Clinical Evidence

Andrew Polmear

University of Sussex Brighton, UK

The publication of Clinical Evidence is a major event in the process of assisting clinicians in making their practices evidence based. Its aims are precise: to provide evidence to assist clinicians in answering the questions most relevant to clinical practice and to highlight areas where that evidence is lacking. The book does not aim to make recommendations, nor does it judge effectiveness or cost-effectiveness. Both beneficial and harmful effects of therapy are presented, but clinicians are left to translate these effects into an estimate of effectiveness for the individual patient.

View larger version (27K): [in this window] [in a new window]   Clinical Evidence can be purchased online at http://www.evidence.org/ for £55; the contents of the book can also be viewed on this site.

 

An explicit and multilayered approach was used in the systematic retrieval and appraisal of the evidence in this text. Topics were chosen from national data on morbidity and mortality, with advice from clinicians and patient groups. Questions were selected for relevance and formulated by editors and contributors in collaboration with primary care physicians and patients. Contributors searched for the evidence to answer these questions, using, as a minimum, the Cochrane Library, Medline, and EMBASE/Excerpta Medica. Searches initially focused on looking for good quality systematic reviews and, failing this, went on to well designed primary studies. Retrieved articles were appraised by using validated methodologic criteria. Evidence from these articles was assembled, summarised, and reviewed by 4 groups of experts, including clinicians with expertise in clinical epidemiology. Finally, the text was checked against the original studies for accuracy.

The contents of this book are generally organised by clinical area, including infectious diseases; endocrine diseases; mental health; neurological disorders; eye diseases; diseases of the ear, nose, and throat; respiratory diseases; digestive diseases; skin diseases; wounds; musculoskeletal diseases; gynaecologic disorders; urologic disorders; sexual health; breast diseases; child health; and cardiovascular diseases. Each section begins with a list of the questions addressed, some key points, and a list of interventions categorised according to their effectiveness. The focal point of each section is a selection of clinical questions and answers detailed enough to include summary statistics, confidence intervals, and references to the key overviews and primary studies. Treatment options are listed after each clinical question, and the benefits and harms of the intervention are summarised. Details on the benefits and harms are also provided in the text.

The clear layout of this book eases the reader through a complex structure. However, the concise writing makes this no easy read. Even the summaries are too complex for the book to be used during consultation with a patient either in primary care or on a ward round. It is better suited for those moments of reflection when the reader wants to review the management of a particular target disorder.

As yet, the contents of Clinical Evidence are limited, which the editors themselves point out. Despite the rigorous process used to identify topics and questions, there are omissions. For example, depression is included but not anxiety; neck pain but not low back pain. Furthermore, only questions about therapy are included thus far, but questions about diagnosis, prognosis, and aetiology may be addressed in the future. Finally, the evidence presented almost entirely omits questions about the organisation of health care. No doubt these important topics will be covered in future editions (which will be published biannually), but the expansion of the material will create a problem of size. An electronic version is planned for the year 2000 that will solve this problem for some readers but not for all. The present volume, however, has made an excellent start with therapy issues, which is where most clinical interest lies. Few clinicians or health care managers can afford to be without this book.

Methods/Quality of information:

Clinical usefulness:

Clinical Evidence. London: BMJ Publishing Group: Philadelphia: American College of Physicians–American Society Internal Medicine;2000.*

*This review is based on Version 1,june 1999.

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