Home' Australian Pharmacist : Australian Pharmacist October 2012 Contents 804 Australian Pharmacist October 2012 I ©Pharmaceutical Society of Australia Ltd.
Continuing Professional Development
SUPPORTING PHARMACY PRACTICE
evidence that will allow us to make the
best patient centred decisions. So to help
us interpret this information there are ve
key steps in the EBM process.
While these steps (1--5) can be applied
to answer a question for patients in
practice, they can also be used (steps 1,
3--5) to evaluate a clinical paper for its
appropriateness (e.g. where step 1 is the
aim of the clinical paper or the 'question'
it is addressing, step 3 is the evaluation
of the paper, step 4 is the applicability
of that paper to your patient or clinical
situation and step 5 is your re ection on
Formulate your need for information (about
prevention, diagnosis, treatment etc.) into
an answerable question.
It is important to break the question
down into its fundamental parts to
allow you to assess what will be the best
evidence. Most clinical questions can be
divided into three parts.
1. The population: who are the relevant
2. The intervention or exposure: e.g. drug,
3. The outcome: what are the patient-
relevant consequences of the exposure
in which we are interested?
Example: A 78-year-old woman with
non-insulin-dependent diabetes mellitus
(NIDDM) and hypertension presents with
atrial brillation (AF) not currently on an
antithrombotic therapy -- what would be
the best choice for stroke prevention?
1. The population: >75 years, female, AF,
2. The intervention or exposure:
3. The outcome: stroke prevention,
adverse e ects of therapy?
Track down the best evidence with which to
answer the question.
Ask yourself: What is the problem (does
it have a measurable outcome e.g. blood
concentration), how frequently does it
occur, does my patient have the problem,
who gets the problem, how can you
So where do we nd 'current
With so much information out
there, where do we look to nd the
• Textbooks -- Unfortunately, a signi cant
amount of the content of textbooks is
out of date by the time it reaches our
bookshelves. Things change quickly in
the medical world and for many books
it is often more than a year between
when it is written and when it hits the
stores. And, it is often the case that
the 'most recent edition' of a text is
actually a number of years old. So to
make it in the modern era a text needs
to be reviewed regularly (at least once
a year), should be heavily referenced
with evidence in support of statements
selected using he principles of EBM.
• Electronic journals -- You can subscribe
to electronic journals of interest to
you (which can be expensive) or a
better ways to keep up-to-date with
'electronic' journals is through alerts
(contents pages for journals of interest,
British Medical Journal or Medical
Journal of Australia updates) and other
resources like evidence databases
and journals. These are an important
addition to our searchable databases
and texts and are 'alert' services that
notify us when there are important new
studies on topics of interest to us.
• Invest in evidence databases --
A signi cant number of electronic
evidence databases are now available.
The best of these is: Evidence based
medicine reviews (EBMR) produced by
Ovid technologies (www.ovid.com).
EBMR combines several electronic
databases including the Cochrane
database of systematic reviews and
Medline among others. The value of
EBMR is the ability to link information
from general databases to evidence-
based services, which assist in
presenting the information according
to the evidence principles.
• Invest in a library subscription -- Many
university libraries (in particular)
o er relatively inexpensive yearly
subscriptions. These libraries have
access to thousands of online medical
journals and databases including the
Cochrane library and Medline to name
a few. It is the best way to have the
most up-to-date range of resources
available at your ngertips.
• Clinical decision support systems
If these systems are based on current
best evidence they can provide valuable
support to clinical decision making and
improve our patient care. Only a few of
these are available at this stage. However,
with advancing technology they will
become more common in the future.
Critically appraise the evidence for its
validity (closeness to the truth), impact (size
of the effect) and applicability (usefulness
to your clinical practice).
'It is important to
break the question
down into its
fundamental parts to
allow you to assess
what will be the best
I Strong evidence from at least
one systematic review of multiple
II Strong evidence from at least one
properly designed randomised
controlled trial of appropriate size.
III Evidence from well-designed trials
such as non-randomised trials,
cohort studies, time-series or
matched case-controlled studies.
IV Evidence from well-designed
non-experimental studies from
more than one centre or research
V Opinions of respected authorities,
based on clinical evidence,
descriptive studies or reports of
Table 1: Levels of evidence:
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