ref> In 1973, John Wennberg began to document wide variations in how physicians practiced.<ref name="wennberg">{{cite journal | vauthors = Wennberg J | title = Small area variations in health care delivery | journal = Science | volume = 182 | issue = 4117 | pages = 1102–1108 | date = December 1973 | pmid = 4750608 | doi = 10.1126/science.182.4117.1102 | s2cid = 43819003 | bibcode = 1973Sci...182.1102W }}</ref> Through the 1980s, David M. Eddy described errors in clinical reasoning and gaps in evidence.<ref name="eddy2">{{cite book | vauthors = Eddy DM |chapter=18 Probabilistic Reasoning in Clinical Medicine: Problems and Opportunities | veditors = Kahneman D, Slovic P, Tversky A |title=Judgment Under Uncertainty: Heuristics and Biases |chapter-url=https://books.google.com/books?id=_0H8gwj4a1MC&pg=PA249 |date=1982 |publisher=Cambridge University Press |isbn=978-0-521-28414-1 |pages=249–267}}</ref><ref name="eddy3">{{cite journal | vauthors = Eddy DM | title = Clinical policies and the quality of clinical practice | journal = The New England Journal of Medicine | volume = 307 | issue = 6 | pages = 343–347 | date = August 1982 | pmid = 7088099 | doi = 10.1056/nejm198208053070604 }}</ref><ref name="eddy4">{{cite journal | vauthors = Eddy DM | title = Variations in physician practice: the role of uncertainty | journal = Health Affairs | volume = 3 | issue = 2 | pages = 74–89 | year = 1984 | pmid = 6469198 | doi = 10.1377/hlthaff.3.2.74 }}</ref><ref name="eddy5">{{cite journal | vauthors = Eddy DM, Billings J | title = The quality of medical evidence: implications for quality of care | journal = Health Affairs | volume = 7 | issue = 1 | pages = 19–32 | date = 1988 | pmid = 3360391 | doi = 10.1377/hlthaff.7.1.19 | doi-access = }}</ref> In the mid-1980s, Alvin Feinstein, David Sackett and others published textbooks on clinical epidemiology, which translated epidemiological methods to physician decision-making.<ref name="feinstein2">{{cite book|author=Feinstein AR|title=Clinical Epidemiology: The Architecture of Clinical Research|date=1985|publisher=W.B. Saunders Company |isbn=978-0-7216-1308-6}}</ref><ref name="sackett">{{cite book | vauthors = Sackett D | veditors = Haynes BR |title=Clinical Epidemiology: How to Do Clinical Practice Research |url=https://books.google.com/books?id=cuvY6TItIwgC&pg=PA59 |year=2006 |publisher=Lippincott Williams & Wilkins |isbn=978-0-7817-4524-6}}</ref> Toward the end of the 1980s, a group at RAND showed that large proportions of procedures performed by physicians were considered inappropriate even by the standards of their own experts.<ref name="chassin">{{cite journal | vauthors = Chassin MR, Kosecoff J, Solomon DH, Brook RH | title = How coronary angiography is used. Clinical determinants of appropriateness | journal = JAMA | volume = 258 | issue = 18 | pages = 2543–2547 | date = November 1987 | pmid = 3312657 | doi = 10.1001/jama.258.18.2543 }}</ref>
=== Evidence-based guidelines and policies === {{Main|Medical guideline}} David M. Eddy first began to use the term 'evidence-based' in 1987 in workshops and a manual commissioned by the Council of Medical Specialty Societies to teach formal methods for designing clinical practice guidelines. The manual was eventually published by the American College of Physicians.<ref name="eddy1992">{{cite book |author=Eddy DM |title=A Manual for Assessing Health Practices and Designing Practice Policies |publisher=American College of Physicians|date=1992 |isbn=978-0-943126-18-0 }}</ref><ref name="field">{{cite book|author=Institute of Medicine| veditors = Field MJ, Lohr KN |title=Clinical Practice Guidelines: Directions for a New Program |location=Washington, DC|publisher=National Academy of Sciences Press|year=1990|isbn=978-0-309-07666-1|page=32|url= http://www.nap.edu/openbook.php?record_id=1626&page=32 |doi=10.17226/1626|pmid=25144032 |pmc=5310095 | bibcode = 1990nap..book.1626I }}</ref> Eddy first published the term 'evidence-based' in March 1990, in an article in the ''Journal of the American Medical Association (JAMA)'' that laid out the principles of evidence-based guidelines and population-level policies, which Eddy described as "explicitly describing the available evidence that pertains to a policy and tying the policy to evidence instead of standard-of-care practices or the beliefs of experts. The pertinent evidence must be identified, described, and analyzed. The policymakers must determine whether the policy is justified by the evidence. A rationale must be written."<ref name="eddy6" /> He discussed evidence-based policies in several other papers published in ''JAMA'' in the spring of 1990.<ref name="eddy6">{{cite journal | vauthors = Eddy DM | title = Clinical decision making: from theory to practice. Practice policies—guidelines for methods | journal = JAMA | volume = 263 | issue = 13 | pages = 1839–1841 | date = April 1990 | pmid = 2313855 | doi = 10.1001/jama.263.13.1839 }}</ref><ref name="eddy7">{{cite journal | vauthors = Eddy DM | title = Clinical decision making: from theory to practice. Guidelines for policy statements: the explicit approach | journal = JAMA | volume = 263 | issue = 16 | pages = 2239–40, 2243 | date = April 1990 | pmid = 2319689 | doi = 10.1001/jama.1990.03440160101046 }}</ref> Those papers were part of a series of 28 published in ''JAMA'' between 1990 and 1997 on formal methods for designing population-level guidelines and policies.<ref name="eddy8">{{cite book |author=Eddy DM |title=Clinical Decision Making: From Theory to Practice. A Collection of Essays |publisher=American Medical Association |year=1996 |isbn=978-0-7637-0143-7}}</ref>
=== Medical education === The term 'evidence-based medicine' was introduced slightly later, in the context of medical education. In the autumn of 1990, Gordon Guyatt used it in an unpublished description of a program at McMaster University for prospective or new medical students.<ref name="howick">{{cite book | vauthors = Howick JH |title=The Philosophy of Evidence-based Medicine |publisher=Wiley |page=15 |isbn=978-1-4443-4266-6 |date=23 February 2011}}</ref> Guyatt and others first published the term two years later (1992) to describe a new approach to teaching the practice of medicine.<ref name="Guyatt" />
In 1996, David Sackett and colleagues clarified the definition of this tributary of evidence-based medicine as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. ... [It] means integrating individual clinical expertise with the best available external clinical evidence from systematic research."<ref name="sackett2">{{cite journal | vauthors = Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS | title = Evidence based medicine: what it is and what it isn't | journal = BMJ | volume = 312 | issue = 7023 | pages = 71–72 | date = January 1996 | pmid = 8555924 | pmc = 2349778 | doi = 10.1136/bmj.312.7023.71 }}</ref> This branch of evidence-based medicine aims to make individual decision making more structured and objective by better reflecting the evidence from research.<ref name="katz">{{cite book | vauthors = Katz DL |title=Clinical Epidemiology & Evidence-Based Medicine: Fundamental Principles of Clinical Reasoning & Research|url=https://archive.org/details/clinicalepidemio0000katz |url-access=registration |year=2001|publisher=Sage|isbn=978-0-7619-1939-1}}</ref><ref name="grobbee">{{cite book | vauthors = Grobbee DE, Hoes AW | title=Clinical Epidemiology: Principles, Methods, and Applications for Clinical Research|year=2009|publisher=Jones & Bartlett Learning| isbn=978-0-7637-5315-3}}</ref> Population-based data are applied to the care of an individual patient,<ref name="doi">{{cite book| vauthors = Doi SA |title=Understanding Evidence in Health Care: Using Clinical Epidemiology|year=2012|publisher=Palgrave Macmillan|location=South Yarra, VIC, Australia|isbn=978-1-4202-5669-7}}</ref> while respecting the fact that practitioners have clinical expertise reflected in effective and efficient diagnosis and thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences.<ref name=sackett2 />
Between 1993 and 2000, the Evidence-Based Medicine Working Group at McMaster University published the methods to a broad physician audience in a series of 25 "Users' Guides to the Medical Literature" in ''JAMA''. In 1995 Rosenberg and Donald defined individual-level, evidence-based medicine as "the process of finding, appraising, and using contemporaneous research findings as the basis for medical decisions."<ref name="rosenberg2">{{cite journal | vauthors = Rosenberg W, Donald A | title = Evidence based medicine: an approach to clinical problem-solving | journal = BMJ | volume = 310 | issue = 6987 | pages = 1122–1126 | date = April 1995 | pmid = 7742682 | pmc = 2549505 | doi = 10.1136/bmj.310.6987.1122 }}</ref> In 2010, Greenhalgh used a definition that emphasized quantitative methods: "the use of mathematical estimates of the risk of benefit and harm, derived from high-quality research on population samples, to inform clinical decision-making in the diagnosis, investigation or management of individual patients."<ref name="greenhalgh1">{{cite book| vauthors = Greenhalgh T |author-link=Trisha Greenhalgh|date=2010|title=How to Read a Paper: The Basics of Evidence-Based Medicine | edition = 4th |url=https://archive.org/details/howtoreadpaperba00tgre |url-access=limited |publisher= John Wiley & Sons|page= [https://archive.org/details/howtoreadpaperba00tgre/page/n20 1]|isbn=978-1-4443-9036-0}}</ref><ref name=sackett2 />
The two original definitions{{which|date=June 2017}} highlight important differences in how evidence-based medicine is applied to populations versus individuals. When designing guidelines applied to large groups of people in settings with relatively little opportunity for modification by individual physicians, evidence-based policymaking emphasizes that good evidence should exist to document a test's or treatment's effectiveness.<ref name="Eddy1990">{{cite journal | vauthors = Eddy DM | title = Practice policies: where do they come from? | journal = JAMA | volume = 263 | issue = 9 | pages = 1265, 1269, 1272 passim | date = March 1990 | pmid = 2304243 | doi = 10.1001/jama.263.9.1265 }}</ref> In the setting of individual decision-making, practitioners can be given greater latitude in how they interpret research and combine it with their clinical judgment.<ref name=sackett2 /><ref name="greenhalgh2">{{cite journal | vauthors = Tonelli MR | title = The limits of evidence-based medicine | journal = Respiratory Care | volume = 46 | issue = 12 | pages = 1435–1440 | date = December 2001 | pmid = 11728302 | author-link = Trisha Greenhalgh | doi = 10.1177/002013240104601207 }}</ref> In 2005, Eddy offered an umbrella definition for the two branches of EBM: "Evidence-based medicine is a set of principles and methods intended to ensure that to the greatest extent possible, medical decisions, guidelines, and other types of policies are based on and consistent with good evidence of effectiveness and benefit."<ref name="eddybmapproach">{{cite journal | vauthors = Eddy DM | title = Evidence-based medicine: a unified approach | journal = Health Affairs | volume = 24 | issue = 1 | pages = 9–17 | date = 2005 | pmid = 15647211 | doi = 10.1377/hlthaff.24.1.9 | doi-access = }}</ref>
=== Progress === In the area of evidence-based guidelines and policies, the explicit insistence on evidence of effectiveness was introduced by the American Cancer Society in 1980.<ref name="guidelines">{{cite journal | vauthors = Eddy D | title = ACS report on the cancer-related health checkup | journal = CA | volume = 30 | issue = 4 | pages = 193–240 | year = 1980 | pmid = 6774802 | doi = 10.3322/canjclin.30.4.194 | s2cid = 221546339 | doi-access =free }}</ref> The U.S. Preventive Services Task Force (USPSTF) began issuing guidelines for preventive interventions based on evidence-based principles in 1984.<ref name="taskforce">{{cite web|url=http://www.uspreventiveservicestaskforce.org/about.htm|title=About the USPSTF|access-date=21 August 2014|archive-url=https://web.archive.org/web/20140815122438/http://www.uspreventiveservicestaskforce.org/about.htm|archive-date=15 August 2014}}</ref> In 1985, the Blue Cross Blue Shield Association applied strict evidence-based criteria for covering new technologies.<ref name="rettig">{{cite book | vauthors = Rettig RA, Jacobson PD, Farquhar CM, Aubry WM |title=False Hope: Bone Marrow Transplantation for Breast Cancer: Bone Marrow Transplantation for Breast Cancer |url=https://books.google.com/books?id=bbcTZLRRVmoC&pg=PA183 |date=2007 |publisher=Oxford University Press |isbn=978-0-19-974824-2 |page=183}}</ref> Beginning in 1987, specialty societies such as the American College of Physicians, and voluntary health organizations such as the American Heart Association, wrote many evidence-based guidelines. In 1991, Kaiser Permanente, a managed care organization in the US, began an evidence-based guidelines program.<ref name="kaiserpermanente">{{cite journal | vauthors = Davino-Ramaya C, Krause LK, Robbins CW, Harris JS, Koster M, Chan W, Tom GI | title = Transparency matters: Kaiser Permanente's National Guideline Program methodological processes | journal = The Permanente Journal | volume = 16 | issue = 1 | pages = 55–62 | year = 2012 | pmid = 22529761 | pmc = 3327114 | doi = 10.7812/tpp/11-134 }}</ref> In 1991, Richard Smith wrote an editorial in the ''British Medical Journal'' and introduced the ideas of evidence-based policies in the UK.<ref name=smith>{{cite journal | vauthors = Smith R | title = Where is the wisdom...? | journal = BMJ | volume = 303 | issue = 6806 | pages = 798–799 | date = October 1991 | pmid = 1932964 | pmc = 1671173 | doi = 10.1136/bmj.303.6806.798 }}</ref> In 1993, the Cochrane Collaboration created a network of 13 countries to produce systematic reviews and guidelines.<ref name="cochrane">{{cite web|url=http://www.cochrane.org|title=The Cochrane Collaboration|access-date=21 August 2014}}</ref> In 1997, the US Agency for Healthcare Research and Quality (AHRQ, then known as the Agency for Health Care Policy and Research, or AHCPR) established Evidence-based Practice Centers (EPCs) to produce evidence reports and technology assessments to support the development of guidelines.<ref name="ahrq">{{cite web|url=http://www.ahrq.gov/research/findings/evidence-based-reports/overview/index.html|title=Agency for Health Care Policy and Research|access-date=21 August 2014}}</ref> In the same year, a National Guideline Clearinghouse that followed the principles of evidence-based policies was created by AHRQ, the AMA, and the American Association of Health Plans (now America's Health Insurance Plans).<ref name="guideline">{{cite web|url=http://www.guideline.gov|title=National Guideline Clearinghouse|access-date=21 August 2014|archive-url=https://web.archive.org/web/20140819030216/http://www.guideline.gov/ |archive-date=19 August 2014}}</ref> In 1999, the National Institute for Clinical Excellence (NICE) was created in the UK<ref name="nice">{{cite web|url=http://www.nice.org.uk|title=National Institute for Health and Care Excellence|access-date=21 August 2014}}</ref> to circulate evidence and guidance on treatments within the NHS.<ref>{{cite journal |last1=Darzi |first1=Ara |author1-link=Ara Darzi, Baron Darzi of Denham |title=Evidence-based medicine and the NHS: a commentary |journal=Journal of the Royal Society of Medicine |date=1 July 2008 |volume=101 |issue=7 |pages=342–344 |doi=10.1258/jrsm.2008.nh8004 |publisher=SAGE Publications |pmid=18591686 |pmc=2442146 |language=en |quote=Elsewhere, in order to improve dissemination of evidence and facilitate the accessibility of treatments for patients, the independent National Institute for Health and Clinical Excellence (NICE) was created. NICE regularly produces national guidance on the promotion of good health and the prevention and treatment of ill health and in particular has considered quality of life issues even when the cost-effectiveness of treatments is debated.}}</ref>
In the area of medical education, medical schools in Canada, the US, the UK, Australia, and other countries<ref>{{cite journal | vauthors = Ilic D, Maloney S | title = Methods of teaching medical trainees evidence-based medicine: a systematic review | journal = Medical Education | volume = 48 | issue = 2 | pages = 124–135 | date = February 2014 | pmid = 24528395 | doi = 10.1111/medu.12288 | s2cid = 12765787 }}</ref><ref>{{cite journal | vauthors = Maggio LA, Tannery NH, Chen HC, ten Cate O, O'Brien B | title = Evidence-based medicine training in undergraduate medical education: a review and critique of the literature published 2006–2011 | journal = Academic Medicine | volume = 88 | issue = 7 | pages = 1022–1028 | date = July 2013 | pmid = 23702528 | doi = 10.1097/ACM.0b013e3182951959 | doi-access = free }}</ref> now offer programs that teach evidence-based medicine. A 2009 study of UK programs found that more than half of UK medical schools offered some training in evidence-based medicine, although the methods and content varied considerably, and EBM teaching was restricted by lack of curriculum time, trained tutors and teaching materials.<ref name="medteach">{{cite journal | vauthors = Meats E, Heneghan C, Crilly M, Glasziou P | title = Evidence-based medicine teaching in UK medical schools | journal = Medical Teacher | volume = 31 | issue = 4 | pages = 332–337 | date = April 2009 | pmid = 19404893 | doi = 10.1080/01421590802572791 | s2cid = 21133182 }}</ref> Many programs have been developed to help individual physicians gain better access to evidence. For example, UpToDate was created in the early 1990s.<ref name="uptodate">{{cite web|url=http://www.uptodate.com/home |title=UpToDate|access-date=21 August 2014}}</ref> The Cochrane Collaboration began publishing evidence reviews in 1993.<ref name=kaiserpermanente /> In 1995, BMJ Publishing Group launched Clinical Evidence, a 6-monthly periodical that provided brief summaries of the current state of evidence about important clinical questions for clinicians.<ref name="clinicalevidence">{{cite web|url=http://www.clinicalevidence.bmj.com/|title=Clinical Evidence|access-date=21 August 2014|archive-date=20 August 2008|archive-url=https://web.archive.org/web/20080820134338/http://clinicalevidence.bmj.com/}}</ref>
=== Current practice === By 2000, use of the term ''evidence-based'' had extended to other levels of the health care system. An example is evidence-based health services, which seek to increase the competence of health service decision makers and the practice of evidence-based medicine at the organizational or institutional level.<ref name="gray">{{cite book|author=Gray, J. A. Muir|date=2009|title=Evidence-based Health Care & Public Health|publisher=Churchill Livingstone|isbn=978-0-443-10123-6}}</ref>
The multiple tributaries of evidence-based medicine share an emphasis on the importance of incorporating evidence from formal research in medical policies and decisions. However, because they differ on the extent to which they require good evidence of effectiveness before promoting a guideline or payment policy, a distinction is sometimes made between evidence-based medicine and science-based medicine, which also takes into account factors such as prior plausibility and compatibility with established science (as when medical organizations promote controversial treatments such as acupuncture).<ref name="AAFP2018">{{cite web |title=AAFP promotes acupuncture |publisher=Science-Based Medicine |date=9 October 2018 |url=https://sciencebasedmedicine.org/aafp-promotes-acupuncture/ |access-date=12 January 2019}}</ref> Differences also exist regarding the extent to which it is feasible to incorporate individual-level information in decisions. Thus, evidence-based guidelines and policies may not readily "hybridise" with experience-based practices orientated towards ethical clinical judgement, and can lead to contradictions, contest, and unintended crises.<ref name=eddy5 /> The most effective "knowledge leaders" (managers and clinical leaders) use a broad range of management knowledge in their decision making, rather than just formal evidence.<ref name=feinstein2 /> Evidence-based guidelines may provide the basis for governmentality in health care, and consequently play a central role in the governance of contemporary health care systems.<ref name=sackett />
== Methods ==
=== Steps === The steps for designing explicit, evidence-based guidelines were described in the late 1980s: formulate the question (population, intervention, comparison intervention, outcomes, time horizon, setting); search the literature to identify studies that inform the question; interpret each study to determine precisely what it says about the question; if several studies address the question, synthesize their results (meta-analysis); summarize the evidence in evidence tables; compare the benefits, harms and costs in a balance sheet; draw a conclusion about the preferred practice; write the guideline; write the rationale for the guideline; have others review each of the previous steps; implement the guideline.<ref name=eddy4 />
For the purposes of medical education and individual-level decision making, five steps of EBM in practice were described in 1992<ref>{{cite journal | vauthors = Cook DJ, Jaeschke R, Guyatt GH | title = Critical appraisal of therapeutic interventions in the intensive care unit: human monoclonal antibody treatment in sepsis. Journal Club of the Hamilton Regional Critical Care Group | journal = Journal of Intensive Care Medicine | volume = 7 | issue = 6 | pages = 275–282 | year = 1992 | pmid = 10147956 | doi = 10.1177/088506669200700601 | s2cid = 7194293 }}</ref> and the experience of delegates attending the 2003 Conference of Evidence-Based Health Care Teachers and Developers was summarized into five steps and published in 2005.<ref name="Sicily statement on evidence-based">{{cite journal | vauthors = Dawes M, Summerskill W, Glasziou P, Cartabellotta A, Martin J, Hopayian K, Porzsolt F, Burls A, Osborne J | display-authors = 6 | title = Sicily statement on evidence-based practice | journal = BMC Medical Education | volume = 5 | issue = 1 | article-number = 1 | date = January 2005 | pmid = 15634359 | pmc = 544887 | doi = 10.1186/1472-6920-5-1 | doi-access = free }}</ref> This five-step process can broadly be categorized as follows:
# Translation of uncertainty to an answerable question; includes critical questioning, study design and levels of evidence<ref>{{cite journal | vauthors = Richardson WS, Wilson MC, Nishikawa J, Hayward RS | title = The well-built clinical question: a key to evidence-based decisions | journal = ACP Journal Club | volume = 123 | issue = 3 | pages = A12–A13 | year = 1995 | pmid = 7582737 | doi = 10.7326/ACPJC-1995-123-3-A12 }}</ref> # Systematic retrieval of the best evidence available<ref>{{cite journal | vauthors = Rosenberg WM, Deeks J, Lusher A, Snowball R, Dooley G, Sackett D | title = Improving searching skills and evidence retrieval | journal = Journal of the Royal College of Physicians of London | volume = 32 | issue = 6 | pages = 557–563 | year = 1998 | doi = 10.1016/S0035-8819(25)01804-5 | pmid = 9881313 | pmc = 9662986 }}</ref> # Critical appraisal of evidence for internal validity that can be broken down into aspects regarding:<ref name="doi"/> #* Systematic errors as a result of selection bias, information bias and confounding #* Quantitative aspects of diagnosis and treatment #* The effect size and aspects regarding its precision #* Clinical importance of results #* External validity or generalizability # Application of results in practice<ref>{{cite journal | vauthors = Epling J, Smucny J, Patil A, Tudiver F | title = Teaching evidence-based medicine skills through a residency-developed guideline | journal = Family Medicine | volume = 34 | issue = 9 | pages = 646–648 | date = October 2002 | pmid = 12455246 }}</ref> # Evaluation of performance<ref>{{cite journal | vauthors = Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O'Brien MA, Johansen M, Grimshaw J, Oxman AD | display-authors = 6 | title = Audit and feedback: effects on professional practice and healthcare outcomes | journal = The Cochrane Database of Systematic Reviews | volume = 6 | issue = 6 | article-number = CD000259 | date = June 2012 | pmid = 22696318 | doi = 10.1002/14651858.CD000259.pub3 | pmc = 11338587 }}</ref>{{Update inline|reason=Updated version https://www.ncbi.nlm.nih.gov/pubmed/40130784|date = July 2025}}<ref>{{cite journal |vauthors=Ivers N, Yogasingam S, Lacroix M, Brown KA, Antony J, Soobiah C, Simeoni M, Willis TA, Crawshaw J, Antonopoulou V, Meyer C, Solbak NM, Murray BJ, Butler EA, Lepage S, Giltenane M, Carter MD, Fontaine G, Sykes M, Halasy M, Bazazo A, Seaton S, Canavan T, Alderson S, Reis C, Linklater S, Lalor A, Fletcher A, Gearon E, Jenkins H, Wallis JA, Grobler L, Beccaria L, Cyril S, Rozbroj T, Han JX, Xu AX, Wu K, Rouleau G, Shah M, Konnyu K, Colquhoun H, Presseau J, O'Connor D, Lorencatto F, Grimshaw JM |display-authors=6 |title=Audit and feedback: effects on professional practice |journal=Cochrane Database Syst Rev |volume=2025 |issue=3 |article-number=CD000259 |date=March 2025 |pmid=40130784 |doi=10.1002/14651858.CD000259.pub4 |pmc=11934852 }}</ref>
=== Evidence reviews === Systematic reviews of published research studies are a major part of the evaluation of particular treatments. The Cochrane Collaboration is one of the best-known organisations that conducts systematic reviews. Like other producers of systematic reviews, it requires authors to provide a detailed study protocol as well as a reproducible plan of their literature search and evaluations of the evidence.<ref name="Tanjong2009">{{cite journal | vauthors = Tanjong-Ghogomu E, Tugwell P, Welch V | title = Evidence-based medicine and the Cochrane Collaboration | journal = Bulletin of the NYU Hospital for Joint Diseases | volume = 67 | issue = 2 | pages = 198–205 | year = 2009 | pmid = 19583554 | url = http://www.nyuhjdbulletin.org/Permalink.aspx?permalinkId=07a150ec-2275-4bbf-9003-6ea200b62a4f | archive-url = https://web.archive.org/web/20130601140339/http://www.nyuhjdbulletin.org/Permalink.aspx?permalinkId=07a150ec-2275-4bbf-9003-6ea200b62a4f | archive-date = 1 June 2013 }}</ref> After the best evidence is assessed, treatment is categorized as (1) likely to be beneficial, (2) likely to be harmful, or (3) without evidence to support either benefit or harm.<ref>{{Citation |title=Grading of Recommendations and Levels of Evidence |date=2015-04-27 |work=Treatment for Post-Traumatic Stress Disorder, Operational Stress Injury, or Critical Incident Stress: A Review of Guidelines [Internet] |url=https://www.ncbi.nlm.nih.gov/books/NBK304764/ |access-date=2025-03-31 |publisher=Canadian Agency for Drugs and Technologies in Health |language=en}}</ref>
A 2007 analysis of 1,016 systematic reviews from all 50 Cochrane Collaboration Review Groups found that 44% of the reviews concluded that the intervention was likely to be beneficial, 7% concluded that the intervention was likely to be harmful, and 49% concluded that evidence did not support either benefit or harm. 96% recommended further research.<ref name="Mapping2007">{{cite journal | vauthors = El Dib RP, Atallah AN, Andriolo RB | title = Mapping the Cochrane evidence for decision making in health care | journal = Journal of Evaluation in Clinical Practice | volume = 13 | issue = 4 | pages = 689–692 | date = August 2007 | pmid = 17683315 | doi = 10.1111/j.1365-2753.2007.00886.x }}</ref> In 2017, a study assessed the role of systematic reviews produced by Cochrane Collaboration to inform US private payers' policymaking; it showed that although the medical policy documents of major US private payers were informed by Cochrane systematic reviews, there was still scope to encourage the further use.<ref>{{cite journal | vauthors = Singh A, Hussain S, Najmi AK | title = Role of Cochrane Reviews in informing US private payers' policies | journal = Journal of Evidence-Based Medicine | volume = 10 | issue = 4 | pages = 293–331 | date = November 2017 | pmid = 29193899 | doi = 10.1111/jebm.12278 | s2cid = 22796658 }}</ref>
=== Assessing the quality of evidence === {{Main|Levels of evidence}} Evidence-based medicine categorizes different types of clinical evidence and rates or grades them<ref>{{cite web|url=http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=grade |title=EBM: Levels of Evidence |publisher=Essential Evidence Plus |access-date=23 February 2012}}</ref> according to the strength of their freedom from the various biases that beset medical research. For example, the strongest evidence for therapeutic interventions is provided by systematic review of randomized, well-blinded, placebo-controlled trials with allocation concealment and complete follow-up involving a homogeneous patient population and medical condition. In contrast, patient testimonials, case reports, and even expert opinion have little value as proof because of the placebo effect, the biases inherent in observation and reporting of cases, and difficulties in ascertaining who is an expert (however, some critics have argued that expert opinion "does not belong in the rankings of the quality of empirical evidence because it does not represent a form of empirical evidence" and continue that "expert opinion would seem to be a separate, complex type of knowledge that would not fit into hierarchies otherwise limited to empirical evidence alone.").<ref name="Tonelli99">{{cite journal | vauthors = Tonelli MR | title = In defense of expert opinion | journal = Academic Medicine | volume = 74 | issue = 11 | pages = 1187–1192 | date = November 1999 | pmid = 10587679 | doi = 10.1097/00001888-199911000-00010 | doi-access = free }}</ref>
Several organizations have developed grading systems for assessing the quality of evidence. For example, in 1989 the U.S. Preventive Services Task Force (USPSTF) put forth the following system:<ref name="USPrevServTaskForce">{{cite book|author=U.S. Preventive Services Task Force|title=Guide to clinical preventive services: report of the U.S. Preventive Services Task Force|url=https://books.google.com/books?id=eQGJHgI_dR8C&pg=PR24 |date=August 1989|publisher=DIANE Publishing|isbn=978-1-56806-297-6|pages=24–}}</ref> * Level I: Evidence obtained from at least one properly designed randomized controlled trial. * Level II-1: Evidence obtained from well-designed controlled trials without randomization. * Level II-2: Evidence obtained from well-designed cohort studies or case-control studies, preferably from more than one center or research group. * Level II-3: Evidence obtained from multiple time series designs with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. * Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Another example are the Oxford CEBM Levels of Evidence published by the Centre for Evidence-Based Medicine. First released in September 2000, the Levels of Evidence provide a way to rank evidence for claims about prognosis, diagnosis, treatment benefits, treatment harms, and screening, which most grading schemes do not address. The original CEBM Levels were Evidence-Based On Call to make the process of finding evidence feasible and its results explicit. In 2011, an international team redesigned the Oxford CEBM Levels to make them more understandable and to take into account recent developments in evidence ranking schemes. The Oxford CEBM Levels of Evidence have been used by patients and clinicians, as well as by experts to develop clinical guidelines, such as recommendations for the optimal use of phototherapy and topical therapy in psoriasis<ref>{{cite web | author = OCEBM Levels of Evidence Working Group |title=The Oxford Levels of Evidence 2' |url=http://www.cebm.net/index.aspx?o=5653 |date=May 2016 |access-date=9 December 2013 |archive-date=5 December 2013 |archive-url=https://web.archive.org/web/20131205135701/http://www.cebm.net/index.aspx?o=5653 }}</ref> and guidelines for the use of the BCLC staging system for diagnosing and monitoring hepatocellular carcinoma in Canada.<ref>{{cite journal | vauthors = Paul C, Gallini A, Archier E, Castela E, Devaux S, Aractingi S, Aubin F, Bachelez H, Cribier B, Joly P, Jullien D, Le Maître M, Misery L, Richard MA, Ortonne JP | display-authors = 6 | title = Evidence-based recommendations on topical treatment and phototherapy of psoriasis: systematic review and expert opinion of a panel of dermatologists | journal = Journal of the European Academy of Dermatology and Venereology | volume = 26 | issue = Suppl 3 | pages = 1–10 | date = May 2012 | pmid = 22512675 | doi = 10.1111/j.1468-3083.2012.04518.x | s2cid = 36103291 }}</ref>
In 2000, a system was developed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. The GRADE system takes into account more dimensions than just the quality of medical research.<ref name="GRADE">{{cite web|url=http://www.gradeworkinggroup.org/|title=Welcome to the GRADE working group|access-date=24 September 2007|archive-url=https://web.archive.org/web/20060207191324/http://www.gradeworkinggroup.org/|archive-date=7 February 2006|url-status=live|website=www.gradeworkinggroup.org}}</ref> It requires users who are performing an assessment of the quality of evidence, usually as part of a systematic review, to consider the impact of different factors on their confidence in the results. Authors of GRADE tables assign one of four levels to evaluate the quality of evidence, on the basis of their confidence that the observed effect (a numeric value) is close to the true effect. The confidence value is based on judgments assigned in five different domains in a structured manner.<ref name="balshem2011">{{cite journal | vauthors = Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, Vist GE, Falck-Ytter Y, Meerpohl J, Norris S, Guyatt GH | display-authors = 6 | title = GRADE guidelines: 3. Rating the quality of evidence | journal = Journal of Clinical Epidemiology | volume = 64 | issue = 4 | pages = 401–406 | date = April 2011 | pmid = 21208779 | doi = 10.1016/j.jclinepi.2010.07.015 | doi-access = free | author3-link = Holger Jens Schünemann }}</ref> The GRADE working group defines 'quality of evidence' and 'strength of recommendations' based on the quality as two different concepts that are commonly confused with each other.<ref name=balshem2011 />
Systematic reviews may include randomized controlled trials that have low risk of bias, or observational studies that have high risk of bias. In the case of randomized controlled trials, the quality of evidence is high but can be downgraded in five different domains.<ref name="GRADE Handbook">{{cite book|title=GRADE handbook for grading quality of evidence and strength of recommendation|year=2009|edition=Version 3.2|editor3-link=Holger Jens Schünemann|veditors=Schünemann H, Brożek J, Oxman A}}<br />{{cite web|title=GRADEPro|website=Cochrane Informatics and Knowledge Management Department|url=http://tech.cochrane.org/gradepro|access-date=1 March 2016|archive-url=https://web.archive.org/web/20160305115426/http://tech.cochrane.org/gradepro|archive-date=5 March 2016}}<br />{{cite book|title=GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013|date=2013|publisher=The GRADE Working Group|veditors=Schünemann H, Brożek J, Guyatt G, Oxman A|url=https://gdt.gradepro.org/app/handbook/handbook.html|access-date=3 September 2019}}</ref> * Risk of bias: A judgment made on the basis of the chance that bias in included studies has influenced the estimate of effect. * Imprecision: A judgment made on the basis of the chance that the observed estimate of effect could change completely. * Indirectness: A judgment made on the basis of the differences in characteristics of how the study was conducted and how the results are actually going to be applied. * Inconsistency: A judgment made on the basis of the variability of results across the included studies. * Publication bias: A judgment made on the basis of the question whether all the research evidence has been taken to account.<ref>{{Cite journal |last1=DeVito |first1=Nicholas J. |last2=Goldacre |first2=Ben |date=April 2019 |title=Catalogue of bias: publication bias |journal=BMJ Evidence-Based Medicine |volume=24 |issue=2 |pages=53–54 |doi=10.1136/bmjebm-2018-111107 |issn=2515-4478 |pmid=30523135|doi-access=free }}</ref>
In the case of observational studies per GRADE, the quality of evidence starts off lower and may be upgraded in three domains in addition to being subject to downgrading.<ref name="GRADE Handbook" /> * Large effect: Methodologically strong studies show that the observed effect is so large that the probability of it changing completely is less likely. * Plausible confounding would change the effect: Despite the presence of a possible confounding factor that is expected to reduce the observed effect, the effect estimate still shows significant effect. * Dose response gradient: The intervention used becomes more effective with increasing dose. This suggests that a further increase will likely bring about more effect.
Meaning of the levels of quality of evidence as per GRADE:<ref name="balshem2011" /> * High Quality Evidence: The authors are very confident that the presented estimate lies very close to the true value. In other words, the probability is very low that further research will completely change the presented conclusions. * Moderate Quality Evidence: The authors are confident that the presented estimate lies close to the true value, but it is also possible that it may be substantially different. In other words, further research may completely change the conclusions. * Low Quality Evidence: The authors are not confident in the effect estimate, and the true value may be substantially different. In other words, further research is likely to change the presented conclusions completely. * Very Low Quality Evidence: The authors do not have any confidence in the estimate and it is likely that the true value is substantially different from it. In other words, new research will probably change the presented conclusions completely.
=== Categories of recommendations === In guidelines and other publications, recommendation for a clinical service is classified by the balance of risk versus benefit and the level of evidence on which this information is based. The U.S. Preventive Services Task Force uses the following system:<ref>{{cite journal | vauthors = Sherman M, Burak K, Maroun J, Metrakos P, Knox JJ, Myers RP, Guindi M, Porter G, Kachura JR, Rasuli P, Gill S, Ghali P, Chaudhury P, Siddiqui J, Valenti D, Weiss A, Wong R | display-authors = 6 | title = Multidisciplinary Canadian consensus recommendations for the management and treatment of hepatocellular carcinoma | journal = Current Oncology | volume = 18 | issue = 5 | pages = 228–240 | date = October 2011 | pmid = 21980250 | pmc = 3185900 | doi = 10.3747/co.v18i5.952 }}</ref> * Level A: Good scientific evidence suggests that the benefits of the clinical service substantially outweigh the potential risks. Clinicians should discuss the service with eligible patients. * Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks. Clinicians should discuss the service with eligible patients. * Level C: At least fair scientific evidence suggests that the clinical service provides benefits, but the balance between benefits and risks is too close for general recommendations. Clinicians need not offer it unless individual considerations apply. * Level D: At least fair scientific evidence suggests that the risks of the clinical service outweigh potential benefits. Clinicians should not routinely offer the service to asymptomatic patients. * Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.
GRADE guideline panelists may make strong or weak recommendations on the basis of further criteria. Some of the important criteria are the balance between desirable and undesirable effects (not considering cost), the quality of the evidence, values and preferences and costs (resource utilization).<ref name="GRADE Handbook" />
Despite the differences between systems, the purposes are the same: to guide users of clinical research information on which studies are likely to be most valid. However, the individual studies still require careful critical appraisal<ref>{{Cite web |title=Appraise the evidence {{!}} BMJ Best Practice |url=https://bestpractice.bmj.com/info/us/toolkit/learn-ebm/appraise-the-evidence/ |access-date=2025-02-10 |language=en-US}}</ref>
=== Statistical measures === Evidence-based medicine attempts to express clinical benefits of tests and treatments using mathematical methods. Tools used by practitioners of evidence-based medicine include: * Likelihood ratio {{Main|Likelihood ratios in diagnostic testing}} The pre-test odds of a particular diagnosis, multiplied by the likelihood ratio, determines the post-test odds. (Odds can be calculated from, and then converted to, the [more familiar] probability.) This reflects Bayes' theorem. The differences in likelihood ratio between clinical tests can be used to prioritize clinical tests according to their usefulness in a given clinical situation. * AUC-ROC The area under the receiver operating characteristic curve (AUC-ROC) reflects the relationship between sensitivity and specificity for a given test. High-quality tests will have an AUC-ROC approaching 1, and high-quality publications about clinical tests will provide information about the AUC-ROC. Cutoff values for positive and negative tests can influence specificity and sensitivity, but they do not affect AUC-ROC. * Number needed to treat (NNT)/Number needed to harm (NNH). NNT and NNH are ways of expressing the effectiveness and safety, respectively, of interventions in a way that is clinically meaningful. NNT is the number of people who need to be treated in order to achieve the desired outcome (e.g. survival from cancer) in one patient. For example, if a treatment increases the chance of survival by 5%, then 20 people need to be treated in order for 1 additional patient to survive because of the treatment. The concept can also be applied to diagnostic tests. For example, if 1,339 women age 50–59 need to be invited for breast cancer screening over a ten-year period in order to prevent one woman from dying of breast cancer,<ref name="BandolierStatins2004">"Patient Compliance with statins" ''Bandolier'' [http://www.medicine.ox.ac.uk/bandolier/booth/cardiac/patcomp.html Review] 2004 {{Webarchive|url=http://web.archive.org/web/20160304055956/http://www.medicine.ox.ac.uk/bandolier/booth/cardiac/patcomp.html |date=12 May 2015 }}</ref> then the NNT for being invited to breast cancer screening is 1339.
=== Quality of clinical trials === Evidence-based medicine attempts to objectively evaluate the quality of clinical research by critically assessing techniques reported by researchers in their publications. * Trial design considerations: High-quality studies have clearly defined eligibility criteria and have minimal missing data.<ref name=":03">{{Cite journal |last1=Bellomo |first1=Rinaldo |last2=Bagshaw |first2=Sean M. |date=2006 |title=Evidence-based medicine: classifying the evidence from clinical trials—the need to consider other dimensions |journal=Critical Care |volume=10 |issue=5 |page=232 |doi=10.1186/cc5045 |issn=1466-609X |pmc=1751050 |pmid=17029653 |doi-access=free }}</ref><ref>{{Cite journal |last=Greeley |first=Christopher |date=December 2016 |title=Demystifying the Medical Literature |journal=Academic Forensic Pathology |volume=6 |issue=4 |pages=556–567 |doi=10.23907/2016.055 |issn=1925-3621 |pmc=6474497 |pmid=31239931}}</ref> * Generalizability considerations: Studies may only be applicable to narrowly defined patient populations and may not be generalizable to other clinical contexts.<ref name=":03"/> * Follow-up: Sufficient time for defined outcomes to occur can influence the prospective study outcomes and the statistical power of a study to detect differences between a treatment and control arm.<ref name=":2">{{Cite journal |last=Akobeng |first=A. K. |date=August 2005 |title=Understanding randomised controlled trials |journal=Archives of Disease in Childhood |volume=90 |issue=8 |pages=840–844 |doi=10.1136/adc.2004.058222 |issn=1468-2044 |pmc=1720509 |pmid=16040885}}</ref> * Power: A mathematical calculation can determine whether the number of patients is sufficient to detect a difference between treatment arms. A negative study may reflect a lack of benefit, or simply a lack of sufficient quantities of patients to detect a difference.<ref name=":2"/><ref name=":03"/><ref name=":1">{{Cite web |date=2007 |title=Statistical Power |url=http://www.bandolier.org.uk/booth/glossary/statpow.html |website=Bandolier}}</ref>
== Limitations and criticism == There are a number of limitations and criticisms of evidence-based medicine.<ref name="Krauss, Alexander. 2018">{{cite journal | vauthors = Krauss A | title = Why all randomised controlled trials produce biased results | journal = Annals of Medicine | volume = 50 | issue = 4 | pages = 312–322 | date = June 2018 | pmid = 29616838 | doi = 10.1080/07853890.2018.1453233 | s2cid = 4971775 | doi-access = free }}</ref><ref name="Timmermans2005">{{cite journal | vauthors = Timmermans S, Mauck A | title = The promises and pitfalls of evidence-based medicine | journal = Health Affairs | volume = 24 | issue = 1 | pages = 18–28 | year = 2005 | pmid = 15647212 | doi = 10.1377/hlthaff.24.1.18 }}</ref><ref>{{cite journal | vauthors = Jureidini J, McHenry LB | title = The illusion of evidence based medicine | journal = BMJ | volume = 376 | pages = o702 | date = March 2022 | pmid = 35296456 | doi = 10.1136/bmj.o702 | s2cid = 247475472 | doi-access = free }}</ref> Two widely cited categorization schemes for the various published critiques of EBM include the three-fold division of Straus and McAlister ("limitations universal to the practice of medicine, limitations unique to evidence-based medicine and misperceptions of evidence-based-medicine")<ref name="Straus-McAlister-2000">{{cite journal | vauthors = Straus SE, McAlister FA | title = Evidence-based medicine: a commentary on common criticisms | journal = CMAJ | volume = 163 | issue = 7 | pages = 837–841 | date = October 2000 | pmid = 11033714 | pmc = 80509 | url = http://www.cmaj.ca/content/163/7/837.full.pdf }}</ref> and the five-point categorization of Cohen, Stavri and Hersh (EBM is a poor philosophic basis for medicine, defines evidence too narrowly, is not evidence-based, is limited in usefulness when applied to individual patients, or reduces the autonomy of the doctor/patient relationship).<ref name="Cohen-2004">{{cite journal | vauthors = Cohen AM, Stavri PZ, Hersh WR | title = A categorization and analysis of the criticisms of Evidence-Based Medicine | journal = International Journal of Medical Informatics | volume = 73 | issue = 1 | pages = 35–43 | date = February 2004 | pmid = 15036077 | doi = 10.1016/j.ijmedinf.2003.11.002 | url = http://skynet.ohsu.edu/~hersh/ijmi-04-ebm.pdf | citeseerx = 10.1.1.586.3699 | archive-url = https://web.archive.org/web/20100703011703/http://skynet.ohsu.edu/~hersh/ijmi-04-ebm.pdf | archive-date = 3 July 2010 }}</ref>
In no particular order, some published objections include: * Research produced by EBM, such as from randomized controlled trials (RCTs), may not be relevant for all treatment situations.<ref name="pmid11489034">{{cite journal | vauthors = Upshur RE, VanDenKerkhof EG, Goel V | title = Meaning and measurement: an inclusive model of evidence in health care | journal = Journal of Evaluation in Clinical Practice | volume = 7 | issue = 2 | pages = 91–96 | date = May 2001 | pmid = 11489034 | doi = 10.1046/j.1365-2753.2001.00279.x }}</ref> Research tends to focus on specific populations, but individual persons can vary substantially from population norms. Because certain population segments have been historically under-researched (due to reasons such as race, gender, age, and co-morbid diseases), evidence from RCTs may not be generalizable to those populations.<ref name="orvyhi">{{cite journal | vauthors = Rogers WA | title = Evidence based medicine and justice: a framework for looking at the impact of EBM upon vulnerable or disadvantaged groups | journal = Journal of Medical Ethics | volume = 30 | issue = 2 | pages = 141–145 | date = April 2004 | pmid = 15082806 | pmc = 1733835 | doi = 10.1136/jme.2003.007062 }}</ref> Thus, EBM applies to groups of people, but this should not preclude clinicians from using their personal experience in deciding how to treat each patient. One author advises that "the knowledge gained from clinical research does not directly answer the primary clinical question of what is best for the patient at hand" and suggests that evidence-based medicine should not discount the value of clinical experience.<ref name="Tonelli99" /> Another author stated that "the practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."<ref name="sackett2"/> * Use of evidence-based guidelines often fits poorly for complex, multimorbid patients. This is because the guidelines are usually based on clinical studies focused on single diseases. In reality, the recommended treatments in such circumstances may interact unfavorably with each other and often lead to polypharmacy.<ref>{{cite journal |last1=Greenhalgh |first1=Trisha |last2=Howick |first2=Jeremy |last3=Maskrey |first3=Neal |title=Evidence based medicine: a movement in crisis? |journal=BMJ |date=13 June 2014 |volume=348 |article-number=g3725 |doi=10.1136/bmj.g3725|pmid=24927763 |pmc=4056639 }}</ref><ref>{{cite journal |last1=Sheridan |first1=Desmond J. |last2=Julian |first2=Desmond G. |title=Achievements and Limitations of Evidence-Based Medicine |journal=Journal of the American College of Cardiology |date=July 2016 |volume=68 |issue=2 |pages=204–213 |doi=10.1016/j.jacc.2016.03.600|pmid=27386775 |doi-access=free }}</ref> * The theoretical ideal of EBM (that every narrow clinical question, of which hundreds of thousands can exist, would be answered by meta-analysis and systematic reviews of multiple RCTs) faces the limitation that research (especially the RCTs themselves) is expensive; thus, in reality, for the foreseeable future, the demand for EBM will always be much higher than the supply, and the best humanity can do is to triage the application of scarce resources. * Research can be influenced by biases such as political or belief bias,<ref>{{Cite book |last=Scheitle |first=Christopher P. |title=The faithful scientist: experiences of anti-religious bias in scientific training |date=2023 |publisher=New York University Press |isbn=978-1-4798-2371-0 |location=New York}}</ref><ref>{{Cite book |last=Cym |first=Rule Anthony |title=Risk and Reason in Clinical Diagnosis |publisher=Oxford University Press |isbn=978-0-19-094402-5 |publication-date=2019 |pages=}}</ref> publication bias and conflict of interest in academic publishing. For example, studies with conflicts due to industry funding are more likely to favor their product.<ref>{{cite journal | vauthors = Every-Palmer S, Howick J | title = How evidence-based medicine is failing due to biased trials and selective publication | journal = Journal of Evaluation in Clinical Practice | volume = 20 | issue = 6 | pages = 908–914 | date = December 2014 | pmid = 24819404 | doi = 10.1111/jep.12147 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Friedman LS, Richter ED | title = Relationship between conflicts of interest and research results | journal = Journal of General Internal Medicine | volume = 19 | issue = 1 | pages = 51–56 | date = January 2004 | pmid = 14748860 | pmc = 1494677 | doi = 10.1111/j.1525-1497.2004.30617.x }}</ref> It has been argued that contemporary evidence based medicine is an illusion, since evidence based medicine has been corrupted by corporate interests, failed regulation, and commercialisation of academia.<ref>{{cite journal | vauthors = Jureidini J, McHenry LB | title = The illusion of evidence based medicine | journal = BMJ | volume = 376 | pages = o702 | date = March 2022 | pmid = 35296456 | doi = 10.1136/bmj.o702 | doi-access = free }}</ref> * Systematic Reviews methodologies are capable of bias and abuse in respect of (i) choice of inclusion criteria (ii) choice of outcome measures, comparisons and analyses (iii) the subjectivity inevitable in Risk of Bias assessments, even when codified procedures and criteria are observed.<ref name="Bias2">{{cite journal | vauthors = Kicinski M, Springate DA, Kontopantelis E | title = Publication bias in meta-analyses from the Cochrane Database of Systematic Reviews | journal = Statistics in Medicine | volume = 34 | issue = 20 | pages = 2781–2793 | date = September 2015 | pmid = 25988604 | doi = 10.1002/sim.6525 | bibcode = 2015StMed..34.2781K | s2cid = 25560005 }}</ref><ref name="Bias3">{{cite journal | vauthors = Egger M, Smith GD, Sterne JA | title = Uses and abuses of meta-analysis | journal = Clinical Medicine | volume = 1 | issue = 6 | pages = 478–484 | date = Nov–Dec 2001 | pmid = 11792089 | pmc = 4953876 | doi = 10.7861/clinmedicine.1-6-478 }}</ref> An example of all these problems can be seen in a Cochrane Review.<ref name="Bias4">{{cite journal | vauthors = Popp M, Reis S, Schießer S, Hausinger RI, Stegemann M, Metzendorf MI, Kranke P, Meybohm P, Skoetz N, Weibel S | display-authors = 6 | title = Ivermectin for preventing and treating COVID-19 | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 6 | article-number = CD015017 | date = June 2022 | pmid = 35726131 | pmc = 9215332 | doi = 10.1002/14651858.CD015017.pub3 }}</ref> * A lag exists between when the RCT is conducted and when its results are published.<ref name="CaseReport">{{cite journal | vauthors = Yitschaky O, Yitschaky M, Zadik Y | title = Case report on trial: Do you, Doctor, swear to tell the truth, the whole truth and nothing but the truth? | journal = Journal of Medical Case Reports | volume = 5 | issue = 1 | article-number = 179 | date = May 2011 | pmid = 21569508 | pmc = 3113995 | doi = 10.1186/1752-1947-5-179 | doi-access = free }}</ref> * A lag exists between when results are published and when they are properly applied.<ref>{{cite web|title=Knowledge Transfer in the ED: How to Get Evidence Used|url=http://blog.bestevidencesystems.com/2013/09/30/knowledge-transfer-in-the-ed-how-to-get-evidence-used/|archive-url=https://archive.today/20131008150056/http://blog.bestevidencesystems.com/2013/09/30/knowledge-transfer-in-the-ed-how-to-get-evidence-used/|archive-date=8 October 2013|work=Best Evidence Healthcare Blog|access-date=8 October 2013}}</ref> * Hypocognition (the absence of a simple, consolidated mental framework into which new information can be placed) can hinder the application of EBM.<ref>{{cite journal | vauthors = Mariotto A | title = Hypocognition and evidence-based medicine | journal = Internal Medicine Journal | volume = 40 | issue = 1 | pages = 80–82 | date = January 2010 | pmid = 20561370 | doi = 10.1111/j.1445-5994.2009.02086.x | s2cid = 24519238 }}</ref> * Values: while patient values are considered in the original definition of EBM, the importance of values is not commonly emphasized in EBM training, a potential problem under current study.<ref>{{Cite journal| vauthors = Yamada S, Slingsby BT, Inada MK, Derauf D |date=1 June 2008|title=Evidence-based public health: a critical perspective|journal=Journal of Public Health|language=en|volume=16|issue=3|pages=169–172|doi=10.1007/s10389-007-0156-7|s2cid=652725|issn=0943-1853}}</ref><ref>{{cite journal | vauthors = Kelly MP, Heath I, Howick J, Greenhalgh T | title = The importance of values in evidence-based medicine | journal = BMC Medical Ethics | volume = 16 | issue = 1 | article-number = 69 | date = October 2015 | pmid = 26459219 | pmc = 4603687 | doi = 10.1186/s12910-015-0063-3 | doi-access = free }}</ref><ref>{{Cite book | vauthors = Fulford KW, Peile H, Carroll H |title=Essential Values-Based Practice |isbn=978-0-521-53025-5 |url=http://www.cambridge.org/gb/academic/subjects/medicine/medicine-general-interest/essential-values-based-practice-clinical-stories-linking-science-people |date=March 2012|publisher=Cambridge University Press }}</ref><ref>{{Cite book |last1=Engebretsen |first1=Eivind |url=https://www.cambridge.org/core/books/rethinking-evidence-in-the-time-of-pandemics/F340CCFA243064856F078EF7AC012E11 |title=Rethinking Evidence in the Time of Pandemics: Scientific vs Narrative Rationality and Medical Knowledge Practices |last2=Baker |first2=Mona |date=2022 |publisher=Cambridge University Press |isbn=978-1-316-51660-7 |location=Cambridge |doi=10.1017/9781009030687}}</ref>
A 2018 study, "Why all randomised controlled trials produce biased results", assessed the 10 most cited RCTs and argued that trials face a wide range of biases and constraints, from trials only being able to study a small set of questions amenable to randomisation and generally only being able to assess the ''average'' treatment effect of a sample, to limitations in extrapolating results to another context, among many others outlined in the study.<ref name="Krauss, Alexander. 2018" />
== Application of evidence in clinical settings == {{medical citations|section|date=May 2026}} Despite the emphasis on evidence-based medicine, unsafe or ineffective medical practices may occur.{{update source|date=May 2026}} Contributing factors include clinicians not keeping up with or acting on current evidence, the rapid pace of scientific change, financial incentives, and patient demand for tests or treatments.{{medcn|date=May 2026}} Even when the evidence unequivocally shows that a treatment is either not safe or ineffective, it may take many years for other treatments to be adopted.{{medcn|date=May 2026}}
Several factors may contribute to lack of uptake or implementation of evidence-based recommendations.<ref>{{cite journal | vauthors = Frantsve-Hawley J, Rindal DB | title = Translational Research: Bringing Science to the Provider Through Guideline Implementation | journal = Dental Clinics of North America | volume = 63 | issue = 1 | pages = 129–144 | date = January 2019 | pmid = 30447788 | doi = 10.1016/j.cden.2018.08.008 | s2cid = 53950224 }}</ref> These include lack of awareness at the individual clinician or patient (micro) level, lack of institutional support at the organisation level (meso) level or higher at the policy (macro) level.<ref>{{cite journal | vauthors = Sharp CA, Swaithes L, Ellis B, Dziedzic K, Walsh N | title = Implementation research: making better use of evidence to improve healthcare | journal = Rheumatology | volume = 59 | issue = 8 | pages = 1799–1801 | date = August 2020 | pmid = 32252071 | doi = 10.1093/rheumatology/keaa088 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Carrier J | title = The challenges of evidence implementation: it's all about the context | journal = JBI Database of Systematic Reviews and Implementation Reports | volume = 15 | issue = 12 | pages = 2830–2831 | date = December 2017 | pmid = 29219863 | doi = 10.11124/JBISRIR-2017-003652 | url = https://orca.cardiff.ac.uk/id/eprint/111395/ }}</ref> In other cases, significant change can require a generation of physicians to be replaced by physicians who were trained with more recent evidence.{{update source|date=May 2026}}
Revision of clinical guidelines to include an implementation plan may facilitate uptake of new procedures,<ref name="Loza_2022">{{cite journal | vauthors = Loza E, Carmona L, Woolf A, Fautrel B, Courvoisier DS, Verstappen S, Aarrestad Provan S, Boonen A, Vliet Vlieland T, Marchiori F, Jasinski T, Van der Elst K, Ndosi M, Dziedzic K, Carrasco JM | display-authors = 6 | title = Implementation of recommendations in rheumatic and musculoskeletal diseases: considerations for development and uptake | journal = Annals of the Rheumatic Diseases | volume = 81 | issue = 10 | pages = 1344–1347 | date = October 2022 | pmid = 35961760 | doi = 10.1136/ard-2022-223016 | s2cid = 251540204 | doi-access = free }}</ref> including analysis of the context, identifying barriers and facilitators, and designing strategies to address them.<ref name="Loza_2022" />
== Education == Training in evidence based medicine is offered across the continuum of medical education.<ref name="Sicily statement on evidence-based"/> Educational competencies have been created for the education of health care professionals.<ref>{{cite journal | vauthors = Albarqouni L, Hoffmann T, Straus S, Olsen NR, Young T, Ilic D, Shaneyfelt T, Haynes RB, Guyatt G, Glasziou P | display-authors = 6 | title = Core Competencies in Evidence-Based Practice for Health Professionals: Consensus Statement Based on a Systematic Review and Delphi Survey | journal = JAMA Network Open | volume = 1 | issue = 2 | pages = e180281 | date = June 2018 | pmid = 30646073 | doi = 10.1001/jamanetworkopen.2018.0281 | s2cid = 58637188 | doi-access = free | hdl = 11250/2587900 | hdl-access = free }}</ref><ref name="Sicily statement on evidence-based"/><ref>{{cite journal | vauthors = Shaughnessy AF, Torro JR, Frame KA, Bakshi M | title = Evidence-based medicine teaching requirements in the USA: taxonomy and themes | journal = Journal of Evidence-Based Medicine | volume = 9 | issue = 2 | pages = 53–58 | date = May 2016 | pmid = 27310370 | doi = 10.1111/jebm.12186 | s2cid = 2898612 }}</ref>
The Berlin questionnaire and the Fresno Test<ref name="pmid12468485">{{cite journal | vauthors = Fritsche L, Greenhalgh T, Falck-Ytter Y, Neumayer HH, Kunz R | title = Do short courses in evidence based medicine improve knowledge and skills? Validation of Berlin questionnaire and before and after study of courses in evidence based medicine | journal = BMJ | volume = 325 | issue = 7376 | pages = 1338–1341 | date = December 2002 | pmid = 12468485 | pmc = 137813 | doi = 10.1136/bmj.325.7376.1338 | author-link2 = Trisha Greenhalgh }}</ref><ref name="pmid143529">{{cite journal | vauthors = Ramos KD, Schafer S, Tracz SM | title = Validation of the Fresno test of competence in evidence based medicine | journal = BMJ | volume = 326 | issue = 7384 | pages = 319–321 | date = February 2003 | pmid = 12574047 | pmc = 143529 | doi = 10.1136/bmj.326.7384.319 }}<br />[http://www.bmj.com/content/suppl/2003/02/10/326.7384.319.DC1 Fresno test]</ref> are validated instruments for assessing the effectiveness of education in evidence-based medicine.<ref name="pmid16954491">{{cite journal | vauthors = Shaneyfelt T, Baum KD, Bell D, Feldstein D, Houston TK, Kaatz S, Whelan C, Green M | display-authors = 6 | title = Instruments for evaluating education in evidence-based practice: a systematic review | journal = JAMA | volume = 296 | issue = 9 | pages = 1116–1127 | date = September 2006 | pmid = 16954491 | doi = 10.1001/jama.296.9.1116 }}</ref><ref name="pmid15514352">{{cite journal | vauthors = Straus SE, Green ML, Bell DS, Badgett R, Davis D, Gerrity M, Ortiz E, Shaneyfelt TM, Whelan C, Mangrulkar R | display-authors = 6 | title = Evaluating the teaching of evidence based medicine: conceptual framework | journal = BMJ | volume = 329 | issue = 7473 | pages = 1029–1032 | date = October 2004 | pmid = 15514352 | pmc = 524561 | doi = 10.1136/bmj.329.7473.1029 }}</ref> These questionnaires have been used in diverse settings.<ref name="pmid21686291">{{cite journal | vauthors = Kunz R, Wegscheider K, Fritsche L, Schünemann HJ, Moyer V, Miller D, Boluyt N, Falck-Ytter Y, Griffiths P, Bucher HC, Timmer A, Meyerrose J, Witt K, Dawes M, Greenhalgh T, Guyatt GH | display-authors = 6 | title = Determinants of knowledge gain in evidence-based medicine short courses: an international assessment | journal = Open Medicine | volume = 4 | issue = 1 | pages = e3–e10 | year = 2010 | pmid = 21686291 | pmc = 3116678 | doi = 10.2174/1874104501004010003 |doi-access=free| author-link15 = Trisha Greenhalgh | first16 = G.H. | first15 = T. | doi-broken-date = 23 February 2026 | author4-link = Holger Jens Schünemann }}</ref><ref name="pmid21286836">{{cite journal | vauthors = West CP, Jaeger TM, McDonald FS | title = Extended evaluation of a longitudinal medical school evidence-based medicine curriculum | journal = Journal of General Internal Medicine | volume = 26 | issue = 6 | pages = 611–615 | date = June 2011 | pmid = 21286836 | pmc = 3101983 | doi = 10.1007/s11606-011-1642-8 }}</ref>
A Campbell systematic review that included 24 trials examined the effectiveness of e-learning in improving evidence-based health care knowledge and practice. It was found that e-learning, compared to no learning, improves evidence-based health care knowledge and skills but not attitudes and behaviour. No difference in outcomes is present when comparing e-learning with face-to-face learning. Combining e-learning and face-to-face learning (blended learning) has a positive impact on evidence-based knowledge, skills, attitude and behavior.<ref>{{cite journal | vauthors = Rohwer A, Motaze NV, Rehfuess E, Young T |title=E-learning of evidence-based health care (EBHC) to increase EBHC competencies in healthcare professionals: a systematic review |journal=Campbell Systematic Reviews |year=2017 |volume=4 |pages=1–147 |doi=10.4073/csr.2017.4 |doi-access=free}}</ref> As a form of e-learning, some medical school students engage in editing Wikipedia to increase their EBM skills,<ref>{{cite journal | vauthors = Azzam A, Bresler D, Leon A, Maggio L, Whitaker E, Heilman J, Orlowitz J, Swisher V, Rasberry L, Otoide K, Trotter F, Ross W, McCue JD | display-authors = 6 | title = Why Medical Schools Should Embrace Wikipedia: Final-Year Medical Student Contributions to Wikipedia Articles for Academic Credit at One School | journal = Academic Medicine | volume = 92 | issue = 2 | pages = 194–200 | date = February 2017 | pmid = 27627633 | pmc = 5265689 | doi = 10.1097/ACM.0000000000001381 }}</ref> and some students construct EBM materials to develop their skills in communicating medical knowledge.<ref>{{cite journal | vauthors = Maggio LA, Willinsky JM, Costello JA, Skinner NA, Martin PC, Dawson JE | title = Integrating Wikipedia editing into health professions education: a curricular inventory and review of the literature | journal = Perspectives on Medical Education | volume = 9 | issue = 6 | pages = 333–342 | date = December 2020 | pmid = 33030643 | pmc = 7718341 | doi = 10.1007/s40037-020-00620-1 }}</ref>
== See also == {{Portal|Medicine}} {{columns-list|colwidth=30em| * Anecdotal evidence * Clinical decision support system (CDSS) * Clinical epidemiology * Consensus (medical) * Epidemiology * Evidence-based dentistry * Evidence-based design * Evidence-based nursing * Evidence-based policy * Evidence-based practices * Evidence-based management * Evidence-based research (Metascience) * Hierarchy of evidence * Medical algorithm * Paradigm shift – the social process by which scientific evidence is eventually adopted * Personalized medicine * Policy-based evidence making * Precision medicine * Scientific evidence }}
== References == {{Reflist}}
== Bibliography == {{refbegin}} * {{cite book | vauthors = Doi SA |title=Understanding evidence in health care: Using clinical epidemiology |year=2012 |publisher=Palgrave Macmillan |location=South Yarra, VIC, Australia |isbn=978-1-4202-5669-7}} * {{cite book | vauthors = Grobbee DE, Hoes AW |title=Clinical Epidemiology: Principles, Methods, and Applications for Clinical Research |year=2009 |publisher=Jones & Bartlett Learning |isbn=978-0-7637-5315-3}} * {{cite book | vauthors = Howick JH |title=The Philosophy of Evidence-based Medicine |year=2011 |publisher=Wiley |isbn=978-1-4051-9667-3 |url=https://books.google.com/books?id=O8djbHBva5IC}} * {{cite book | vauthors = Katz DL |title=Clinical Epidemiology & Evidence-Based Medicine: Fundamental Principles of Clinical Reasoning & Research |url=https://archive.org/details/clinicalepidemio0000katz |url-access=registration |year=2001 |publisher=Sage |isbn=978-0-7619-1939-1}} * {{cite book | vauthors = Stegenga J |title=Care and Cure: An Introduction To Philosophy of Medicine |publisher=University of Chicago Press |year=2018 |url=https://www.press.uchicago.edu/ucp/books/book/chicago/C/bo29193227.html |isbn=978-0-226-59517-7}} {{refend}}
== External links == {{Wiktionary}} * [https://files.jamanetwork.com/sdebm/ Evidence-Based Medicine – An Oral History], ''JAMA'' and the ''BMJ'', 2014. {{open access}} * [https://www.cebm.net/ Centre for Evidence-based Medicine at the University of Oxford.]
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Category:Evidence-based medicine Category:Evidence Category:Health informatics Category:Health care quality Category:Clinical research