European College of Equine Internal Medicine

Evidence-based practice in equine clinic: Much more than evidence-based medicine

This short comment aims to evaluate the instruments used in equine clinical management and to compare with those used in human medicine. The objective is to be able to assess the current state of the matter and propose a practical and effective plan for clinical management in the near future.

State of the art: historical perspective

Evolution in clinical management can be clearly divided into 5 very well differentiated historical phases:

  1. Quality
  2. Protocols
  3. Consensus
  4. Evidence-base medicine
  5. Patient safety

1. Quality

The sixties are characterized by a great evolution in human medicine.  A large number of scientific journals, construction of hospitals and specialties emerge. All this requires control and rules. In accordance with these new needs, "Evaluating of quality of medical care" written by Donabedian is published, which build the pillars of quality, based on three fundamentals: structures, processes and results.

  1. The accreditation of health facility structures must meet essential requirements for their use.
  2. The indicators of processes and results, systematically summarize the monitoring and results of previously agreed processes. There are several organizations that work in quality such as The Joint Commission or European Foundation for Quality Management. Its goal is to obtain professional excellence.

These indicators have been extremely useful for the modernization of the clinic in general, but they cannot be health indicators of quality due to the disparity of criteria and heterogeneity of decisions since in certain circumstances they can be subjective. These drawbacks encouraged the development of a new instrument in the 70s in medicine: the protocols.

2. Protocols

The U.S. Medical Institute publishes " A strategy of evaluating health care ". With this initiative, the IOM promotes the definition of protocols to achieve homologation of clinical work. Among these instruments we can mention algorithms or decision trees and clinical audits. At present the use of algorithms in equine clinic have not been very developed. In general veterinary medicine, attempts have been made to apply clinical audits, but it has not yet been possible to assess their practical usefulness nor have they been widely developed.

3. Consensus

They arise to avoid the disparity of protocols due to their lack of scientific justification and define levels of agreement on controversial issues. Its purpose is to create a new collective opinion.

A group of California researchers publishes "Consensus methods: characteristics and guidelines for uses". There is no doubt that these instruments continue to have great utility in the equine clinic. We can cite for example those carried out by the American and European Colleges of Internal Medicine.

In the nineties, the end of traditional medicine can be delimited to give way to Evidence-Based Medicine, with the incorporation of great scientific information and the use of internet use in the bibliographic search.

4. Evidence-base medicine

In the nineties a team of epidemiologists published "Evidence based in medicine", a methodology that aims to facilitate the arrival of scientific findings to clinical practice. Its actions are mainly randomized clinical trials, meta-analysis, odd-ratio and systematic reviews.

As a result of this dynamic, several institutions appear to help analyze and disseminate such evidence, such as COCHRANE, with more than 30,000 volunteers around the world to evidence systematic reviews and GRADE, which according to experts can be considered the most reliable system to transform scientific evidence into clinical recommendations.

Clinical practice guidelines are systematically developed recommendations that aim to make clinical decisions based on the best available evidence. The AGREE institution is an instrument developed in 2003 with the aim of improving the quality of these clinical guidelines.  The current version is AGRE II. The difference between protocols and clinical guidelines is the degree of evidence. The protocols are elaborated based on corporate criteria while the guidelines are supported through a scale of evidence.

In human medicine, two tools were used to move from theory to practice: trajectories and care routes. In veterinary medicine they were never used because to date, veterinarians have focused on effectiveness unlike clinical guidelines that focused on efficacy.

In veterinary medicine, institutions have already appeared that have made a great effort to bring evidence-based Veterinary Medicine to the level of human medicine, such as RCVS with knowledge summary, SYREAF, the Centre for Evidence-based Veterinary Medicine or Veterinary Guidelines of Washington University, but its use by the wide public is very limited.

Although in recent years a great effort has been made to introduce secondary studies such as CAT and systematic reviews in veterinary scientific journals, it is necessary to cite the great difference of the hierarchy pyramid in human medicine compared to veterinary medicine. In human medicine is more developed the part of secondary research as summary systematic reviews with Meta-analysis and Randomized Clinical Trials and in veterinary the largest part of the publications are research studies, which has greatly limited the development of Clinical Practice Guidelines for lack of high evidence studies.

In human medicine it has been determined that more than 70% of doctors use EBM. Perhaps because the EBM, has not been able to be applicable to the vast majority of equine clinicians. The problem is that to carry out this type of studies in a primary way requires hard work.

5. Patient safety :  Evidence-Based Practice (EPB)

In the 20s the US Institute of Medicine published "to error is human" about unwanted effects and complications caused by medical action, related to the crisis of evidence, where patient safety is increasing its importance. Two are the most important movements on this approach in the clinic, one is Right Care where it corrects the concept of quality of care, conducting a review of practices of low value and on use and misuse of medicines and medical practices. The second movement is called value-based health care. This new concept of modern clinical management emphasizes the experience and involvement of the patient as well as their preferences and a more multidisciplinary teamwork of health workers, where the patient is listened to provide a care service according to their priorities.

All these movements of recent appearance are totally applicable to veterinary medicine and articles have already appeared on these modern concepts of clinical management in veterinary medicine. An example of this concept is the manifesto on better animal health based on evidence, published in September 2020 in the journal Veterinary Record where in 10 points defines all the relevant points of EBP: working in partnership with clients to achieve the best health, making sure that research is relevant or increasing awareness of the value and need for systematic use of the best available evidence when making clinical decisions.

In conclusion, we can define EBP as conscious, explicit and judicious use of the best evidence for decision-making about patient care. In this decision-making, EBP emphasizes communication skills.

Unlike EBM, EBP performs its action in more concise fields of medicine and in more limited areas.  To give an example in human medicine, EBP is performed in pediatrics by the pediatricians’ association of a veterinary country or region.  It is for this reason that the EBP in equine clinic has to be led by the European veterinary colleges and the national associations of equine veterianarians,  taking into account other sectors involved such as farriers and physiotherapists, without forgetting the opinion of the owners of the horses.