How to practise evidence-based surgery

Abstract Every year an estimated 234 million major surgical procedures are undertaken worldwide. In 2009–10, 4.8 million hospital admissions involved surgical input in England alone and around four in five adults are likely to have an operation in their lifetime. Despite these enormous numbers, objective evidence for the indications and benefits (or otherwise) of surgical procedures is often lacking. Lack of robust research into surgical disease and treatments has been criticized, and less than 2% of national funding for health research involves surgical projects. This seems surprising, as inappropriate surgical treatments can be hazardous for the patient and costly to the healthcare system. The demand for evidence-based clinical practice is increasing, driven by public and professional expectations. The scarcity of high-quality studies across many different fields of surgery has led to ambiguity in the management of many common surgical conditions, with widely varying clinical outcomes in different geographical areas. Surgical treatments are costly and need to be justified, not only on clinical benefit, but on their cost effectiveness compared to other treatments. This article outlines the various approaches that have been adopted to evaluate evidence of benefit for surgical treatments, and their application in a clinical setting. The components of evidence-based medicine and the GRADE method of evaluating quality of evidence are explored. The importance of taking into consideration cost-effectiveness and patient attitudes to treatment is also discussed.