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Does teaching evidence-based health care to health professionals

improve patient outcomes?
Evidence-based medicine (EBM) is defined as the integration of best research evidence with
clinical expertise and patient values (1). This concept has gained some acceptance in many
academic, clinical and healthcare spheres. It is a self-directed lifelong learning process where
patient care generates the need for current, relevant and valid research-based health care
information. The practice of EBM generally consists of five steps: first, converting information
required into answerable research questions; then, locating the best evidence that answers the
question; critical appraisal of the evidence for its usefulness and validity; application of the
appraisal results in clinical practice; and evaluation of performance (2). In order to allow for an
all-inclusive approach to health care delivery, evidence-based health care (EBHC) has replaced
EBM in most recent literature.
Glasziou et al in 2008 suggested that EBHC become an essential part of the educational
curriculum for all health professionals (3). For effective application of EBHC and consequent
enhancement in health care quality, learning of research principles as well as application of an
evidence-based approach are essential (3). Teaching EBHC to health professionals is expected
to increase EBHC knowledge, attitude, skills and practice and ultimately result in improving
patient outcomes.
Current evidence lacks evaluation of EBHC training on patient outcomes. An overview of
systematic reviews published recently revealed the range of outcomes assessed in many
systematic reviews included EBHC knowledge, skills, attitudes and behavior with a focus on
critical appraisal skills (4). Although EBHC training has been shown to increase appropriate
treatment (5), this evidence is not from a randomized trial but a before-after study. This
weakens the causal interpretations that can be drawn from the study.
Evaluating the effect of teaching EBHC to health professionals on patient outcomes is fraught
with challenges. These are similar to those encountered when undertaking patient outcomes
research in medical education. Some of these limitations will be covered in the succeeding
This describes a situation where the impact of the education of a health professional e.g.,
medical doctor is gradually reduced as it gets filtered through other members of the healthcare
team such as nurses, pharmacists and physiotherapists involved in the health provision

pathway (6). Each of these could correct erroneous behaviors of a health professional, or
prevent appropriate behaviors from resulting in significant appreciable patient outcome. In the
end, these factors dilute the healthcare professionals actions (7) and weaken the effect of the
teaching activities.
Inadequate Sample Size
Medical education research studies that evaluate patient outcomes are often under-powered
due to inadequate sample size. As a result of imperfect measurements and diluted effects, what
would be required is an intervention that has a large effect size or a very large sample size.
Short of these, any findings from these studies will most likely not be statistically significant.
Establishing a causal link
It has been shown that studies which use patient outcomes often have a lot of bias associated
with them and have poor generalizability (8). As a result, limited inferences and conclusions can
be drawn from these studies. Most commonly employed study designs in medical education
research using patient outcomes include cross-sectional and cohort designs. These types of
study designs typically do not facilitate the establishment of a strong causal link between the
education intervention and patient outcomes as randomized studies would (8).
Selection of potentially biased outcomes
This occurs when the patient outcomes selected by the investigators do not fully reflect the
field of interest. Many important patient outcomes are not easily measured (9). This results in
the reporting of outcomes that are more easily measured and not outcomes that best reflect
the goals of the medical educational curriculum. To mitigate against this, some sections have
called for linking important patient outcomes with more accessible (surrogate) outcomes (6).
Because bridging an educational activity causally to important patient outcomes through a
single link can be challenging, it has been suggested that two or more links be used (6). For
instance, demonstrating that improvement in critical appraisal skills of an oncologist is
associated with longer survival in cancer patients implies that critical appraisal skills could be
used in successive research as surrogate outcomes. The use of surrogate outcomes is not
without its challenges (10). The underlying principle is that there must be a strong correlation
between the surrogate outcome chosen and the patient outcome.


Teaching EBHC to the 21
century healthcare professional is non-negotiable. The speed of the
increase in knowledge has made the acquisition of EBHC skills as essential as the basic clinical
skills themselves. The ultimate goal being the improvement of patient outcomes such as longer
survival, shorter duration of illness, reduced incidence of disease, etc. However, establishing a
relationship between the teaching of EBHC and these important patient outcomes has proven
difficult to do. Challenges include dilution by healthcare provision pathways, inadequate
powering of studies, as well as failure to establish a causal link and potential bias in the
selection of outcomes (6). Overcoming these challenges requires the development of novel
study design methods which take these factors into account with or without the use of
surrogate outcomes, randomized studies, larger sample size or intervention effect size and
adjusting for the confounding effects of other factors involved in the healthcare provision
pathway (11). Establishing a strong causal relationship between teaching EBHC to health
professionals and improved patient outcomes will result in increased funding and acceptance of
these educational activities in many spheres of the academic, clinical, and healthcare


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