Editing Evidence-based medicine (section)

== Application of evidence in clinical settings ==
Despite the emphasis on evidence-based medicine, unsafe or ineffective medical practices continue to be applied, because of patient demand for tests or treatments, because of failure to access information about the evidence, or because of the rapid pace of change in the scientific evidence.<ref name="Epstein">{{Cite news|url=https://www.propublica.org/article/when-evidence-says-no-but-doctors-say-yes|title=When Evidence Says No, But Doctors Say Yes| vauthors = Epstein D |date=22 February 2017|publisher=ProPublica|access-date=24 February 2017}}</ref>  For example, between 2003 and 2017, the evidence shifted on hundreds of medical practices, including whether [[hormone replacement therapy]] was safe, whether babies should be given certain vitamins, and whether [[antidepressant drugs]] are effective in people with [[Alzheimer's disease]].<ref>{{cite journal | vauthors = Herrera-Perez D, Haslam A, Crain T, Gill J, Livingston C, Kaestner V, Hayes M, Morgan D, Cifu AS, Prasad V | display-authors = 6 | title = A comprehensive review of randomized clinical trials in three medical journals reveals 396 medical reversals | journal = eLife | volume = 8 | page = e45183 | date = June 2019 | pmid = 31182188 | pmc = 6559784 | doi = 10.7554/eLife.45183 | doi-access = free }}</ref> Even when the evidence unequivocally shows that a treatment is either not safe or not effective, it may take many years for other treatments to be adopted.<ref name="Epstein" />

There are many factors that contribute to lack of uptake or implementation of evidence-based recommendations.<ref>{{cite journal | vauthors = Frantsve-Hawley J, Rindal DB | title = Translational Research: Bringing Science to the Provider Through Guideline Implementation | journal = Dental Clinics of North America | volume = 63 | issue = 1 | pages = 129–144 | date = January 2019 | pmid = 30447788 | doi = 10.1016/j.cden.2018.08.008 | s2cid = 53950224 }}</ref> These include lack of awareness at the individual clinician or patient (micro) level, lack of institutional support at the organisation level (meso) level or higher at the policy (macro) level.<ref>{{cite journal | vauthors = Sharp CA, Swaithes L, Ellis B, Dziedzic K, Walsh N | title = Implementation research: making better use of evidence to improve healthcare | journal = Rheumatology | volume = 59 | issue = 8 | pages = 1799–1801 | date = August 2020 | pmid = 32252071 | doi = 10.1093/rheumatology/keaa088 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Carrier J | title = The challenges of evidence implementation: it's all about the context | journal = JBI Database of Systematic Reviews and Implementation Reports | volume = 15 | issue = 12 | pages = 2830–2831 | date = December 2017 | pmid = 29219863 | doi = 10.11124/JBISRIR-2017-003652 | url = https://orca.cardiff.ac.uk/id/eprint/111395/ }}</ref> In other cases, significant change can require a generation of physicians to [[Retirement|retire]] or die and be replaced by physicians who were trained with more recent evidence.<ref name="Epstein" />

Physicians may also reject evidence that conflicts with their anecdotal experience or because of cognitive biases – for example, a vivid memory of a rare but shocking outcome (the [[availability heuristic]]), such as a patient dying after refusing treatment.<ref name="Epstein" /> They may overtreat to "do something" or to address a patient's emotional needs.<ref name="Epstein" /> They may worry about malpractice charges based on a discrepancy between what the patient expects and what the evidence recommends.<ref name="Epstein" /> They may also overtreat or provide ineffective treatments because the treatment feels biologically plausible.<ref name="Epstein" />

It is the responsibility of those developing clinical guidelines to include an implementation plan to facilitate uptake.<ref name="Loza_2022">{{cite journal | vauthors = Loza E, Carmona L, Woolf A, Fautrel B, Courvoisier DS, Verstappen S, Aarrestad Provan S, Boonen A, Vliet Vlieland T, Marchiori F, Jasinski T, Van der Elst K, Ndosi M, Dziedzic K, Carrasco JM | display-authors = 6 | title = Implementation of recommendations in rheumatic and musculoskeletal diseases: considerations for development and uptake | journal = Annals of the Rheumatic Diseases | volume = 81 | issue = 10 | pages = 1344–1347 | date = October 2022 | pmid = 35961760 | doi = 10.1136/ard-2022-223016 | s2cid = 251540204 | doi-access = free }}</ref> The implementation process will include an implementation plan, analysis of the context, identifying barriers and facilitators and designing the strategies to address them.<ref name="Loza_2022" />