Clinical practice has never been more challenging or more complex. The rise in patient knowledge and expectation, increasing opportunities to improve health outcomes, challenging targets for service delivery and quality, and the continuing growth of evidence based medicine are all contributing factors to this. In addition, over the past decade, the patterns of health delivery in primary care have changed as different professional groups develop their role to encompass work traditionally undertaken by doctors. Nurses and Pharmacists have added delivering chronic illness management, recognising and treating minor ailments, health promotion and illness prevention to their traditional roles, and are increasingly taking responsibility for prescribing clinical interventions.
The best clinical practice combines at least 3 elements: the clinician’s skills and expertise, the patient’s preferences and values, and the knowledge derived from an analysis of the evidence from research. The third part of this triad, evidence, is seen as a critical vehicle for delivering systematic, consistent and optimal levels of care, the best outcomes for patients and the most appropriate use of scarce resources.
Unfortunately, for clinicians in primary care, keeping up with changes in the evidence base is increasingly not feasible. The figures are bewildering; 25,000 journals in print, 8,000 articles published each day, and an estimated 30kg of guidelines published per family doctor per year.
Evidence based practise does not mean simply remembering a relevant study that caught your eye, any more than it means blindly enforcing an evidence based intervention against the wishes of the patient. To determine an evidence based approach one needs to formulate an answerable question, conduct an appropriate search, evaluate and critically appraise the search, then interpret the evidence in order to advise the patient. In the early days of the EBM movement, advocates dreamed of a world where such activity would form a basis for all clinicians’ professional behaviour. More recently, it has been recognised that in most circumstances, clinicians will of necessity need to use an external “secondary” resource - one that provides the evidence pre-filtered, searched, appraised and interpreted.
There are many resources claiming to be evidence based, so the task for the busy clinician is deciding which of these to trust. As a framework for evaluating, the following features should provide a guide:
Transparency: Does the resource provide a guide detailing how it was constructed? Is it sufficient that if you wished you could re-create the data?
Systematic search: Which databases were searched to derive the evidence summaries and recommendations, and when?
Critical Appraisal: Were parameters for filtering and appraising the evidence determined a priori, and are they sufficient to minimise bias?
Results: Are the results of the research concentrating on reporting outcomes that matter to patients, as opposed to quasi-clinical parameters such as laboratory results?
Updating: How often is the content updated, and how quickly does it reflect changes in the evidence?
BMJ Clinical Evidence has been providing systematic reviews of the current evidence since 1999. It now presents what is known about the benefits and harms of over 3000 interventions in about 540 common clinical situations. All reviews are updated every 12 months with a new systematic search. Over one million clinicians worldwide enjoy free access to this resource in paper, online or via PDA, including all those in Scotland and Wales. It is translated into 7 different languages.
In this issue of the NPCA newsletter, we invite you to take advantage of a free six week trial of the BMJ Clinical Evidence website. This will enable you to explore the new features we have introduced since November 2006. These include:
• “Key points” summaries for each review, providing all the basics, and readable within 1-2 minutes
• Drug safety alerts from the 3 major international licensing agencies including the MHRA, EMEA and FDA
• Links within each review to emerging evidence published since the last search, appraised for validity, and reviewed by practising clinicians for importance and relevance.
• Links to validated guidelines produced by NICE, SIGN and other major providers, embedded within each review
• An extended search facility to cover the Cochrane Library and other BMJ journals
• Editorials and news features reporting important EBM developments
Our aim is to provide a one-stop shop for clinicians who wish to use evidence as an aid within the consultation. An independent academic study recently evaluated international EBM resources and rated the BMJ Clinical Evidence website as the best such resource available in the UK. Only the American College of Physician’s PIER scored higher.
Whether you already think you know BMJ Clinical Evidence, from having received the book in the past, or you are interested to find out for yourself, we hope that you will take this opportunity to acquaint or re-acquaint yourself. We will welcome your feedback, and hope that you will choose to subscribe yourself, or persuade your practice to do so on your behalf.
To activate your free trial please go to http://www.clinicalevidence.com/NAPC/
Dr David Tovey
Editorial Director
BMJ Clinical Evidence
