The benefits of ‘facts first’
Ophthalmology can benefit from more rigorous application of evidence-based medicine that integrates individual clinical expertise with the best available external clinical evidence from systematic research, said Rudy MMA Nuijts MD, PhD, in his Ridley Medal Lecture delivered as part of the Opening Ceremony of the 36th Congress of the ESCRS.
“This principle of the integration of clinical expertise with scientific evidence is very alive and relevant today. We have registries, artificial intelligence and image analysis which will all help us to answer clinical questions more efficiently,” he said.
In a wide-ranging lecture entitled “Facts first”, Prof Nuijts, professor of ophthalmology at the University Eye Clinic Maastricht, The Netherlands, focused on the challenges and benefits of using evidence-based medicine (EBM) to answer key questions in ophthalmic clinical practice.
He noted that decision making in medicine traditionally relied on the opinion of a prominent physician – so-called “eminence-based care”.
“Our training has been rooted in eminence-based decision making based on our clinical experience. However, we need to remember that clinical experience may cynically be described as ‘making the same mistakes with increasing confidence over an impressive number of years’,” said Dr Nuijts.
In part to address this deficiency, EBM came to the fore in the early 1990s and has become a major driving force for many national healthcare organisations, prompting a shift from “trust in experts” to “trust in numbers”, said Dr Nuijts.
EBM advocates the use of up-to-date “best” scientific evidence from healthcare research as the basis for making medical decisions. The quality of evidence used to answer a particular clinical question can be schematically represented by an EBM pyramid, said Prof Nuijts. Systematic reviews and meta-analyses are at the top of the pyramid representing the highest levels of evidence, while expert opinion is at the bottom and therefore regarded as the least influential.
At the heart of EBM is the concept that high-quality scientific research carries most weight, said Prof Nuijts.
“While ophthalmologists might well ask why the EBM pyramid is important or relevant in their day-to-day practice, the answer is that institutions increasingly use the EBM principle to regulate the admission of new products and innovations to the market,” he said.
In the Netherlands, for instance, the primary tasks of the National Health Care Institute are managing the basic healthcare package and encouraging improvements in healthcare quality. It advises the Dutch Minister of Public Health, Welfare and Sport on the content of the basic package and essentially plays the role of package supervisor, explained Prof Nuijts.
“For new proposals they assess whether care fulfils ‘established medical science and medical practice’. So, our regulatory healthcare system is basically asking for ‘facts first’”, he said.
EBM may also prove useful in speeding up the approval process for new devices and drugs. To illustrate how this might work in real terms, Prof Nuijts took the example of four research initiatives taken in recent years to search for evidence for new innovations: toric IOLs, prevention of macular oedema after cataract surgery, long-term endothelial cell loss in phakic IOLs and corneal lamellar surgery.
Rounding off his talk, Prof Nuijts quoted the American psychologist Carl Rogers who said: “The facts are always friendly, every bit of evidence one can acquire, in any area, leads one that much closer to what is true.”