Evidence-Based Medicine in Managed Care: A Survey of Current and Emerging Strategies

Paul H. Keckley, PhD


Medscape General Medicine. 2004;6(2):56 

In This Article

Evidence-Based Practice: The Framework for Managed Care

Evidence-based medicine is not a new concept. British epidemiologist Archie Cochrane is regarded as the originator of the concept. His efforts in the mid-1950s to 1960s to categorize studies led to the pre-eminence of randomized, controlled studies as the gold standard for evaluating the validity and reliability of clinical research.[9]

David Sackett's definition is widely used as the basis for pedagogy in evidence-based medicine. He defined evidence-based medicine as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care or individual patients. The practice of EBM means integrating individual clinical expertise with the best available clinical evidence from systematic research."[10] He noted that "good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough."

In the context of Sackett's definition, evidence-based medicine is largely physician-centric. It requires physicians to combine their training and experience with the current science to diagnose and treat patients, and presumes a level of discretion in the balancing of the two. In many institutions, it is used synonymously with "medical decision making" and taught by medical librarians.[11]

Absent in this widely held traditional view is the necessary role of the patient in evaluating the science and participating in treatment planning.

Gray Muir and his colleagues[12] introduced a broader definition: "Evidence based clinical practice is an approach to decision making in which the clinician uses the best scientific evidence available, in consultation with the patient, to decide upon the option which suits the patient best."

In this context, patient adherence is a consideration in addition to physician adherence. It presumes the important role of the clinician in making diagnostic and prognostic decisions but expands to include the role of educating patients about treatment options and engaging them in care management decisions. In this model, the clinician's role is to coach; the patient's role is to make an informed decision and participate actively in their own care.

There are, therefore, 3 critical integrated processes involved in the practice of evidence-based medicine:

  1. Evidence-based practice involves ongoing systematic review of the "science" supporting the diagnosis and treatment planning for a condition by clinicians and patients. Often, the science is incorporated into guidelines, or a "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances."[13]

  2. Evidence-based practice involves the integration of the science with the clinician's training and practice experience.

  3. Evidence-based practice involves the active participation of patients in making decisions about their care. Though foreboding in concept, the premise is simple: evidence-based decision-making requires that consumers comprehend their diagnosis and engage in a reasoned assessment of available treatment options and the benefits and risks associated with each.

The practice of evidence-based medicine is an ongoing process involving clinicians and patients: staying abreast of science, filtering science through the patient's preferences, and shared decision-making with patients are its keys. Anticipating criticism of EBM as "cookbook" medicine, Sackett noted:

Evidence-based medicine is not cookbook medicine. Because it requires a bottom-up approach that integrates the best external evidence with individual clinical expertise and patient choice, it cannot result in slavish, cook-book approaches to individual care. External evidence can inform, but never replace individual clinical expertise and it is this expertise that decides whether the external evidence applies to the individual patient at all, and if so, how it should be integrated in a clinical decision. [1]

The pedagogy of evidence-based practice, therefore, centers around engaging questions of patients as well as practitioners. The integration of both is key to providing the most appropriate care to the patient.

There exist, however, many hurdles in achieving engaged consumers. The majority of consumers expect "their physician" to be the decision-maker.[14] Most consumers -- 77% -- are ill-equipped or otherwise uncomfortable making decisions about their care and prefer their physician to make decisions for them.[15]

Managed care has historically played a key role in influencing the behaviors of both physicians and patients. Evidence-based medicine is the basis for these efforts. How plans incorporate evidence-based medicine in their medical management activities, and plans to modify these strategies, are the foci of this study.