Evidence-based medicine: an overview of key concepts

Since Sackett et al established the defining principles almost 20 years ago, the concept evidence-based medicine (EBM) has grown and is reflected in the current US healthcare reform debate. To determine the relevancy of EBM elements to wound care, a review of the literature was conducted using several electronic databases. English-language literature was searched for articles published between 1985 and 2009 with regard to EBM principles, study design, systematic reviews, meta-analysis, safety, and clinical practice guidelines to find insightful and balanced studies and commentary. Current literature shows general agreement on the hierarchy of clinical trial design and the value of systematic reviews and meta-analysis but a divergence of opinions about optimal EBM rating schemes remains. Randomized controlled trials will continue to be the gold standard of trial design to evaluate treatment efficacy, but they often are poorly executed. The value of comparative observational trials is frequently underrated and although systematic reviews and meta-analysis are valuable for summarizing the evidence, care needs to be taken to avoid pitfalls. Research also suggests that clinical practice guideline implementation studies are needed if their content is to be fully appreciated by practicing clinicians. Thus, while EBM has advanced considerably in the last 20 years, tradition-based care is still evident in wound care. The challenge is to ensure EBM continues to integrate individual clinical expertise with the best available external clinical evidence from high quality research.