Establishment of strong medical associations that create standards of medical care and monitor

their implementation.
Algorithm of actions
Work in evidence-based medicine consists of four main stages:
• Formulation of a clear clinical problem based on the specifics of the patient.
• Search for literature on the problem.
• Evaluation (critical approach) of research for their validity and usefulness.
• Application of useful findings in clinical practice.

The answer to this problem can be found in monographs, journals, collections of works,
abstracts, general scientific and popular science publications, databases, electronic
publications.
A monograph is one of the main sources of information that can be used to search for
bibliographic references, but the information provided is rapidly becoming obsolete and does
not contain full recommendations for clear, reasonable action.
Journals are the main source of primary scientific information, reflect current trends in science
and practice, but often have highly specialized topics. There are not many interdisciplinary
journals.
Medical journals must be read in order to be aware of their professional field; know how
qualified specialists work with patients, how to use diagnostic methods, know the clinical
features and course of the disease; understand the etiology and pathogenesis of diseases;
distinguish useful treatment from useless and harmful intervention; navigate the reports on the
need, benefits, benefits and cost-effectiveness of treatment and prevention.
Systematic reviews are traditional descriptive reviews, which often contain shifted estimates
of the final results due to the lack of application of the scientific approach. An alternative
approach, which is becoming increasingly popular, is to compile systematic reviews that
include appropriate statistical generalization of facts (meta-analysis). Evidence-based clinical
medicine depends on the availability of qualitative generalizations that can be obtained from
carefully compiled systematic reviews.
Systematic reviews collect, critically evaluate, and summarize the results of primary research
on a particular topic or problem. Approaches that reduce the possibility of systematic and
accidental errors are used in the preparation of systematic reviews. Systematic examinations
help physicians stay up-to-date, despite the huge number of medical publications, and can help
substantiate clinical decisions with research, although they do not in themselves allow
decisions to be made and do not replace clinical experience.
The advantages of systematic reviews are:
• the presence of a total reliable result;
• the ability to identify problems of individual sensitivity;
• promoting the formation of integrated information networks and expanding
professional communication;
• evaluation (critical approach) of research on the validity and benefits; - application of
useful findings in clinical practice.

To select the material and the author, you can evaluate the work and its significance, and for
this use:
• Citation index - a measure of the significance of the scientific work of any scientist or
research team accepted in the scientific world. The value of the citation index is
 determined by the number of references to the publication, or to the author's name in
other sources.
• Hirsh index, or h-index - a scientometric indicator that is a quantitative characteristic
of the productivity of a scientist, group of scientists, scientific organization or the
country as a whole. The mechanism for calculating the Hirsch index is quite simple:
the Hirsch index is equal to N if a scientist (scientific institution) has published N
scientific articles, each of which has been cited at least N times. All other articles were
cited less than N times.
• Impact factor - an indicator of citation of scientific journals, which determines their
informational significance. Today it is recognized that the impact factor of the journal
is one of the formal criteria by which you can compare the level of research in related
fields of knowledge.
• I-10 index is a citation index, which means that a scientist (journal, organization,
country) has published at least 10 papers, each of which has been cited 10 or more
times. The number of works cited less than once can be any.

Scientometric database - bibliographic and abstract database, a tool for tracking citations of
scientific publications. The scientometric database is also a search engine that generates
statistics that characterize the state and dynamics of demand, activity and impact indices of
individual scientists and research organizations. The most relevant are such scientometric
databases as:
• SCOPUS - the largest abstract interdisciplinary scientometric database and a tool for
tracking citations of articles published in scientific journals. Indexes scientific journals,
conference proceedings and serials.
• WEB of SCIENCE - the world's most authoritative analytical and citation database of
journal articles of the Philadelphia Institute of Scientific Information. It contains a
system for correcting the identification of scientists and takes into account all citations
in scientific papers that are placed in it.
• Index Copernicus - an online scientometric database with information about the
authors of publications, research institutions, publications and projects. It has several
performance assessment tools that allow you to track the impact of research papers and
publications, individual scientists or research institutions.
• Google Scholar - a free access search engine that provides full-text search of scientific
publications of all formats and disciplines. The service takes into account the total
number of citations, the total number of cited publications and the Hirsch index.

Meta-analysis
Traditional descriptive analysis of medical information often leads to distortion of information.
An alternative approach, which is becoming increasingly popular, is a systematic analysis with
statistical generalization of data (meta-analysis). Meta-analysis includes determining the main
purpose of the analysis, the choice of methods for evaluating the results, a systematic search
for information, generalization of quantitative information, its analysis using statistical
methods, interpretation of results.
What are the statistical methods and when they are used:
What does a statistical test do?
Statistical tests work by calculating test statistics, a number that describes how the relationship
between the variables in your test differs from the null hypothesis of no relationship. It then
calculates the p-value (probability value). The value of p estimates how likely it is that you will
see the difference described by the test statistics if the null hypothesis of no connection were
true. If the value of the test statistics is more extreme than the statistics calculated by the null
hypothesis, then we can conclude that there is a statistically significant relationship between
the variables of the forecast and the results. If the value of the test statistic is less extreme than
the value calculated from the null hypothesis, then you cannot conclude that there is a
statistically significant relationship between the forecast variables and the results.
Statistical assumptions
Statistical tests make some general assumptions about the data they verify:
• Independence of observations (ie without autocorrelation): The observations / variables
you include in your test are unrelated (for example, multiple measurements of one
subject are not independent, while measurements of several different subjects are
independent).
• Homogeneity of variance: the variance in each group being compared is the same
among all groups. If one group has much more variation than others, it will limit the
effectiveness of the test.
• Data normality: data follow a normal distribution. This assumption applies only to
quantitative data.

If your data do not match the assumptions about the normality or homogeneity of the variance,
you may be able to perform a nonparametric statistical test that allows comparisons to be made
without any assumptions about the distribution of the data.
If your data does not meet the assumption of independence of observations, you can use a test
that takes into account the structure of your data (re-measurement tests or tests that include
blocking variables).
Types of variables
The types of variables you have usually determine what type of statistical test you can use.
Quantitative variables represent the number of things (for example, the number of trees in a
forest). Types of quantitative variables include:
• Continuous (also known as variable ratios): represent measures and can usually be
divided into units of less than one (for example, 0.55 grams)
• Discrete (also integer variables): represent the number and usually cannot be divided
into units less than one (for example, 1 human).

Categorical variables represent the grouping of things (for example, different species of trees
in the forest). Types of categorical variables include:
• Sequential: submit data in order ( ratings).
• Nominal: represent group names (for example, trademarks or species names).
• Binary: represents data with a result of yes / no or 1/0 (for example, win or lose).

Choice of parametric test: regression, comparison or correlation

Parametric tests usually require more stringent requirements than non-parametric ones and are
able to draw stronger conclusions from the data. They can be performed only with data that
meet the general assumptions of statistical tests. The most common types of parametric tests
include regression tests, comparative tests, and correlation tests.
Regression tests
Regression tests are used to check causation. They look for the effect of one or more continuous
variables on another variable.
Comparative tests
Comparative tests look for differences among groups. They can be used to test the effect of a
categorical variable on the average of some other characteristic. T-tests are used when
comparing the means of two groups (for example, the average height of men and women). The
ANOVA and MANOVA tests are used when comparing the performance of more than two
groups (for example, the average height of children, adolescents and adults).
Correlation tests
Correlation tests check whether two variables are related, without suggesting causal
relationships. They can be used to check the automatic correlation of two variables that you
want to use in (for example) a multiple regression test.
Choice of nonparametric test
Nonparametric tests do not make as many assumptions about the data and are useful when one
or more general statistical assumptions are violated. However, the conclusions they draw are
not as strong as in parametric tests.

There are several types of meta-analysis:

• cumulative meta-analysis - allows you to demonstrate the curve of accumulation of
estimates in the process of new evidence;
• prospective meta-analysis - useful not only for summarizing previous clinical trials, but
also for those trials that are planned to be performed in the future. This approach can
be implemented where a network of information exchange and joint programs already
exists. In practice, instead of prospective, hybrid prospective-retrospective meta-
analysis is often used, which combines the obtained results with previously published
ones. This allows the use of general evidence for individuals in each of the group trials,
although they may differ in better planning;
• meta-analysis of individual data - which is based on the study of the results of treatment
of individual patients, in contrast to the literature. This approach is only available to
participants in a clinical trial network who have access to a medical history.

Finding information for meta-analysis requires some experience. In the absence of a systematic
approach, many important studies may not be considered. Even a thorough computer search
does not always reveal the required research due to poor indexing. For this reason, computer
selection should be supplemented by "manual" search of research, study of bibliographies in
articles and inquiries of researchers and drug manufacturers working in the field.
The highest level of reliability is provided by randomized controlled trials, but under certain
conditions, for example, in the analysis of adverse effects, retrospective (case-control) or
prospective studies, ie observational studies, are more informative. However, many analysts
believe that only the results of randomized controlled trials can be used as evidence.
When summarizing data, a critical evaluation of the studies being compared is mandatory.
Sometimes the generalization of the results is impossible due to the small amount of research
material, their incomparability with each other or a similar statement. In some cases, some
fairly reliable tests may differ qualitatively from many others, which does not allow them to be
combined for statistical analysis. In this case, an alternative to meta-analysis may be the
"synthesis of the best evidence", which is used in the absence of reliable research.
In such cases, a thorough analysis of available research is conducted to determine whether the
information obtained is sufficient for conclusions. Next, the findings should be verified in a
randomized controlled trial.
If there are sufficiently homogeneous studies, their statistical combination is justified, which
allows a more objective assessment of the effect. Statistical methods of data aggregation are
numerous and varied, and their choice depends on the characteristics of the available indicators.
There are methods to combine data on survival, dose-response, informativeness of diagnostic
tests.
Meta-analysis is conducted in order to summarize existing information and disseminate it in a
way understandable to readers.
Advantages of meta-analysis
Meta-analysis allows a scientifically sound and reproducible way to summarize information
obtained from different sources, which gives a number of advantages. In particular, it can
combine studies whose data are statistically inaccurate, which will provide a reliable total
result. At generalization the heterogeneity of results which studying of the reasons allows to
reveal other clinical problems can be shown. For example, the effectiveness of treatment
depends on the individual characteristics of the organism. Accordingly, it is possible to predict
the results of therapy in certain groups of patients in the presence of these features and test this
hypothesis in future studies. During the meta-analysis, the authors constantly communicate
with their research colleagues to clarify certain aspects of their published messages or to search
for other research. As a result, information networks are formed, which in the future will
facilitate individual and long-term meta-analysis.

Cochrane databases
In his program book, the famous English epidemiologist Archie Cochran pointed out that
society is in the dark about the true effectiveness of medical interventions. Decisions based on
reliable information are not possible due to the lack of generalized data on the effectiveness of
medical interventions. Cochran wrote: "It is a shame that physicians have not yet created a
system of analytical generalization of all current randomized clinical trials (RCTs) in all
disciplines and specialties with periodic updates."
In 1987, Cochrane conducted the first systematic review of RCTs on pregnancy and perinatal
issues, and invited physicians in other specialties to use this experience. He stressed that
scientific medical examinations should be created on the basis of a systematic collection and
analysis of facts, and then regularly updated with new ones. Without this, it is not possible to
judge the advantages or disadvantages of an intervention, make decisions quickly and maintain
the quality of care at a decent level. In addition, it is difficult to plan new ones without
systematically updating research reviews. Researchers and the organizations that fund them
often do not pay attention to promising topics.
Cochrane's dream of systematic updating reviews, which would cover all relevant tests of
medical interventions, was embodied in the Cochrane Cooperation - an international
organization whose goal is to search for and summarize the most reliable information about the
results of medical interventions. As suggested by Cochran, the methodology for compiling and
updating reviews of controlled trials in obstetrics and perinatology has been taken into account
by the UK National Health Service's Research and Development Program. Funds have been
allocated for the organization of the Cochrane Center to coordinate its efforts, both in the UK
and abroad, as well as to establish and update systematic reviews in all areas of medicine.
Principles of Cochrane Cooperation
In the years that have passed since its establishment, the Cochrane Cooperation has undergone
significant changes, without deviating from the declared tasks and principles. The main task of
this international organization is to create, update and disseminate systematic reviews of the
results of medical interventions, which should facilitate stakeholders in decision-making in
various fields of medicine.
Cochrane Cooperation is based on eight principles:
• the spirit of cooperation;
• enthusiasm of the participants;
• no duplication in the work;
• minimization of prejudices and systematic errors;
• constant updating of data;
• relevance of reviews;
• availability of reviews;
• constant improvement of quality of work.

Systematic reviews - the main result of the Cochrane Cooperation - are regularly published in
electronic form under the name "Cochrane Database of Systematic Reviews" (Cochrane
Database of Systematic Reviews). International problem groups are involved in compiling and
updating the Cochrane Reviews. The group is attended by researchers, doctors, representatives
of consumer organizations - all who are interested in obtaining reliable, up-to-date and relevant
information in the field of prevention, treatment and rehabilitation of various diseases.
The Cochrane Electronic Library consists of four separate databases.
1) The Cochrane database of systematic reviews contains final reviews and review protocols
that are being prepared.
2) The Cochrane Register of Controlled Tests is a bibliographic database of all identified
controlled test publications.
3) The abstract database of reviews on the effectiveness of medical interventions contains
structured abstracts of those systematic reviews that have been critically evaluated by the staff
of the York Center for Compilation and Dissemination of Reviews (UK).
4) The Cochrane database on the methodology of examinations is a bibliography of articles on
methods of synthesis and analysis of clinical trial results.
Cochrane Database of Systematic Reviews
No one owns the exclusive copyright to the systematic reviews contained in the Cochrane
Electronic Library. This allows authors to ensure the widest possible dissemination of the
results of their work.
Cochrane Register of Controlled Tests
The Cochrane Test Trials Register is a bibliographic database of controlled test publications
identified by Cochrane Association members and other organizations. The database creation
process reflects the efforts being made to systematically study journals and other medical
journals around the world to create an internationally universal and unbiased source of data for
systematic reviews. As none of the existing bibliographic databases can be considered
complete, the project is carried out jointly with the US National Library of Medicine (PubMed)
and Reed Elsevier Publishing House, Amsterdam, the Netherlands (published by Embase).
Randomized controlled trials as sources of evidence
Once a high-quality systematic review has been found, which answers the question, RQFs
published after the date of the search information for the review are searched, or three years
before the review is published, if it was not specified.
If systematic reviews are not found, search for RCTs on relevant topics, at any time published
in the Cochrane Electronic Library and in the Best Evidence database, as well as in the last
three years in the Medline and Embase databases.
Step 1. Cochrane Register of Controlled Tests It contains more links than the Medline database.
Step 2. Database on the Best Evidence CD
It contains abstracts of RWCs that have passed quality control, and comments to them.
Step 3. Search for the last three years in Medline and Embase databases.
This search allows you to identify RCTs that are not yet included in the Cochrane Electronic
Library and the Best Evidence database.
Research reports on side effects and complications of interventions can be found in the
Cochrane Electronic Library and in the Best Evidence database. After searching, they go to the
Medline database, using the term "adverse effects" (/ ae) from the Medical Subject Headings
(MeSH) of the National Medical Library of the United States.
When using the term MeSH ae.fs. (adverse effects - floating subheading) reveal all articles,
one or more sections of which are devoted to side effects and complications of interventions.
To narrow the search, these can be combined (the word AND) with other keywords (for
example, systematic review on hypertension, cohort studies on asthma).
A concise guide to evidence-based medicine
Clinical Evidence concise is a regularly updated database of treatments that are widely used in
common diseases. The guide is published twice a year in English by BMJ (Biomedical Journal)
and once in Russian by Mediasphere. The guide briefly presents the current data on medical
and preventive interventions obtained in the process of exhaustive search of medical literature.
Based on these data, interventions are classified into those whose effectiveness or harm has
been proven, expected, not established, or unlikely. The handbook is not a textbook or a clinical
recommendation. It brings together the most reliable of the existing evidence, or states that
there is none or not enough for definitive conclusions.
At the same time, according to the compilers, a number of features make it a unique publication:
• the content of the directory is determined primarily by the clinical issues under
consideration, rather than the availability of data obtained in the process of research on
a particular topic. The preparation of sections does not begin with the search, evaluation
and generalization of existing evidence, but with the formulation of important clinical
questions, which are then answered using reliable information available at the time of
preparation of the next issue;
• The compilers of the handbook identify gaps in clinical data that are important for
clinical practice, but do not try to fill them in on their own. The authors believe that it
will be useful for doctors to know in which cases their uncertainty in their own actions
is not due to gaps in knowledge, but the lack of evidence;
• the directory is updated every 6 months (it is published once a year in Russian); the
electronic version is updated monthly. This allows the reader to regularly receive the
latest information in various fields of medicine.

It should be noted that the compilers of the handbook seek to refrain from any
recommendations. It is believed that a simple summary of existing evidence will ensure their
widespread use. Experience in the development and implementation of clinical guidelines
suggests that it is virtually impossible to provide advice that would be useful in any situation.
Therefore, the approach to the interpretation of existing evidence should not be standard, but
individual, taking into account the specific clinical situation. Based on the materials in the
guide, you can develop clinical guidelines that are used in a particular region (country), and
doctors or patients can form their own opinion about the best interventions. The directory only
contains the existing evidence, the final decision is made by the doctor or patient
independently.

Principles of directory creation

The thematic sections of the handbook contain information obtained in the process of rigorous
selection of reliable data relevant to medical practice.
Choice of main topics. In some sections of the handbook, diseases (conditions) are considered,
which are either the most common in outpatient and inpatient care, or have important clinical
and social significance. When deciding on the choice of topics for the first issues of the
handbook, data on the frequency of referrals, morbidity and mortality in the UK were analyzed;
the advice of general practitioners and relevant patient groups was also taken into account. The
website www.clinicalevidence.com presents a list of sections that will be included in future
issues of the guide.
Choice of clinical issues. The clinical issues addressed in the handbook relate to the advantages
and disadvantages of preventive or medical interventions, with the greatest attention being paid
to clinical outcomes that are crucial for patients.
The selection of issues taking into account the relevance for medical practice was carried out
by consultants and compilers of the section with the active participation of general practitioners
and relevant groups of patients. In each subsequent issue of the handbook, new clinical issues
emerge and existing ones are updated. Readers can suggest new questions by filling out and
submitting a comment and suggestion form on www.clinicalevidence.com, or by contacting
the guide directly.
Search and evaluation of data. The authors find the answer to each question in the process of
searching for relevant information in electronic databases Cochrane Library, Medline,
EMBASE and some others.
Sources of information include: systematic surveys, randomized controlled trials (RCTs), if
necessary, cohort studies, the Internet.

Evidence-based medicine resources

• ACP Journal Club. The Best New Evidence For Patient Care - Summarize the best new
evidence for internal medicine
• American College of Physicians (ACP). Internal Medicine. Doctors for Adults -
National organization of physicians specializing in the prevention, detection and
treatment of diseases in adults
• Australian National Healthand Medical Research Council - Library of Clinical
Recommendations of the Australian National Health Research Council
• Best Evidence - Abstract and full-text database on medicine
• BritishMedicalJournal
• CanadianMedicalAssociation - a database of clinical guidelines developed or approved
by the Canadian Medical Association
• Center Health Evidence - Center for Evidence-Based Medicine, University of Alberta
• Center for Evidence-based Medicine at the University of Oxford
• Clinical Evidence - International database of systematic reviews
• Cochrane Collaboration open learning material for reviewers
• Cochrane Library
• Current Controlled Trials - An international database that combines registers of
randomized controlled trials in various fields of medicine
• eGuidelines - a database of abstracts of clinical recommendations, protocols, standards
and materials for their creation and implementation in medical practice, published in
the journals Guidelines, Guidelinesin Practice, Medendium
• Embase - Bibliographic database
• Evidence Based Medicine. University Library at the University of Illinois at Chicago -
Evidence-Based Medicine Resources at the University of Illinois Library
• Evidence-Based Medicine - a database of specialized information
• Health Canada - Population and Public Health - Database of clinical guidelines of
Canada
• Health Services / Technology Assessment Texts - Science-Based Reviews from the
Agency for Health and Research Quality (AHRQ)
• Informed Health Online. Institute for Quality and Efficiency in Health Care - Medical
Information Network of the Institute for Quality and Efficiency in Health Care
(IQWiG)
• Introduction to Evidence-Based Practice. Duke University Medical Center Library and
the Health Sciences Library at the University of North Carolina - Introduction to
Science-Based Practice
• JAMAevidence - Basic tools for understanding and applying the medical literature and
making clinical diagnoses
• Lamar Soutter Library. University of Massachusetts Medical School - Center of
Evidence-Based Medicine, University of Massachusetts Medical School
• Medscape - A web resource for doctors and other health professionals
• National Guadeline Clearinghouse - A public resource based on actual clinical
guidelines
• National Institute for Clinical Excellence - A database of clinical guidelines developed
by the UK National Health System
• New Zeland Guidelines Group - Clinical guidelines for various health issues
• PRODIGY (Clinical Guidance) - Draft up-to-date clinical guidelines to assist GPs in
making informed decisions
• ScHARR-Lock's Guide to the Evidence - Search engine for retrieving bibliographic
lists of identified reviews and recommendations
• Scottish Intercollegiate Guidelines Network - Compendium of clinical guidelines
developed by the Scottish SIGN Group
• Section on Evidence Based Health Care, The New York Academy of Medicine - New
York Medical Academy Resource Center
• Sheffield Evidence for Effectiveness and Knowledge - Links to various sources of
evidence-based medicine: guides, tests, descriptions of clinical situations, access to
full-text medical journals, etc.
• Suny Downstate Medical Center Evidence Based MedicineTutorial - Suny Downstate
Medical Research Brooklyn Medical Research Library
• Supercourse Epidemiology, the Internet and Global Health - Online courses on
epidemiology and evidence-based medicine
• The Cochrane Collaboration
• The Evidence for Policy and Practice Information and Coordination Center
• The Faculty of Medicine & Dentistry at the Universityof Alberta - Faculty of Medicine
and Dentistry of the University of Alberta in Edmonton
• The KT Clearinghouse. The Canadian Institute of Health Research - Center for
Evidence-Based Medicine, University of Toronto
• The Ministry of Health. New Zealand Guidelines Group - Promoting the Use of
Evidence in Health Care and Disability
• The National Institute for Health and Care Excellence - National Institute for Health
and Clinical Care
• The New England Journal of Medicine
• The University of Sheffield. Evidence Based Information Practice - Electronic database
of resources for science-based medical practice
• TurningResearchIntoPractice - Medical search system with an emphasis on evidence-
based medicine
• University of Alberta Evidence-based Practice Center - Evidence-Based Practice
Center, University of Alberta
• University of Michigan. Department of Pediatrics. Evidence-Based Pediatrics Web Site
- University of Michigan Pediatrics
• University of Southern California. Department of Family Medicine - Department of
Family Medicine, University of Southern California
• UpToDate - Part of WoltersKluwerHelth, a leading provider of information and
business intelligence for students, professionals and institutions in the fields of
medicine, patient care, healthcare and pharmacy
• The School of Evidence-Based Medicine is a resource for Ukrainian doctors, which
combines scientific and practical work, educational activities, creates a platform for the
exchange of experience and professional development.