The same combination of clinical experience and EBM skills that enables healthcare professionals to resolve patient-specific pharmacotherapeutic questions also aids healthcare professionals' continued efforts to keep up to date. The process is the same: (a) recognize information needs (the areas of one's practice), (b) identify literature relevant to clinical practice, (c) critically appraise the evidence for validity and usefulness, and (d) devise a mechanism to implement new evidence in daily practice.



(In this usefulness formula, relevance represents patient-oriented evidence that matters and affects healthcare, validity refers to a true estimate of the effect, and work factor describes the effort required to review the information.)

As with human knowledge in general, medical information is growing exponentially. Clinicians have difficulty staying current; a few statistics explain why. The National Library of Medicine contains more than 11 million citations covering nearly 4,500 biomedical journals.52 The number of citations doubled in just six years, from 1995 to 2001. Each year, 10,000 RCTs addressing the impact of healthcare interventions are published. Some influence how clinicians practice, others provide preliminary evidence that is either too early to act on or irrelevant to clinical practice, and others are seriously flawed and should not be implemented. Who has time to read it all and separate the good from the bad? A literature-sorting strategy, using the EBM approach, is one solution.

1. First, the clinician must recognize the areas important in his or her practice (e.g., internal medicine, cardiology, nuclear medicine, nutrition, psychiatry, or pharmacokinetics).

2. Second, scan the literature for clinically relevant studies in that area of interest or practice. These are studies addressing clinical outcomes likely to be relevant to clinical practice and possibly change prescribing behaviors, such as those that report the effect of a pharmacotherapy on quality of life, cost-effectiveness, mortality, or morbidity. In contrast, trials addressing the impact of drug therapy on surrogate end points (e.g., biochemical markers) are most often irrelevant to current clinical practice and rarely would result in a change in practice. When in a “keeping up-to-date mode,” choose the studies reporting clinically relevant outcomes over those with surrogate end points.

3. Third, critically appraise the evidence for validity and usefulness. When addressing therapeutic efficacy, RCTs are considered the “gold standard” and should be preferred over observational studies for most clinical questions. Scan the abstracts of RCTs for obvious design flaws and size of the effect before appraising further.

TABLE 6-7 Evidence-Based Abstraction Services
ACP Journal Club (http://www.acponline.org/journals/acpjc/jcmenu.htm)
Audience: Internal medicine, primary care
Selection criteria: Original articles, systematic reviews, English, adult, clinically relevant with important outcomes, randomized controlled trials for treatment questions
Journals scanned: 26 journals
Bandolier Bandolier - Evidence based thinking about health care
Audience: Internal medicine
Selection criteria: Those that look remotely interesting are read, and those that are both interesting and make sense are summarized
Journals scanned: Each month PubMed and the Cochrane Library are searched for systematic reviews and meta-analyses recently published
Evidence-Based Cardiovascular Medicine Evidence-based Cardiovascular Medicine | 1361-2611 | Elsevier
Audience: Cardiology (adult and pediatric)
Selection criteria: Original articles, English, clinically relevant, adult or pediatric, human, randomized, double-blinded, controlled trials
Journals scanned: 25 journals mostly cardiology specialty journals
Evidence-Based Medicine (Evidence-Based Medicine - BMJ Journals)
Audience: Internal medicine, general and family practice, surgery, psychiatry, pediatrics, and obstetrics and gynecology
Selection criteria: Original articles; Cochrane Reviews; randomized, controlled trial or therapeutic efficacy trial; clinically relevant outcomes; 80% followup
Journals scanned: More than 100 journals
Evidence-Based Mental Health (Evidence-Based Mental Health - BMJ Journals)
Audience: Mental health clinicians
Selection criteria: Original articles; Cochrane Reviews; randomized, controlled trials or therapeutic efficacy trials; clinically relevant outcomes; 80% followup
Journals scanned: Not available
Journal Watch series (NEJM Journal Watch: Summaries of and commentary on original medical and scientific articles from key medical journals)
Audience: General medicine, dermatology, cardiology, psychiatry, women's health, emergency medicine, infectious disease, neurology, gastroenterology (specialty Journal Watch for each audience)
Selection criteria: Not given
Journals scanned: More than 300 journals