The Case for Evidence-Based Medicine in Managing Workplace Injuries
January 10, 2024 | Categories: ODG by MCG
Hippocrates said of the practice of medicine, “There are in fact two things, science and opinion; the former begets knowledge, the latter ignorance.” This quote could be interpreted to mean clinical opinions should not be considered. We know in modern medical practice that this should not be the case, though his statement on knowledge is accurate. The concept of clinical experience and scientific knowledge supports what some have described as making medicine an art form supported by science. In 1992, the term evidence-based medicine (EBM) was born in a JAMA article as part of a series from a workgroup on EBM. This collective was chaired by the distinguished academic, Dr. Gordon Guyatt.1 In 2014, he published an editorial, Evidence-Based Medicine -An Oral History, which included interviews with pioneers in the development of the EBM concept and its application.2 It is a valuable read for practitioners to understand why the concept came into existence. The original definition: “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” is still accepted as one of the best.
There are plenty of opinions as to why the concept of EBM was developed. Co-founder, Brian Haynes, a professor at McMaster University worried about limitations he was seeing with “expert-based medicine” during Freudian lectures where no evidence on the theories being presented was available (or known to exist). Others, including Dr. David Sackett who some consider to be the father of EBM, saw a need to support clinical medicine with statistical support for treatment decisions and began to teach the concept of critical appraisal of evidence. The sheer volume of scientific literature being published annually was – and continues to be – staggering. A process to look at this literature in a structured way quickly became necessary. The idea was to teach medical students these concepts while still in medical school. Out of critical appraisal came the term “Evidence-Based Medicine” as mentioned above by Dr. Guyatt. A collaboration with JAMA gave increased legitimacy to the movement and many others have honed the concepts over time, including incorporation of patient values in the process. A continued collaboration by its founders spread throughout Western medicine and organizations such as the Cochrane Collaboration were born.
Appraising and Grading Evidence
EBM requires a process to evaluate literature in a systematic approach. Two components that are not mutually exclusive are (a) critical appraisal by the reviewer; and (b) a hierarchical approach to grading the literature. Critical appraisal is an assessment of research studies that helps to determine applicability to the clinical scenario being addressed, including treatment regimens and outcomes. It analyzes the quality and generalizability of the study and judges the statistical methods utilized, reporting clinically relevant information.
This process requires practice when looking at individual studies. A “hierarchy” of evidence grades may also be useful when comparatively evaluating the quality of literature. Many different hierarchies have been created to describe the evidence base One example is that which is used in the development of ODG by MCG’s clinical guidelines; it is a simple rating system with three Evidence Grades (which are also utilized in the development of the MCG Care Guidelines). Cited references in the Evidence Summary are graded according to the underlying study design and the limitations inherent in each, which impacts how the results should be interpreted by a reader. The evidence hierarchy is as follows:
Evidence Grade 1 (EG 1):
- Randomized controlled trials with meta-analysis
- Randomized controlled trials
- Systematic reviews
Evidence Grade 2 (EG 2):
- Observational studies: examples include: Cohort studies with statistical adjustment for potential confounders; Cohort studies without adjustment; Case series with historical or literature controls; Uncontrolled case series
- Published guidelines
- Statements in published articles or textbooks
Evidence Grade 3 (EG 3):
- Unpublished data: examples include:
• Large database analyses
• Written protocols or outcomes reports from large practices.
• Expert practitioner reports
ODG considers this our means of “grading” the evidence. This is meant to be a framework; this does not imply that lower levels of evidence should be discarded wholesale, but that the relevant clinical situation should be considered (i.e., clinician judgment applied).
The Benefits of EBM
It will always be debated by stakeholders with different interests as to the importance of having and using EBM. Protecting injured workers both before and after their injury is vital for all parties. When companies take a patient/employee-centric approach and subsequently prevent or decrease disability, everyone wins. Long-term temporary disability has long-lasting consequences, both financial and physical, on employers, employees, and their families. Workers’ compensation guidelines, like ODG by MCG, take the approach of leveraging evidence-based medicine content to achieve optimal medical outcomes while minimizing the potential financial impact that disability may have on all parties. Using analytics can also help employers directly prevent unhealthy lifestyles and the potential disability of their employees.
Additionally, the following benefits make it hard to argue with the merits and applications that ODG by MCG provides in workers’ compensation, auto injuries, and prevention of long-term disability.
- Allows consistent quality of care from the review of rigorous peer-reviewed research and application of best practices when formulating a treatment plan
- Enhances patient safety by reducing risks associated with some treatments
- Assists providers and patients with information that promotes informed decision-making to assess all options together
- Assists with holding all parties accountable and helps with transparency in healthcare decisions
- Helps prevent or reduce health inequities by applying the same standards to everyone, reducing unwarranted variations of care based on non-medical factors
- Provides a source of continuous learning and improvement for healthcare professionals
- Reduces unnecessary use of resources and disability by approaching patient care with the goal of producing the best potential outcomes
- Reduces treatment delays and system friction by promoting timely approval and payment for treatment consistent with guidelines
Challenges and Limitations of EBM
EBM is not without its critics and limitations. However, evidence-based medicine done appropriately is not “cookbook” medicine, but a source of external evaluation of best practice and scientific support that complements clinical expertise with individual patients. Some common challenges around evidence-based tools can be:
- Rigid application can limit flexibility to care for individual needs and ignores patient values
- Focuses too much on quantitative data, neglecting patient experience and individualized care
- Time-consuming (and resource-intensive) research is required to evaluate medical literature
- Lack of skill by providers to evaluate and interpret complex literature
- Academic and experimental studies can limit what the private sector can utilize as treatment due to availability and costs
- Ethical issues with some treatments both for individuals and providers
- Limited available research for some diagnoses and conditions
- Randomized controlled trials can be expensive and slow to perform, and high-quality studies are unlikely to be performed on all treatments/interventions
Best Practices for Developing Clinical Practice Guidelines
A good clinical practice guideline rooted in EBM with transparent criteria can overcome the above concerns. ODG by MCG is a leader in providing these tools to assist stakeholders in achieving optimal healthcare outcomes. ODG by MCG uses multiple processes to accomplish its goal of providing best-in-class EBM clinical practice guidelines.
Within this structure, literature is constantly being identified, read, and analyzed for potential inclusion.
- Systematic review of medical databases for new literature
- Grading of clinical studies
- Periodic review of guidelines to evaluate the need for updates
- Adherence to standardized internal methodology
- Standards in place to minimize conflicts of interest or biases
- Transparency of the evidence base with citations included for each guideline
Clinical practice guidelines have become a foundational tool in the efficient and effective use of EBM. Providers are crunched for time in today’s medical practices, leaving less time for decision-making. Having clinical practice guidelines can help to decrease peer-to-peer needs and allow more time to be spent with patients to achieve the end goal of a positive outcome.
Providers can easily incorporate guideline utilization with established steps that have been part of their education for decades. First, formulating a clinical question, searching for the evidence to answer the question, and critical appraisal of the evidence are all steps that are streamlined for the provider by guidelines, subsequently allowing the application of the evidence and monitoring the outcome to complete the continuum of care.
ODG by MCG provides more than just evidence-based clinical content. A hallmark is the easy search function that produces clinical topics, as well as diagnosis and procedure codes that are clinically relevant. ODG provides disability-related data based on single or multiple conditions and data to anticipate the impact of comorbidities on the duration of disability. This can provide valuable information on expected outcomes for all stakeholders. An undervalued benefit of ODG is the educational support that can be provided to the patient to help in their recovery.
Evidence-based medicine is part of the fabric of current medical care and clinical practice guidelines help support physician-driven improvements. By fostering a collaborative approach between payers and providers, such tools can also help expedite payment, as well as save valuable time and resources. This is where ODG by MCG can be a valuable clinical partner for both parties as they work to improve outcomes in workers’ compensation, disability, and auto injury.
– Troy J. Prevot, MBA, PA-C | ODG by MCG Director of Strategic Solutions. Published on January 9, 2024.
The information contained in this article concerns the ODG guidelines (or solutions) as of the date of publication, and may not reflect revisions made to the guidelines (or solutions) or any other developments in the subject matter after the publication date of the article.
- Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992;268(17):2420-2425.
- Smith R, Rennie D. Evidence-Based Medicine—An Oral History. JAMA. 2014;311(4):365–367. doi:10.1001/jama.2013.286182
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