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Another book on evidence-based medicine in primary care! I wonder why? The ostensible reason is found on the first page of chapter 1: “to catalyse primary care staff into considering, and hopefully adopting, this approach. …” So this book has been designed to get those of us in general practice to DO the evidence thing. No. The real reason that this book has been written is found in the section called, rather mysteriously (especially to those of us less than intimately acquainted with the British National Health Service), “Evidence-based primary care commissioning and prescribing” that has yet to cross the Atlantic (let alone the Pacific!). Commissioning refers to the placing of health budgeting in the hands of those working in primary care in the UK. The enormity of this revolution has left the rest of us in the world breathless. Since its inception in 1990, commissioning has been expanded from being voluntary and practice based to compulsory and based on larger units of primary care practices called “primary care groups” (PCGs). Clearly, PCGs will have to learn to deal with evidence if they are going to make good decisions about healthcare expenditure.
The question is: does the book enable primary care workers to do commissioning sensibly? Does it encourage or even stimulate primary care teams to adopt an evidence-based healthcare stance? Mmmm. Let us see.
The book is divided into 3 sections: general issues (with chapters on what evidence-based medicine is, how to keep up with reading, guidelines, and getting patients and consumers involved); commissioning; and finally “evidence-based primary care in practice,” which is a section devoted to several common problems with worked up examples. Sprinkled among all these topics are several useful bits and pieces. For example, a 15 page chapter providing a crash course in statistics. It leads us at a breathtaking pace through odds ratios, absolute risk reductions, confidence intervals, numbers needed to treat, and funnel and L'Abbé plots amongst others. I wonder if people in the healthcare team who started off naive about this stuff would be much the wiser after reading such curt explanations. Even careful face to face teaching in Masters of Public Health courses leaves many people in too vague a state to be able to use these concepts with any confidence. Moreover, Gibbs (the statistician who wrote this statistics section) packs in stuff outside his area of expertise, such as efficient searching techniques. The crash course in health economics (chapter 13) is only 10 pages and merely scratches the surface of the subject. However, the examples in the subsequent chapter on cardiovascular screening were helpful, showing how one can estimate the effects of such interventions in the primary care workforce, and balance that with the estimate of health benefits.
Unfortunately, the section with clinical examples seems to have failed not just my ideals of evidence-based health care but the editor's as well! Some of the topics include sore throat, and what looked at first like an interesting diagnostic piece on headache. However, these sections never delivered what they promised. Too many of the discussions relied on guidelines or primary randomised trials. Why were no references to the Cochrane review of antibiotics for sore throat included? Why were no answerable questions asked of headache — that might change practice? (Instead, we are offered a consensus list of diagnostic criteria, sniff.) This is not how I see evidence-based health care changing the way we think about caring for patients.
Another disappointment was Gabbay's advice on keeping up with reading. No mention of the abstract journal Evidence-Based Medicine (or Evidence-Based Nursing, Evidence-Based Mental Health, or Evidence-Based Health Policy). Oh dear. Surely it is sensible to have a group of clinicians around the world sifting through what we might find useful, and having it sorted by quality too?
So, sorry folks. I can't see who exactly would find this a useful book other than people like me, watching with interest to see how the UK's National Health Service will expect their PCGs to dish out the health dough sensibly. I doubt any member of the healthcare team, clipping on the weighted belt of PCG responsibilities, would feel confident diving into the commissioning deep end with only these 300-odd pages to keep them afloat.
Quality of information: ★★☆☆☆
Clinical usefulness: ★☆☆☆☆
Chris Del Mar has several conflicts of interest; most relevant is his Cochrane review on antibiotics for sore throat and Coordinating Editorship of the Acute Respiratory Infections Cochrane Collaborative Review Group.
The Evidence-Based Primary Care Handbook can be purchased online at http://www.rsm.ac.uk/pub/bkgabbay.htm for £21.50.
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