Evidence-based medicine

Evidence-based medicine in Germany

In contrast to the situation in the United States or Canada, evidence-based medicine in Germany has always been more strongly promoted by the health care policy makers than by doctors. But it now plays an increasingly important role in the standard work of many medical professionals and in health care in Germany.

The concept of evidence-based medicine originated in the English-speaking world and reached Germany in the 1990s. It promotes medicine that no longer takes anything for granted and always demands proof and justification for specific medical interventions. In line with this approach, and because of the resistance it was met with, there followed numerous debates and arguments about what evidence-based medicine could achieve and how the German health care system would have to be changed.

New ideas, new networks

Probably one of the first German-language publications that pointed out these international developments and their significance appeared in 1995 and was written by the social medicine specialist David Klemperer. The new ideas he described were taken up by others working in the fields of research, medical self-regulation and social medicine. In 1998 the Berlin Medical Association and the German Federal Medical Association held a first symposium dedicated to the topic of "evidence-based medicine." The German Network for Evidence-based Medicine (DNEbM) was founded that same year. A working group at first, it has been a non-profit association since 2000. The Network helps to spread and develop the concepts and methods of EbM and patient-focused health care in clinical practice, teaching and research. It also organizes annual conventions and offers training and seminars.

The German Cochrane Centre was founded in Freiburg in 1999. It is a member of the international Cochrane Collaboration and reports on their work, among other things. It also offers training and seminars, and is a first point of contact for anyone in Germany interested in creating systematic reviews.

The other major institutions involved in evidence-based medicine include the German Agency for Quality in Medicine (AQuMed) and the Association of the Scientific Medical Societies in Germany (AWMF). AQuMed, which was founded in 1995, is a scientific institute run by the German Medical Association and the National Association of Statutory Health Insurance Physicians. It supports both of these bodies in issues of quality assurance and plays a major role in the development of guidelines. The guidelines are developed by the various professional associations, and the coordination of their development is one of the tasks the umbrella organization AWMF is responsible for. Guidelines serve as decision aids for doctors and patients. They aim to help ensure that treatment is as good as possible, quality-assured and ideally evidence-based.

Evidence-based health care

Implementing evidence-based health care means applying the principles of evidence-based medicine to all areas of the health care system, including decisions about guiding the health care system as a whole. For example, this would mean that insurers only cover treatments with a proven benefit.

The debate over whether patient care had failed to move with the times also reached German health care institutions in the late 1990s. In 2000 the term "evidence-based guidelines" appeared for the first time in the Social Code Book (SGB) V. In 2001 the "Expert Council for the Assessment of the Development of the Health Care System" described evidence-based medicine as being urgently needed in order to do something about excesses, deficiencies and mistakes in the care and treatment provided within the German health care system. The council's report on "suitability-to-needs and efficiency" recommended implementing the basic principles of evidence-based health care.

The introduction in 2002 of disease management programs (DMPs) for people with chronic diseases was one decision based on their report. DMPs should incorporate the principles of evidence-based medicine. The goal is to achieve systematic and well-coordinated treatment for certain medical conditions in order to enable participants to have a good quality of life.

IQWiG's role

The Institute for Quality and Efficiency in Health Care (IQWiG, Germany) - the publisher of this website - was founded in 2004. It was established primarily by two sections in the German Social Code, Book 5 (SGB V, 139a and 139b) which define the tasks and methods of IQWiG. They state that "the Institute is to ensure that the assessment of medical benefits is to be performed in accordance with the internationally recognized standards of evidence-based medicine."

IQWiG's primary legal mandate is to produce independent, evidence-based reports – for instance, on the effect of medication, non-drug treatments or screening tests. These reports are often used as a basis for decisions by the German Federal Joint Committee (G-BA) concerning health care directives. The G-BA stipulates which medical services are covered by statutory health insurers in Germany. IQWiG is also responsible for providing the general public with easy-to-understand health information about important medical conditions.

So the introduction of evidence-based medicine in Germany was more of a "revolution from the top down." In contrast to the U.S. and Canada, it was more strongly promoted by health care policy makers than by doctors who wanted to improve their own work. But evidence-based medicine has now found its way into the everyday work of many doctors in Germany, for instance in evidence-based directives issued by the G-BA, evidence-based guidelines, and written patient information – or in frank discussions with their patients about the advantages and disadvantages of various treatment options.