O'Hare Ann M, Rodriguez Rudolph A, Bowling Christopher Barrett
Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, WA, USA Health Services Research and Development Center of Innovation, VA Puget Sound Health Care System, Seattle, WA, USA Department of Medicine, University of Washington, Seattle, WA, USA.
Hospital and Specialty Medicine Service, VA Puget Sound Health Care System, Seattle, WA, USA Department of Medicine, University of Washington, Seattle, WA, USA.
Nephrol Dial Transplant. 2016 Mar;31(3):368-75. doi: 10.1093/ndt/gfv003. Epub 2015 Jan 29.
The last several decades have witnessed the emergence of evidence-based medicine as the dominant paradigm for medical teaching, research and practice. Under an evidence-based approach, populations rather than individuals become the primary focus of investigation. Treatment priorities are largely shaped by the availability, relevance and quality of evidence and study outcomes and results are assumed to have more or less universal significance based on their implications at the population level. However, population-level treatment goals do not always align with what matters the most to individual patients-who may weigh the risks, benefits and harms of recommended treatments quite differently. In this article we describe the rise of evidence-based medicine in historical context. We discuss limitations of this approach for supporting real-world treatment decisions-especially in older adults with confluent comorbidity, functional impairment and/or limited life expectancy-and we describe the emergence of more patient-centered paradigms to address these limitations. We explain how the principles of evidence-based medicine have helped to shape contemporary approaches to defining, classifying and managing patients with chronic kidney disease. We discuss the limitations of this approach and the potential value of a more patient-centered paradigm, with a particular focus on the care of older adults with this condition. We conclude by outlining ways in which the evidence-base might be reconfigured to better support real-world treatment decisions in individual patients and summarize relevant ongoing initiatives.
在过去几十年里，循证医学已成为医学教学、研究和实践的主导模式。在循证医学方法下，群体而非个体成为主要研究对象。治疗重点很大程度上由证据的可获得性、相关性和质量以及研究结果决定，并且基于其在群体层面的意义，结果被认为或多或少具有普遍意义。然而，群体层面的治疗目标并不总是与个体患者最关心的问题一致，个体患者可能对推荐治疗的风险、益处和危害有截然不同的权衡。在本文中，我们将在历史背景下描述循证医学的兴起。我们讨论这种方法在支持实际治疗决策方面的局限性，尤其是在患有多种合并症、功能障碍和/或预期寿命有限的老年人中，并描述为解决这些局限性而出现的更多以患者为中心的模式。我们解释循证医学的原则如何帮助塑造当代定义、分类和管理慢性肾脏病患者的方法。我们讨论这种方法的局限性以及更以患者为中心的模式的潜在价值，特别关注患有这种疾病的老年人的护理。我们通过概述重新构建证据基础以更好地支持个体患者实际治疗决策的方法来得出结论，并总结相关的正在进行的倡议。
