COVID-19 and the future of evidence-based medicine

December 14, 2020
Peter Bonis, M.D.

The pandemic has underscored the need for speedy access to reliable, effective clinical guidance

The COVID-19 pandemic has created unprecedented challenges across the health care ecosystem. Hospitals and health systems are once again faced with onslaughts of critically ill patients amid staffing shortages and capacity constraints. By now, however, clinicians are armed with better knowledge and experience learned from the early stages of the pandemic.

COVID-19 exacerbated the global need for reliable healthcare information while shrinking the timeline for creating it due to unparalleled urgency. In response, many health care publications have modified their editorial processes to help disseminate findings as quickly as possible. The result has been the release of a dizzying volume of research since the start of the pandemic, but there have been shortcomings. In mid-June of 2020, two prominent COVID-19 study retractions sparked nationwide headlines and threatened the credibility of a few of the world’s most respected medical journals. 

Out of necessity, the pandemic has led to the expanded availability of findings in early stages of research, often causing confusion for the public and healthcare professionals. Synthesizing the available evidence rigorously in a format that is transparent and usable by frontline health care providers is challenging, but such information is a requirement for health care systems trying to deliver state-of-the-art care.

This is particularly important when dealing with complex conditions in which information is changing rapidly: emerging infectious diseases, cancer and other conditions where high-quality clinical trials published in peer-reviewed journals are slower to evolve than the availability of emerging observations from clinical practice and other sources of experiential data.

Best evidence of the moment

A body of evidence, ideally from well-conducted randomized controlled trials and systematic reviews remain the gold standard for establishing an evidentiary basis to guide practice. But the process takes time, and even under the best of circumstances such studies remain vulnerable to bias such that the treatment effect is not always reproducible.

In addition, clinical trials cannot address the myriad of practical questions that arise in day-to-day practice. In the meantime, clinicians must make the best decisions they can for their patients. In that respect, the paradigm has shifted somewhat where it is the best evidence of the moment that matters. 

7 critical elements to advance the best evidence of the moment approach:

1) Understand the important clinical questions. A community of authors, editors, peer-reviewers and users must work together to define the clinical questions that matter and modify them as new information evolves.

2) Synthesized evidence. Rigorous processes are required to identify and systematically review relevant sources of evidence. These must be synthesized thoughtfully and presented to clinicians in a way that they can be understood quickly and accurately.

3) Recognizable expertise. Clinical experts are essential to translate evidence into recommendations for care. Experts must understand the evidence and what it means for managing patients. 

4) Peer review. A team effort is required to ensure that recommendations for care are clear, useful and reflect contemporary thinking. Formal peer-review processes are essential. Feedback from end users should also be incorporated into the editorial process.

5) Transparency. Clinicians need to understand how recommendations for care were derived and the limitations of the evidence so they can formulate their own perspective and assess the applicability of the guidance to the patient in front of them. Grading the strength of recommendations and the quality of evidence using a validated approach can provide a short-hand guide to assist in that process. 

6) Rigor and speed. The process must be efficient but cannot sacrifice required stringent and reproducible processes to achieve timeliness.

7) Easy-to-find information. Clinical decision support should come in formats that make the relevant information easily discoverable. Work-flow integration is an important component.  

The optimization of the best evidence-of-the-moment approach distills published research and other sources of evidence to help health care professionals, patients and other stakeholders align care around best practices. Such an approach can reliably cull the massive amount of information that research and clinical experience generate at head-spinning speed and transform it into reliable and actionable recommendations for patient care. Such information is critical for health care organizations striving to deliver consistent, high-quality, contemporary care.

Dr. Bonis is chief medical officer of clinical effectiveness for Wolters Kluwer, Health