Editors choice: an annotated bibliography of EBM articles selected by the Clinical Evidence editorial team

Our editors showcase the papers that have influenced them in their work, whether it be informing their decision to become part of the world of evidence-based medicine (EBM) or helping them with methodological issues and statistical questions. The selection shows both the diversity of the editors' interests and the range of issues in EBM.

Sackett DL, Rosenberg MC, Gray JA, et al. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71-72.


The most popular article among our team, rated by several editors. This often-quoted editorial puts EBM into a clinical context. It also includes a definition, namely, "EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients". A really good definition of what we are aiming for, with some history and a lot of food for thought.

Bastian H, Glasziou P, Chalmers I. Seventy-five trials and eleven systematic reviews a day: how will we ever keep up? PLoS Med 2010;7:e1000326.


This paper highlights the challenges of keeping systematic reviews current and clinically relevant - where do we begin with all this research? It provides some useful suggestions for how to tackle this issue.

Atkins D, Eccles M, Flottorp S, et al. Systems for grading the quality of evidence and the strength of recommendations I: critical appraisal of existing approaches. The GRADE Working Group. BMC Health Serv Res 2004;4:38.


This early paper by the GRADE Working Group examined the shortcomings of six, then current, systems for grading the strength of evidence and strength of recommendations derived from evidence. It pre-dated subsequent publications on the GRADE system.

Sackett DL, Straus SE, Richardson WS, et al. Evidence-based medicine: how to practise and teach EBM. 2nd Edition. London: Churchill Livingstone, 2000. 

This book is a great place to start for people who are new to EBM, and also for people who need to refresh their memories! It uses practical examples to illustrate how to analyse, and critically appraise all kinds of evidence. This includes what the statistics are, how to calculate and interpret them, and finally how to apply the findings to everyday practice.

Straus SE. What's the E for in EBM? BMJ 2004;328:535-536.


This short editorial identified the complex issues around getting evidence into practice and evaluating any effect. It pre-dated further papers in the BMJ which examined the evidence on whether EBM changes care.

Hart JT. The inverse care law. Lancet 1971;1:405-412.


This paper stated the availability of good medical care tends to vary inversely with the need for the population served. This outlines the challenge to EBM. Even when the best practice is identified, it needs to be delivered to those most at need. 

Concato J, Shah N, Horwitz RI. Randomised controlled trials, observational studies, and the hierarchy of research designs. N Eng J Med 2000;342:1887-1892.


What evidence do we use? This paper examines issues around the hierarchy of research designs. It discusses the effects of methodological quality in RCTs and observational studies, and how results from both may be similar or differ.

Shojania KG, Sampson M, Ansari MT, et al. How quickly do systematic reviews go out of date? A survival analysis. Ann Intern Med 2007;147:224-233.


This paper addresses the thorny issue of speed of update of systematic reviews, providing a quantitative analysis of ‘signals for change’ for reviews – where new evidence would potentially change conclusions and adds fuel to an ongoing debate - when does new data really make a clinical difference?

Shrier I, Boivin JF, Platt RW, et al. The interpretation of systematic reviews with meta-analyses: an objective or subjective process? BMC Med Inform Decis Mak 2008;8:19.


This paper questions the power of data as a tool for decision making in its own right, suggesting that no matter how well you collate data, it cannot be enough to guide decision making, clinical interpretation has a strong role to play – evidence is essential but it is not sufficient.

Glasziou P, Chalmers I, Rawlins M, et al. When are randomised trials unnecessary? Picking signal from noise. BMJ 2007;334:349-351.


This paper convincingly demonstrates the following EBM anecdote about the reliance on randomised trials. You realise that the efficacy of parachutes in preventing injury or death has never been put to randomised double-blind placebo controlled trials. Clearly the efficacy is questionable and at best variable. Clearly the policy of the mass issuing of parachutes to paratroopers and coercion of skydivers to use them is questionable.

Donald A. Balancing the benefits and harms of care. BMJ 2004;329:59.

This article by previous editor of Clinical Evidence and EBM guru Anna Donald written in the early stages of the breast cancer that would later take her life hit home to me the seriousness and value of the work we do and the importance of getting it right. To quote Anna: "above all else, I needed treatment information that was specific and properly evidence based. My job had accustomed me to having reliable evidence for most health questions. But when the crunch came I surprised even myself with my need for it. By evidence based, I mean information derived from a rigorous method of screening all available research for validity to my question. I found that positive answers were helpful (such as antioestrogen drugs are likely to work), but so too were negative ones (we don't yet know the effects of chemotherapy on cognition) as they enabled me to make honest decisions and to take into account other, more certain considerations."

Crislip M. Flu vaccine efficacy.


An entertaining and interesting debate about the efficacy of the flu vaccines, with input from both supporters and detractors.

Bland JM, Altman DG. Comparisons within randomised groups can be very misleading. BMJ 2011;342:d561.


This paper nicely explains, by means of a published example and a simulation, how RCTs that report significance of changes from baseline within groups should not be interpreted as a valid comparison between groups.

Dawson L, Zarin DA, Emanuel EJ, et al. Considering usual medical care in clinical trial design. PLoS Med 6:e1000111.


Describes some of the considerations in having a "usual care" arm in clinical trials.  This is an overview article, and discusses the issue generally. However, it describes specific case examples to illustrate its points.

Hawe P, Shiell A, Riley T. Complex interventions: how "out of control" can a randomised controlled trial be?  BMJ 328:1561.


Easy to read article on a conceptually difficult topic. Imagine this as a good starting point if you are interested in designing, interpreting, or even learning more about trials of complex interventions.

Spruance SL, Reid JE, Grace M, et al. Hazard ratio in clinical trials. Antimicrob Agents Chemother 2004;48:2787-2792.


This paper uses examples of reporting in RCTs and a conversation with a patient to nicely explain the judicious use and interpretation of hazard ratios.

Grahame-Smith D. Evidence-based medicine: challenging the orthodoxy. J R Soc Med 1998;91(suppl 35):7-11.


Opinion piece, which was published ~13 years ago.  However, I like the example of polypharmacy and comorbidities in an elderly lady presented, and reminder about the appropriateness of direct extrapolation of evidence to such a complex case.