Larson E B
University of Washington Medical Center, Seattle 98195, USA.
Jt Comm J Qual Improv. 1999 Sep;25(9):480-5. doi: 10.1016/s1070-3241(16)30462-x.
Evidence-based medicine (EBM) and practice guidelines have been embraced by increasing numbers of scholars, administrators, and medical journalists as an intellectually attractive solution to the dilemma of improving health care quality while reducing costs. However, certain factors have thus far limited the role that EBM might play in resolving cost-quality trade-offs.
Beyond the quality of the guideline and the evidence base itself, critical factors for success include local clinician involvement, a unified or closed medical staff, protocols that minimize use of clinical judgment and that call for involvement of so-called physician extenders (such as nurse practitioners and physician assistants), and financial incentive. TROUBLESOME ISSUES RELATED TO COST-QUALITY TRADE-OFFS: Rationing presents many dilemmas, but for physicians one critical problem is determining what is the physician's responsibility. Is the physician to be the patient's advocate, or should the physician be the advocate of all patients (the patients' advocate)? How do we get physicians out of potentially conflicted roles? EBM guidelines are needed to help minimize the number of instances physicians are asked to ration care at the bedside. If the public can decide to share and limit resources--presumably based on shared priorities--physicians would have a basis to act as advocates for all patients.
Although EBM alone is not a simple solution to the problems of increasing costs and public expectations, it can be an important source of input and information in relating the value of service and medical technology to public priorities.
循证医学（EBM）和实践指南已被越来越多的学者、管理人员和医学记者所接受，成为在提高医疗质量的同时降低成本这一两难困境中颇具吸引力的解决方案。然而，某些因素迄今限制了循证医学在解决成本与质量权衡问题中可能发挥的作用。
除了指南的质量和证据基础本身外，成功的关键因素包括当地临床医生的参与、统一或封闭的医务人员队伍、尽量减少临床判断使用并要求所谓的医师助理（如执业护士和医师助理）参与的方案，以及经济激励。
与成本-质量权衡相关的棘手问题：资源分配带来了许多困境，但对医生来说，一个关键问题是确定医生的责任是什么。医生应该是患者的代言人，还是应该成为所有患者的代言人？我们如何让医生摆脱潜在的冲突角色？需要循证医学指南来尽量减少医生在床边被要求进行资源分配的情况。如果公众能够决定共享和限制资源——大概是基于共同的优先事项——医生将有理由成为所有患者的代言人。
尽管仅靠循证医学并非解决成本增加和公众期望问题的简单办法，但它可以成为将服务价值和医疗技术与公众优先事项联系起来的重要信息和投入来源。
