Occupational Medicine 2005;55:1–2

doi:10.1093/occmed/kqh118

EDITORIAL
Evidence-based decision making in approach requiring the conscientious (to apply the best
occupational health evidence when possible), judicious (to use recommen-
dation for patients/workers/community), explicit (to
Evidence-based medicine (EBM) is founded on the transparently demonstrate the reliability of each decision)
appealing paradigm of promoting the identification, integration of relevant scientific evidence relating to the
appraisal and application of the best practices in health stakeholders’ needs. This definition does not replace
care, supporting doctors in the decision making process. clinical skills or other abilities, and the experience of
The continuous development of health care presents a professionals, but provides a picture of the relationships

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solid ground for more effective practices; however, among different components of the decision process [8].
research findings in the health services suggest that The health problem is a key factor in the decision
there is a gap between evidence and practice [1]. EBM process. Differing from the EBM model, in the evidence-
has raised awareness among practitioners and decision based occupational health model the problem can involve
makers, but the approach is not followed in everyday a community of workers or an individual. Circumstances
practice for several reasons. These include the complex are another key factor: the problem may be approached
literature organization, its irrelevance to clinical practice, differently in different settings, depending on the different
the difficulty in applying its results to the individual context and time in which it occurs. Unlike the EBM
patient and the barrier to change. As a consequence, model, patients’ preferences should be viewed as the
ineffective practices are performed for several reasons, preferences of the different stakeholders (the employer,
including over-reliance on a surrogate outcome, the love the company management, the representative of the
of a wrong pathophysiological model and the need to do workers, the inspection labour, the trade union and the
something [2]. workers preferences), since interventions cannot be
So far, health service research in occupational health carried out unless the stakeholders’ needs and interests
has not provided relevant information about the appro- are met. In comparison with clinical research, the
priateness of usual practices. However, there is a growing research for evidence in occupational health is different
awareness and pressure that a decision in occupational both in the evidence searching stage (RCT studies are
health practice should be supported by the best available often unavailable) and in the evidence appraisal stage
evidence in order to maximize the outcome. In the past (evidence alone is not always an adequate guide to action
few years, Occupational Medicine has hosted papers and and applicability, and economic evaluation and barriers
editorials dealing with this intriguing topic [3 – 5] to implementation should be considered).
supporting the need to transfer scientific evidence into The stakeholders’ needs can be translated into action
daily practice. However, as for general practitioners, within this framework. This requires starting the tra-
several obstacles exist when approaching problems ditional five-step EBM process [7], to which an
according to the EBM principles: lacking skill in additional step was recently added [9]: (i) transforming
formulating answerable questions, insufficient time the problem into a question; (ii) answering the question
required to find information and scarce capacity of based on the internal evidence (the evidence derived from
integrating evidence to make decisions. knowledge acquired through education and training, and
Like health care professionals, occupational health experience built from daily practice); (iii) finding the
professionals must rely on the best available evidence external evidence (information from scientific literature)
supporting the appropriateness of diagnostic tests and to answer the question; (iv) critically appraising the
preventive or clinical interventions. Therefore, like in external evidence for its validity and usefulness; (v)
health care, scientific literature is a crucial element of the integrating internal and external evidence to answer the
evidence-based decision making process. The appropri- question; and (vi) evaluating the decision.
ateness of the practice is one of the key elements of any The first step consists of converting information
intervention, as was stated 20 years ago by the Inter- needs/problems into questions to be answered. The
national Labour Office [6], who suggested that quality- evidence-based approach guides professionals in struc-
oriented services founded on sound evidence-based turing well-built questions that result in patient/commu-
practice should be supplied. nity-centred answers. Asking the right question is
The principles of EBM can be adapted in occupational difficult, yet fundamental to evidence-based practice or
health practice, whose evidence-based decision process skill. The process begins with a patient question or
can be defined as the current best evidence in making problem. A well-built question usually includes four
decisions [7]. The decision process consists of an components, referred to as the PICO. The acronym

Occupational Medicine, Vol. 55 No. 1

q Society of Occupational Medicine 2005; all rights reserved 1
2 OCCUPATIONAL MEDICINE

PICO identifies the patient/population (P), the interven- both comments and criticisms on this topic, and
tion (I), the condition/comparison/control (C) and submission of problems for which this approach was
the outcome (O). P indicates a worker or a workers’ used. Should the topic raise the interest of occupational
group, I includes the intervention or the practice adopted health professionals, a new peer-reviewed series, ‘evi-
(e.g. medical examination or screening tests, information dence-based occupational health in practice’, could be
to workers), C identifies the condition (e.g. exposure to launched. This series would aim at guiding the decision
chemicals, ergonomic factors or unexpected excess of making process according to the EBM principles largely
health changes) and O represents the outcome (e.g. blood adopted in different medical specialities, thereby helping
lead reduction or reduction of accidents in the population readers to develop skills of using research evidence in their
following the intervention). The four components should practice and making knowledge transfer from research
be integrated in an answerable question, e.g. ‘in a group into practice more effective.

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of operating room workers (P) exposed to anaesthetics
(C), does a training course (I) reduce the levels of urinary Giuliano Franco
anaesthetics at the end of the shiftwork (O)?’ After the Department of Internal Medicine,
second step (answering the question based on the School of Medicine, Largo del Pozzo 71,
evidence acquired from personal knowledge and experi- I-41100 Modena, Italy
ence), the third step involves a well-conducted literature
search for finding the best external evidence. Finding
relevant evidence requires conducting a focused search
(based on the keywords provided by the question) of the References
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