复旦大学：《循证医学》课程教学资源（参考教材）Unit 01 循证医学概论（授课老师：陈世耀）.pdf_P11-P14

Review www.thelancet.com Published online February 16, 2017 http://dx.doi.org/10.1016/S0140-6736(16)31592-6 7 viewed as the natural accompaniment of the human experience. It is true, for instance, that most compelling randomised trials highlighted in EBM-oriented texts have been conducted by the pharmaceutical industry. EBM writings have provided guides for detecting misleading study designs and interpretation—for example, choosing an inferior comparator98 or undertaking mega-trials and then misrepresenting very small eff ects as major breakthroughs.99 The extent to which such warnings and guides have adequately protected clinicians from misleading presentations is at best questionable, and probably limited. EBM practitioners in particular, and the medical community in general, need to continue to push back against these distortions that often result in “too much medicine”.100 However, no critic ever suggested that reliable evidence should not be a key to eff ective problem solving and decision making. Humans are “informavores”101—we need evidence to eff ectively function in the world around us. The next 25 years EBM has disseminated three major tenets: an increasingly sophisticated hierarchy of evidence, the need for systematic summaries of the best evidence to guide care, and the requirement for considering patient values in important clinical decisions. EBM has contributed to, and perhaps spawned, a number of related initiatives. These initiatives include a focus on comparative eff ectiveness research,102 over or under diagnosis and over or under treatment,100 measurements of the quality of care,103 improving publishing standards,104 ensuring all trials are registered,70,105 and avoiding waste in research production, including discontinued use of misguided interventions that have become part of established practice.106 These initiatives refl ect the broad scope of the EBM movement, which has expanded to include disciplines such as nursing, dentistry, public health, and health policy (socalled evidence-based health care), as well as recognition for the need of evidence-based implementation science to ensure optimal function of clinics, hospitals, and health systems.52 EBM will have to address several challenges in the next quarter century. Failure to publish, and indeed suppression of research results, remains a problem. Optimal delivery of clinical care requires far more effi cient production and rapid dissemination of both systematic reviews and practice guidelines.107 Achieving this goal will require further advances in building experienced research teams geared toward rapid turnaround in creating rigorous evidence summaries, automatised and text-mining software,108 and the widespread adoption of electronic platforms that greatly facilitate rapid updating. Dissemination must include patient-friendly and clinician-friendly electronic access on all types of devices, including smart phones, to electronic medical records and, particularly for patients, social media.45,109,110 EBM will need to address the place of evidence generated by so-called big data111 mining in relation to traditional observational studies and randomised trials for the development of a “continuously learning health care system”.112 EBM has yet to generate a coherent theory of health-care decision making113 and will continue to partner with other disciplines, such as cognitive and decision sciences, toward this goal.114 On a more practical level, major challenges remain in providing clinicians with tools to make shared decision making at the point of care entirely practical and effi cient, and a positive experience for both patients and clinicians. In conclusion, eff orts are well underway in each of the problematic areas of EBM, and progress is certain. 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