Adapt or die: how the pandemic made the shift from EBM to EBM+ more urgent

Abstract

Evidence-based medicine (EBM’s) traditional methods, especially randomised controlled trials (RCTs) and meta-analyses, along with risk-of-bias tools and checklists, have contributed significantly to the science of COVID-19. But these methods and tools were designed primarily to answer simple, focused questions in a stable context where yesterday’s research can be mapped more or less unproblematically onto today’s clinical and policy questions. They have significant limitations when extended to complex questions about a novel pathogen causing chaos across multiple sectors in a fast-changing global context. Non-pharmaceutical interventions which combine material artefacts, human behaviour, organisational directives, occupational health and safety, and the built environment are a case in point: EBM’s experimental, intervention-focused, checklist-driven, effect-size-oriented and deductive approach has sometimes confused rather than informed debate. While RCTs are important, exclusion of other study designs and evidence sources has been particularly problematic in a context where rapid decision making is needed in order to save lives and protect health. It is time to bring in a wider range of evidence and a more pluralist approach to defining what counts as ‘high-quality’ evidence. We introduce some conceptual tools and quality frameworks from various fields involving what is known as mechanistic research, including complexity science, engineering and the social sciences. We propose that the tools and frameworks of mechanistic evidence, sometimes known as ‘EBM+’ when combined with traditional EBM, might be used to develop and evaluate the interdisciplinary evidence base needed to take us out of this protracted pandemic. Further articles in this series will apply pluralistic methods to specific research questions.

Desperately Seeking Intersectionality in Digital Health Disparity Research: Narrative Review to Inform a Richer Theorization of Multiple Disadvantage

“…In sum, the current literature on digital health disparities is not only sparse but also in need of richer theorization to generate explanations of how different dimensions of disadvantage interact. We have argued elsewhere that the overemphasis in evidence-based medicine on empirical research at the expense of explanatory theory on the causes of phenomena (what some have called EBM+ ) may produce impoverished findings [ 76 ]. This builds on earlier work emphasizing the crucial importance of theory in selecting which hypotheses to test and how when studying disparities [ 77 , 78 ].…”

Guided by the science? Questions for the UK’s covid-19 public inquiry

“…However, evidence is socially constructed and can be highly contested. 12 Different sources, and indeed types, of evidence are given different weight in developing policy: it is important to consider whose science counts, and why. To be useful in informing responses to future pandemics, the inquiry must come to a view about how the scientific evidence figured in decision making, and how approaches to bridging the evidence-to-policy boundary could have been more effective.…”

“…Another challenge will be assessing how the decision making process was informed and influenced. Throughout the pandemic politicians and their scientific advisers insisted that decision making would be “guided by the science.” However, evidence is socially constructed and can be highly contested 12. Different sources, and indeed types, of evidence are given different weight in developing policy: it is important to consider whose science counts, and why.…”

Evidence-based medicine has already adapted and is very much alive

“…Greenhalgh et al 1 argue that the COVID-19 pandemic has uncovered a need for a shift in the evidence-based medicine (EBM) paradigm in which mechanistic evidence is also used as a complementary source for decision-making. Their justification is based on limitations of evidence hierarchies, which prioritise meta-analyses and randomised controlled trials (RCTs) 1 ; and the urgency, threat and complexity of a pandemic. However, in defence of EBM, we present a counter argument.…”