Kimmy Moore, MPH Contributing Editor
These past few weeks the use of current evidence-based information regarding patient care has become a controversial topic. By definition, practitioners' use of EBM is necessary to provide optimal care. This fact has been demonstrated repeatedly with measurable clinical results. Recently, services offering well-maintained databases on PDAs and desktops have become especially popular with large, teaching hospitals - known for being the early adopters of most great medical advances. (mobihealthnews, of course, believes this information should be available at practitioners' fingertips via PDAs and mobile devices.)
A recent study by Bonis, Pickens, Rind, and Foster (2008) examined the health impacts of the use of a evidence-based clinical knowledge support system. They selected four outcomes well-established in the literature: complications, length of stay, mortality, and patient safety. While accounting for hospital characteristics, Bonis, et. al. found that subscribing hospitals had less complications, shorter lengths of stay, and fewer patients safety issues than hospitals without subscriptions. These results were statistically significant and persisted regardless of whether the use of the support system was considered dichotomously or continuously (hits per week on the support system website). Mortality rates did not differ.
These results seem straight forward; however, to avoid prejudice there are a few issues that must be considered before applying these results. One consideration is bias. Although the researchers did account for many factors associated with the outcomes and hospital characteristics, they could not incorporate everything - no study can. In regards to generalizability, these results do not necessary reflect the effect that all hospitals could expect to have if they ordered the support service because other factors may be at play. Lastly, clinical significance must be considered. For example, the length of stay in subscribing hospitals was on average 4 hours less than in other hospitals. Four hours may be a minor difference in the typical time of day of discharge, but more likely reflects a substantial difference of several days in a subset of patients with a particular diagnosis.
None of these considerations negate the decidedly positive results of the study. Not only does this study demonstrate the real-world effectiveness of an evidence-based clinical knowledge support system (which, in this study's case was a product called UpToDate); but underscores the importance of making that information readily available though the use of mobile technology.
As a public-health professional, it is mind-boggling to think that anyone could oppose evidence-based practices. The $1.1 billion set aside in the stimulus package for evidence-based medicine research is, if anything, not enough. Opponents, including Rush Limbaugh, argue that they don't want the government telling doctors how to treat their patients. That's ridiculous. The White House is not conducting clinical trials or making house-calls. That money will be divided among adequately trained health professionals to perform important research that will improve care and the health of our nation. You don't want your doctor taking cues from the government? Well, I don't want my doctor ignoring the medical advances of the twenty-first century.
In regards to the other extreme, the limited evidence presented by Bonis, et. al. does not support the mandated or subsidized use of mobile evidence-based clinical knowledge support system as some proponents have suggested. We need more in-depth studies on the use of the support system per patient case among an even distribution of hospitals before such incentive programs are established.
EBM is necessary to advance the field of medicine and the use of mobile technology makes it even more accessible. There must be adequate evidence before any healthcare protocol is recommended, mandated, or subsidized. After all, EBM is the accumulation, critique, and application of such evidence.
Kimberly Moore has a Master of Public Health degree and is a doctoral candidate in epidemiology at the University at Albany, SUNY. She frequently disseminates study results to her academic peers, general public and public health practitioners. Moore has experience consulting with the pharmaceutical industry and serves as contributing editor to mobihealthnews.
