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Scientific Evidence-Based Foot and Ankle Care
In this chapter a description of evidence-based foot and ankle care will be described that is no different than evidence-based medicine (EBM) care other than being focused on orthopedic foot and ankle care. First and foremost, it is important for health care providers to have a comprehensive understanding of what scientific evidence-based (SEB) care is. Next, a detailed description of how to practice SEB care using modern epidemiology techniques will be provided. This will include how to use the results of systematic reviews of current literature to provide practical SEB recommendations for patient care. Last, we will explore the importance and future of SEB care and why all health care providers should strive to provide SEB patient care.
What is scientific evidence-based medicine?
EBM is the conscientious, explicit, judicious, and reasonable use of modern, best available research-based clinical studies to assist health care professionals in making decisions about the care of individual patients. EBM integrates clinical experience patient values with the best available research information. It is important to understand that if one is to practice EBM this will involve the use of best available evidence, and this does not necessarily mean that all clinical decisions will be made with the use of high-quality evidence.
Unfortunately, for many clinical care decisions there is a paucity of high-quality evidence. Simply put, not all clinical decisions can be made using the highest quality research study or a meta-analysis of level 1 randomized control trials (RCT) because these studies do not exist for most clinical care entities. This may be due to the limitations of RCTs including high cost in terms of time and money, problems with generalizability (participants that volunteer to participate might not be representative of the population being studied) and loss to follow-up. Regardless, when health care professionals are practicing EBM care, they must follow scientific principals and use the best available evidence. This would dictate that if there were low-quality and high-quality studies available, then scientific principals would suggest that a higher quality study is the best available evidence and must supersede the use of a lower quality study. Further, common sense coupled with the use of clinical experience, patient values, and resource considerations may also need to be considered when practicing EBM care.
From this point onward the term scientific evidence-based (SEB) care will be used to replace the term EBM care. The term scientific may seem like a redundant detail, but many have learned from the global Covid-19 pandemic that some individuals present evidence that is not scientific and as a result can do harm when providing care. As such, all health care providers should aspire to use SEB care for their patients.
How to practice scientific evidence-based medicine
The practice of SEB care is complex, but considering limited, well-defined steps will make the process easier. In this chapter we describe the practice of SEB care in five steps ( Fig. 4-1 ):
- 1.
Ask a clinical question.
- 2.
Acquire the peer-reviewed published literature that address the clinical question.
- 3.
Assess the quality of each relevant publication assembled using scientific methodologies.
- 4.
Summarize the literature to provide a consensus and treatment recommendation.
- 5.
Rate your performance.
Ask a Clinical Question
The practice of SEB care begins with formulating a clinical question. The clinical care question may be straightforward and often arises from a clinical scenario. As an example, one could consider a patient who suffers an Achilles tendon rupture, providing an example of a clinical care question for treatment. Simply put, the question may begin as “What method of treatment is best for Achilles’ tendon ruptures?” This clinical question may seem simple, but it is broad given it includes the term “best” with no outcome measure defined. As such it is important to formulate a more precise clinical question by including the outcome measure of importance.
There may be more than one outcome measure, and the best treatment may vary depending on the outcome measure selected. For example, it is likely that an SEB review will obviously provide results that suggest nonoperative treatment of a subcutaneous midsubstance rupture of the Achilles tendon is best if the outcome of interest is infection. However, it may be less obvious whether open operative treatment or nonoperative treatment using functional rehabilitation is best to prevent rerupture as the outcome of interest. In summary, the formulation of an SEB clinical care question must be precise and will often arise directly from a clinical care scenario and desired outcome.
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