Evidence‐based medicine and clinical audit: what progress in equine practice?

It is over five years since we published editorial leaders in Equine Veterinary Education on the subjects of evidence-based medicine and clinical audit (Rossdale et al. 2000; Mair 2001). It seems timely, therefore, to readdress these topics and consider whether they will ever achieve the importance and relevance in equine practice that they have achieved in human healthcare. Evidence-based medicine (EBM) has been defined as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best external clinical evidence from systematic research (Sackett et al. 1996). The concept of EBM was introduced in the 19th century, but only really flourished in the last few decades of the 20th century (Rigby and Michaels 2005). In mid-19th century Paris, Pierre-Charles-Alexander Louis used statistics to measure the effectiveness of bloodletting, the results of which helped put an end to the practice of leeching. At the end of the 19th century Ernest A. Codman, an orthopaedic surgeon working in Massachusetts, developed his ‘End Result Idea’, a notion that all hospitals should follow up every patient it treats “long enough to determine whether or not its treatment is successful, and if not, why not?” in order to prevent similar failures in the future (Kaska and Weinstein 1998). In the UK, one of the most important early advocates of EBM was Archie Cochrane, who conducted trials in prisoner-of-war camps on the use of yeast supplements to treat nutritional oedema. In 1972 he published his book Effectiveness and Efficiency. He advocated the use of the randomised controlled trial (RCT) as the gold standard in the research of all medical treatment, and, where possible, systematic reviews of these trials. One of the first systematic reviews of RCTs was of the use of corticosteroid therapy to improve lung function in threatened premature birth. Although RCTs had been conducted in this area, the true conclusions of the results were not clear from the individual studies, but became clear with the systematic review. The review showed that corticosteroids (an inexpensive and readily available therapy) reduced the risk of these babies dying from complications of immaturity by 30–50% (Anon 1999). In 1992, as part of the UK National Health Service (NHS) research and development programme, the Cochrane Collaboration was established. In 1995, the first centre for EBM in the UK was established at the Nuffield Department of Clinical Medicine, University of Oxford. The main driving force behind this centre was David Sackett, who had moved to a new Chair in Clinical Epidemiology in 1994 from McMaster University in Canada, where he had pioneered self-directed teaching for medical students. From these roots, interest in EBM has exploded across the world. EBM is not limited to hospital-based medicine, but is increasingly being practised in nursing, general practice and dentistry. The veterinary profession, in comparison to the professions servicing human healthcare, is very small, and opportunities to practice EBM are therefore restricted. However, there is an increasing interest in veterinary EBM, including within equine practice, and it is expected that the concept will evolve and expand in future years. While it is universally acknowledged that clinical experience is of paramount importance, the rapidly changing world of medicine and veterinary science means that clinicians must keep abreast of new advances and, where appropriate, integrate research findings into everyday clinical practice. Neither research nor clinical experience alone is enough to ensure high-quality patient care; the two must complement each other. In order to practice EBM, 5 steps are needed: