PTJ Helps Clinicians Link Evidence to Patient Care

Have you ever had a patient with an unusual problem—or a typical problem that presents in an unusual way? Do patients ever ask you questions about an intervention based on information that they googled on the Internet? Do your students ask questions about the effectiveness of one treatment approach over another? If you’ve answered yes to one or more of these questions, you might have found yourself wishing that you better understood how to find and interpret evidence about the usefulness of one intervention compared to another or about the value of a particular diagnostic finding in determining the best plan of care. As a practitioner, you have to make many clinical decisions in the course of a day, often without adequate time or access to the best evidence. And even when some evidence is available, there are many factors that can affect clinical decisions, such as patient circumstances and preferences and clinician experience and education.¹

What do you do when there is uncertainty about the optimal management of a patient? You might resolve to do a quick search of the literature before the patient returns for the next visit, but good searches take time, something you don’t have. Or maybe you are able to carve out time for a search and actually turn up a seemingly useful study—only to find that it doesn’t apply very well to your patient after all or that the conclusions were equivocal anyway. In a survey of physical therapists published in 2003, the majority agreed that using evidence in practice was necessary and that use of evidence improved the quality of patient care and decision making.² At the same time, they identified insufficient time as one of the top 3 barriers to using evidence in their practice.

Because evidence is cumulative—and because it is rare for a single study, no matter how well it's conducted, to provide definitive evidence—certainty in clinical decision making may be impossible. So, one approach for the busy clinician is to rely on the results of systematic reviews to inform daily practice. Well-conducted systematic reviews critically examine and summarize the available body of evidence, usually randomized clinical trials, to identify benefits and harms of specific interventions. Other systematic reviews may identify optimal prognostic strategies or provide prognostic estimates for various disorders. By synthesizing results of individual studies, systematic reviews can save the clinician time in searching and reading individual studies, and, because systematic reviews include an assessment of the risk of bias of individual studies, they also can help the clinician judge the validity of research findings.

Systematic reviews are, in themselves, scientific studies. They start with a clinical question; apply a detailed, methodical, and reproducible search of all available literature; and use specific criteria for selection of studies related to the question. In this way, bias is minimized. Selected studies are then critically appraised to determine the quality of their methods, and, in the case of clinical trials, a pooled estimate of the treatment benefit (and harms) may be ascertained, with an indication of the overall strength of the evidence. Systematic reviews can provide implications for clinical practice; however, in many instances, the varying level of both quality and generalizability of the studies in the review precludes definitive recommendations for practice. This is particularly frustrating for clinicians who may be unsure about how best to then use the information in their clinical decision making. Furthermore, treatment decisions for individual patients often require a weighing of the risks and benefits of many possible treatment choices, the preferences of the patient, and the feasibility of the interventions in a particular setting.

And that's why we’re launching <LEAP> Linking Evidence and Practice (page 9). This new series will offer real-life clinical scenarios, provide relevant information from Cochrane systematic reviews and other sources, and discuss the use of this evidence in practice. The Cochrane Collaboration is an international not-for-profit organization that aims to help health care providers, patients, and policy makers make well-informed decisions on health care treatments by synthesizing, maintaining, and disseminating high-quality systematic reviews.³ The collaboration includes 52 Cochrane review groups that comprise people from around the world who share an interest in developing and maintaining systematic reviews relevant to a particular health area. For example, the Cochrane Musculoskeletal Group (CMSG), one of the largest Cochrane review groups, has more than 600 active researchers, health care professionals, and consumer representatives from 26 countries (including 10 developing nations) who conduct and disseminate research on musculoskeletal conditions.⁴ Cochrane reviews are well known for a rigorous and systematic approach to collecting and appraising evidence, and many advances in the provision of health care have come from the efforts of Cochrane Collaboration members.*

The goal of <LEAP> is to provide clinicians with best available evidence for various conditions in a format that is designed to streamline the application of evidence to practice. Over the coming year we will present a variety of clinical cases along with a synthesis of best available evidence for each case. Emphasis usually will be on interventions, but vignettes also may be designed with a focus on diagnosis or prognosis. The primary emphasis with all cases will be to summarize evidence in a way that is clear and accessible. We look forward to your feedback and your suggestions on how this new feature can enhance your care provision of care. Contact us at LEAP{at}apta.org.

• © 2010 American Physical Therapy Association