Evidence-based medicine is a branch of science that suggests using only those diagnostic methods and treatments that have been proven effective in scientific research. In Europe and the USA, an evidence-based approach to medicine has been used for 20-25 years, which has made it possible to increase its effectiveness and safety for patients. In Russia, the transition to the principles of evidence-based medicine has been observed only in the last few years.
General information
Doctors until the 70s of the last century, when prescribing an examination and choosing a treatment, relied on their own experience and the opinions of colleagues. This led to the fact that strange approaches to therapy appeared in medicine. For example, coughs and pains in children were offered to be treated with heroin, and patients were sent to the dentist to eliminate schizophrenia.
Doctors and patients have seen that the effectiveness of the approach based on personal experience is low. In the second half of the 20th century, thereevidence-based medicine, which in foreign literature is called evidence based medicine (medicine based on evidence). The main principle is to use for treatment only the list of drugs and methods that have shown high efficacy and safety during clinical trials. Today, this is the "gold standard" of medicine.
In Russia, the scientific approach to the treatment of diseases is common in some medical and educational institutions. A large number of medicines, dietary supplements and procedures do not have an evidence base for their effectiveness and safety.
Evidence Based Medicine
Evidence-based medicine is not an independent part of medicine. This is a set of rules for conducting medical research, which was formed at the end of the 20th century. It is followed during laboratory, preclinical and clinical trials of any medicines and medical procedures.
Modern medicine uses three international standards:
- Good laboratory practice governing the handling of medicinal products outside the human body, such as research on laboratory animals, etc.
- Good clinical practice indicating how clinical drug trials should be conducted.
- Good medical practice. Regulates the use of medicines and medicinalprocedures in patients.
Three standards describe the principles of an evidence-based approach to medicine without taking into account ethical and organizational issues. Thanks to their use, the effectiveness and safety of treatment can be compared mathematically, comparing two known approaches or using a placebo as a control.
The placebo effect is a psychological phenomenon in which a dummy drug leads to a clinical effect, such as the disappearance of pain in a person. On average, placebo works in 25% of mentally he althy people. In some people with anxiety disorders, it reaches 60% or more. This leads to the fact that after prescribing treatment to the patient, the doctor cannot be sure that the recovery is associated with the drug used. To exclude the placebo effect, clinical trials of any drug are conducted in terms of evidence-based medicine.
Effectiveness of treatment
Degree of evidence for a particular treatment method may vary. The easiest way to understand this is by changing the medical approach to treating influenza. The opinion of experts is divided: someone believes that a viral infection should be treated, and someone that it goes away on its own. In Russia and foreign countries, there are few drugs for the treatment of influenza that have an evidence base. Evidence-based physicians do not prescribe them to all patients with suspected influenza, but base their choice of treatment on the clinical picture and laboratory tests: nasal swab and rapid influenza tests. Also taken into account is the degreethe severity of the disease, contraindications to the appointment and possible risks are assessed. Speaking of evidence, experts distinguish two concepts: the class of recommendation and the level of evidence. There are only three levels: A, B and C. Level A evidence is of the greatest importance for the choice of treatment. Such data are obtained from single or multiple large randomized clinical trials. They are the "gold standard" of the scientific approach to medicine.
A randomized clinical trial is based on the division of patients into 3 groups: a control group (testing a placebo), an experimental group (testing a new drug) and a comparison group (using a standard method of therapy). The word "randomized" means that the patients were assigned randomly to them, and not to the investigators. Also, in a randomized study, a blinding method is used - a person does not know if he is receiving a dummy or medication. As a result, specialists can check for the presence of a placebo effect, as well as compare the effectiveness of the drug under development with it. The highest level of evidence is in double-blind studies, when neither the doctor nor the person is aware of the type of therapy being given. Another researcher is analyzing the results.
Evidence level B corresponds to studies that did not randomly assign patients to groups, or their number was small. If the evidence is based on single studies or physician experience, then it is grade C.
Recommendation class defines how specialistsin a particular area refer to this method of treatment. If the drug has proven its effectiveness in randomized trials and experts agree with its use, then it has the first class. In this case, the class of evidence is I. If the opinion of experts is not unambiguous, then the use of the drug has class II. At the same time, there is a gradation of evidence:
- IIa - most studies and doctors confirm the effectiveness of the remedy.
- IIb – evidence and positive opinions are sporadic. In this case, the risk of using the drug outweighs the possible benefits of prescribing it.
Determines the class of recommendation and the degree of evidence of specialized organizations - the World He alth Organization, the International Society of Cardiology, etc. They issue guidelines for doctors that contain information on treatment methods.
Evidence-based medicine in Russia
Approaches to he alth care differ in individual countries, for example, in Russia and the CIS countries, the foundations of evidence-based medicine are used only by individual medical institutions and doctors. Doctors who follow the principles of evidence-based medicine are actively engaged in educational work among colleagues. However, as practice shows, a small percentage of specialists use the principles of science in prescribing treatment. This is especially evident in remote cities and towns, where access to modern educational materials for medical workers is difficult.
This approach leads to the fact that the systemcertification of medicines has certain defects. For example, any foreign drug, before entering the Russian market, must be certified by Russian organizations. The level of their scientific verification is lower than in foreign certification centers, but is required.
At the same time, in Russia there are a large number of drugs that do not have a high level of evidence. These are drugs that have passed separate clinical trials without randomization and placebo testing. The lack of a rigorous approach to the evidence base leads to an increase in the number of such drugs in domestic medicine.
How does a patient evaluate the prescribed treatment?
The law "On the Fundamentals of Protecting the He alth of Citizens in the Russian Federation" indicates that the sick person himself makes the final decision about his treatment. The doctor must substantiate and convince the patient of the correctness of the appointment or select analogues of the treatment method.
The main way to understand the correctness of the selected treatment is to consult with another specialist and get a second opinion. Doctors using approaches and medicines of evidence-based medicine will help to exclude non-existent diagnoses, for example, intestinal dysbacteriosis, vegetovascular dystonia, and others that are quite common in modern practice. It is important to note that you should not refuse the services of a doctor who uses treatment approaches based on personal experience. It is necessary to discuss the upcoming therapy with him, discuss the methods of evidence-based medicine.
You can check the prescribed treatment usingclinical guidelines issued by professional associations in Russia, as well as using authoritative resources, for example, the website of the World He alth Organization. If the medicine recommended by the doctor is not in them, then you should consult with another specialist.
Correct diagnosis
Rational prescription of treatment and use of medicines is possible only with the correct diagnosis. Diagnosis of diseases is carried out according to certain algorithms, which make it possible to exclude pathologies with similar diagnoses.
There are several problems in our country that hinder a rational approach to the treatment of diseases.
The first problem is the length of the medical consultation. Standards of medical care indicate that the reception of one patient should not exceed 12 minutes. During this time, the specialist does not have time to collect all the complaints of the person and conduct a detailed examination.
The second problem is the wrong order of ordering diagnostic tests. For example, people with headaches are often given an immediate magnetic resonance imaging (MRI) scan. This method allows only a narrow range of diseases to be detected and should not be used first in the examination of patients. There are exceptions, such as a combination of headache with loss of neurological function. In this case, the symptoms correspond to tumor lesions that are detected by MRI. Its appointment speeds up the correct diagnosis.
The third problem is the use of methodsdiagnostics without evidence of their effectiveness. A classic example is iridology, when a disease is detected based on changes in the iris of the eyes.
Choosing a treatment is a task that requires collaboration between doctor and patient. The use of evidence-based medicine approaches ensures high efficiency and safety of treatment. Patients seeking medical attention should be advised to obtain a second opinion from several specialists. Reviews of evidence-based medicine in leading medical institutions are positive.
