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Bringing the best evidence to the point of care 

Bringing the best evidence to the point of care

Chapter:
Bringing the best evidence to the point of care
Author(s):

Paul P. Glasziou

DOI:
10.1093/med/9780199204854.003.020301
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date: 23 April 2017

Neither our memories nor our textbooks are complete and up to date with all the research relevant to the patients we will see today. The scattering of necessary research across a vast ocean of literature makes it inaccessible at the point of clinical decision. The consequences for patient care have given rise to the discipline of evidence-based medicine (EBM), whose two central concerns are with the quality of research evidence and with its appropriate usage in clinical care.

How can we keep abreast of new developments or fill gaps in our knowledge that we identify during our day-to-day clinical practices? Evidence suggests that the billions of pounds invested yearly in traditional continuing medical education does not change clinical behaviour. Part of the problem is due to not knowing, and part is due to not doing.

Not knowing

This arises from information overload, e.g. over 1500 studies and 55 randomized trials are added to Medline each day, hence filtering for the best research is a central concern of EBM. The key initial method is to employ a ‘hierarchy of evidence’ to identify the likely best research: e.g. if we are interested in the effects of a treatment, randomized controlled trials (RCTs) are usually the ideal study; but if no RCTs exist, we then go to the next level of evidence, and so on. This is a first step only: we then need to critically appraise any evidence found for its validity and the sizes of any effects.

Not doing

To use EBM in clinical practice we need to (1) keep abreast of major new studies that should alter our clinical practice; and (2) formulate and answer clinical questions as they arise with our patients—instead of trying to keep up to date with all areas of clinical practice, hoping that we have read and remembered the correct articles when we need to apply them, we shift focus to answering questions as they arise. The steps in answering clinical questions are: (1) formulating an answerable question; (2) formulating an information gathering strategy; (3) assessing the quality and relevance of the information retrieved; and (4) applying the results to our patient. Undergraduate and postgraduate students should be skilled in each of these steps, and use them in their ongoing medical practice.

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