Evidence-based medicine (EBM) should not be the sole basis for clinical practice; external evidence is necessary but not sufficient in guiding professional practice (Guyatt et al., 2000). Kemm (2006) poses ‘What constitutes evidence?” and highlights the consequences of ignoring narrative descriptions and sociological methods whilst overemphasizing epidemiological and probabilistic reasoning. Specialists in health promotion value lay knowledge and direct experience which are aspects that have been traditionally underappreciated in EBM (Kemm, 2006). For my health promotion project, it is imperative to grasp the lived experience of patients with epilepsy and their caregivers to identify the impacts on quality of life and areas for improvement.
The interpretation of “evidence-based” has evolved, becoming less restrictive and recognizing limitations of linear causal models. When assigning credibility to evidence it is important to address concerns about causation, validity, and bias. Even randomized controlled trials (RCTs), which have often been used as a gold standard, have limitations. Kemm (2006) explains a limitation of RCTs in community level interventions is a lack of consideration for context. RCTs do not guarantee a particular treatment works for a particular patient which creates a need for subgroup analysis (Kemm, 2006). Kemm (2006) states “Context affects both the way in that an intervention operates and the outcomes.” For epilepsy management, there is not a one size fits all approach. In addition to individual differences in terms of seizure types, there are geographical differences within British Columbia with respect to access to specialized centers with Epileptologists and Neurophysiology Technologists.
Professional practice should not use “evidence-based” as a way to assert claims without scrutiny. Appropriate use of medical treatments can improve by exploring available evidence instead of persisting with ineffective interventions (Kemm, 2006). Figure 1 shows the necessary steps to achieve best practice that is evidence-based (University of Canberra, 2022).
Figure 1. Steps of Evidence-Based Practice (University of Canberra, 2022).
There are two types of uncertainty errors (Kemm, 2006):
Type 1 Error: Inferring that no difference exists when in truth it does.
Type 2 Error: Inferring a difference exists when in truth there is none.
According to Kemm (2006), type 1 errors are usually accepted but there may be benefits of accepting more risks of type 2 errors when using evidence to inform policy. Policy makers and researchers have different perspectives on the utility of evidence in decision making. Policy makers view evidence as producing a range of solutions which can be selected from as needed whereas researchers tend to view policy making as a linear process with a distinct decision point at which evidence would be useful (Kemm, 2006). It is important that research is compiled and presented in a meaningful way to policy makers to enhance its relevance or utility (Petticrew et al., 2004). Epilepsy research tends to focus on the etiology of seizures and may not capture the psychosocial impacts. Policy makers would benefit from understanding why seizures are happening as well as what that means for quality of life to adequately decide on change initiatives and regulations.
Technology has made it easier to perform large systematic literature searches that follow a rule-based selection process. Having two or more reviewers rate information following rules and being transparent and explicit in their reasoning helps minimize biases or the influence of the researcher on the results (Kemm, 2006). However, it is possible that valuable information and articles are excluded (e.g., the favoured method was not used so it was excluded from the results) or too much weight may be assigned to a small amount of articles that are selected (Kemm, 2006). Meta-analysis is a way to estimate an effect by combining the results of several different studies (Kemm, 2006). Kemm (2006) suggests that combining systematic reviews with expert judgement could yield more reliable conclusions.
Guyatt, G.H., Haynes, R.B., Jaeschke R.Z.,, Cook, D.J., Green, L., Naylor, C.D., Wilson, M.C. & Richards, W.S. (2000). Users guide to the medical literature XXV: evidence based medicine: principles for applying the usters guides to patient care. Journal of the American Medical Association, 284, 1290-1296.
Kemm, J. (2006). The limitations of “evidence-based” in public health. Journal of Evaluation in Clinical Practice, 12(3), 319-324.
Petticrew, M. Whitehead, M., McIntyre, S., Graham, H. & Egan, M. (2004). Evidence for public health policy on inequalities: 1 the reality according to the policymakers. Journal of Epidemiology and Community Health, 58, 811-816.
University of Canberra (2022). Evidence-based practice in health. Library Guides. Retrieved Sept. 8, 2023 from https://canberra.libguides.com/evidence#s-lg-box-12888056
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