Clinical decision-making is one of the most important elements of patient care. Advances in technology and the shift towards value-based care and allow physicians to supplement their clinical experience with decision support tools and rely on evidence-based medicine to enhance their decision-making abilities. Below is an outline from Harrison’s Principles of Internal Medicine that examines which decision support tools and evidence-based medicine techniques can best assist with the clinical decision-making process, as well as potential shortfalls one should avoid when using these tools.
Decision-Making Support Tools
Over the last 40 years, many attempts have been made to develop computer systems to aid clinical decision-making and patient management. Conceptually attractive because computers offer ready access to the vast information available to today’s physicians, they may also support management decisions by making accurate predictions of outcome, simulating the whole decision process, or providing algorithmic guidance. Computer-based predictions using Bayesian or statistical regression models inform a clinical decision but do not actually reach a “conclusion” or “recommendation.” Artificial intelligence systems attempt to simulate or replace human reasoning with a computer-based analogue. To date, such approaches have achieved only limited success. Reminder or protocol-directed systems do not make predictions but use existing algorithms, such as guidelines, to guide clinical practice. In general, however, decision support systems have had little impact on practice. Reminder systems, although not yet in widespread use, have shown the most promise, particularly in correcting drug dosing and promoting adherence to guidelines. Checklists, as used by pilots for example, have garnered recent support as an approach to avoid or reduce errors.
Evidence-based medicine (EBM) constitutes the integration of the best available research evidence with clinical judgment as applied to the care of individual patients. EBM places great emphasis on the processes by which clinicians gain knowledge of the most up-to-date and relevant clinical research to determine for themselves whether medical interventions alter the disease course and improve the length or quality of life. The meaning of practicing EBM becomes clearer through an examination of its four key steps:
1. Formulating the management question to be answered
2. Searching the literature and online databases for applicable research data
3. Appraising the evidence gathered with regard to its validity and relevance
4. Integrating this appraisal with knowledge about the unique aspects of the patient
The process of searching the world’s research literature and appraising the quality and relevance of studies thus identified can be quite time-consuming and requires skills and training that most clinicians do not possess. Thus, identifying recent systematic overviews of the problem in question may offer the best starting point for most EBM searches.
Generally, EBM tools such as Evidence-Based Medicine Reviews, the Cochrane Library, and MEDLINE provide access to research information in one of two forms. The first, primary research reports, is the original peer-reviewed research work that is published in medical journals. The second form, systematic reviews, is the highest level of evidence in the hierarchy because it comprehensively summarizes the available evidence on a particular topic up to a certain date. To avoid the potential biases in review articles, predefined explicit search strategies and inclusion and exclusion criteria are used to find all of the relevant scientific research and grade its quality. When appropriate, a meta-analysis quantitatively summarizes the systematic review findings. However, it must always be remembered that even though advances have been made in terms of evidence and how it relates to patient therapies, not every patient treated will respond to therapy the same way an “average” patient may.
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