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Translation of Evidence Into Clinical Practice.

2016 by the National Kidney Foundation, Inc. All rights reserved. 1548-5595/$36.00 http://dx.doi.org/10.1053/j.ackd.2016.12.002 E medicine (EBM) emerges from the belief that delivery of care to patients will be more effective and efficient if decisions are based, as much as possible, on unbiased robust evidence regarding prognosis, etiology, diagnosis, and therapy/prevention. Although acknowledging a degree of uncertainty in every clinical decision, EBM has always challenged practitioners to pursue evidence to reduce uncertainty as much as possible. Application of only the most rigorous evidence can minimize the uncertainly inherent in medical decisions. Acknowledging uncertainty is uncomfortable for many practitioners and consumers of medical care where absolute certainty has always been valued, rewarded, and even expected. In this context, those practitioners or patients who require certainty may view EBM as a failed framework precisely because a robust evaluation of the evidence finds many questions that are imperfectly or incompletely answered. Rather than a failure, EBM emphasizes that when the evidence is incomplete, any final decisions about clinical care should reflect the patient’s preferences and goals. A fresh look at the wide scope of evidence that might inform patients’ decisions, as in this issue of Advances in Chronic Kidney Disease, allows one to appreciate fully both the potential of best evidence to improve care and to recognize the limitations of this corpus of evidence when exploited to incentivize improvements in specific aspect of the delivery of care by the community. When considering the promise and pitfalls of translating best evidence from clinical studies into the clinical practice of nephrology at the bedside, it is informative to begin with a case that exposes some of the challenges and contractions inherent in the EBM approach in a patientcentered care clinical environment. Consider Ms. R, a 74-year-old woman with ESRD secondary to hypertension who receives in-center hemodialysis thrice weekly. Her recent Kt/Vas a measure of dialysis adequacy is below the target value for the dialysis provider, and thus, an increase in her time on dialysis is ordered. In an effort to implement patient-centered care, Ms. R is informed of the order and she objects to an increase in her prescribed time on dialysis. In attempting to inform Ms. R regarding the implications of her care decision, her nephrologist indicates that the increased time is mandated by the “regulatory” authorities and that the evidence demonstrates that she will not do well with a shorter time on dialysis. Ms. R wishes to make the choice about her dialysis time; she wants to know how likely is it she will not do “well” and how this decision will impact her quality of life and health status. Although the clinician states that the ordered change is based on evidence, the patient remains to be convinced. How does one effectively translate the “evidence” both to inform our recommendations and the patient’s decisions about their care? How does one best acknowledge uncertainty in the evidence without communicating a nihilistic view of evidence-driven decision making?