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Chiropractic Journal of Australia : CJA June 2013
62 Chiropractic Journal of Australia Volume 43 Number 2 June 2013 Based on this current trend, the use of evidence in clinical practice should be subject to a major overhaul, as well as determining effcacy and practicality for the manual clinical setting. I would respectfully submit that randomised double-blinded placebo controlled studies have been over- emphasised for some time and their relevance needs to be greatly reassessed. There are also varieties of formal evidence hierarchy systems proposed by a number of government bodies aimed at classifying levels of evidence. The lack of consistency in these adds further complications, and confusion for the clinician. Sackett defines evidence-based practice as: "The conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients. ... [It] is not restricted to randomised trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions." 8 This renowned authority effectively highlights one weakness of changing models of EBP – that of change, by stating “current best evidence". For instance, a practitioner may fail to adequately justify his treatment with published Level 1 evidence, only to fnd that the hierarchy of evidence is out of date. Naturally safety considerations are also a primary consideration. But one important factor must be stated; that is, if it is important to listen to a patient at the initial consultation, surely it is just as important to listen to them during, and particularly at the end of it. BACKGROUND Categorisation levels of the best available evidence have changed in recent years. Randomised blinded placebo controlled based studies were once the so-called gold standard, but in recent years they have been overtaken by meta-analysis studies. However, of late, some consider self-assessed patient satisfaction as being more applicable.4,5 In my opinion and after all, the patients’ results and benefts should be one of the key considerations in clinical management and dominate input on outcome studies. Strangely, anecdotal evidence of a negative nature seems to be acceptable, but not to the degree of a case report of a positive nature. In researching this paper, I am surprised at the support in the literature for anecdotal9,10 and empirical evidence and the questioning of the suitability of RCTs in day-to-day clinical practice.11 In 2000, Charlton succinctly expressed support for anecdotal evidence in the Lancet when he stated, "Observations can be criticised for being anecdotal. However, in the search for greater scientifc objectivity, the habit of curiosity, once the very quintessence of medical discovery, may be lost. Anecdotal observations alone cannot be taken to show cause and effect, but they may provide stimuli for potentially important research." 12 Best practice can be a misleading term. It implies that every practitioner should do the same procedure or technique for all the same conditions. This is quite impractical given the options of techniques and many other variables present in health care practices. However, similar conditions are just that, they are only similar, not the same. Patients' responses vary unpredictably, practitioner skills and techniques vary, plus the variations in patients’ ages, body types and socio-economic factors are just a few other considerations. In addition, acceptance of EBP is not universal in practice. One study showed that only 57% (19%-90% compliance) of consultations conformed to best practice guidelines.13 To accept EBP as being limited to conditions for which treatment is supported by a large body of formal evidence – specifcally, randomised controlled clinical trials (RCTs) – seems to lack an understanding of the tenets of EBP. It should not be an unquestioned devotion to the RCTs or fxed-formula health care, but a system of care based on these basic principles: • Use of the best available external clinical evidence derived from systematic research; • Use of the individual doctor's clinical expertise; taking into account the patient's predicaments, rights and preferences in making clinical decisions about his or her health care, • Safety in its efficacy, and finally and very importantly, • Patient satisfaction -- a positive outcome here tends to override or at least have infuence over the previous four criteria.14 The “best available external clinical evidence” is science- based research, particularly patient-centred clinical research. It needs to be the type that evaluates the reliability and validity of diagnostic procedures, the power of prognostic indicators and the effcacy and safety of treatments, as well as the patient's own assessment of their result. (After Perle 14) In a further complication, the US Institute of Medicine reported that it takes an average of 17 years for knowledge from RCTs to be made available to the public.15 Evidence Based Practice is still Evolving Various forms of evidence have been hailed as appropriate for clinical practice over the decades. Doubts have existed and emphasis changed on most of these.16 I would submit however, that they all have a certain justifcation and a role to play in varying degrees. Perhaps the clearest opinion against rigid, binding, evidence based practice has been expressed at a recent World Pain Congress in Milan. Signifcant reservations as to its appropriateness were opined by Dr Andrew Moore (Oxford) who stated that "evidence based medicine is rubbish" he then proceeded to show how and why EBM only provided ‘average’ results. His comment is a logical conclusion because if all practices were evidenced-based, "THERE WOULD BE NIL ADVANCES IN MEDICAL TREATMENT, BUT SIMPLY A DESCENDING MEAN OF 'AVERAGE' PRACTICE!" I consider this a particularly enlightening and pertinent observation.17 Acupuncture has been adopted throughout the health care world seemingly without the strict evidence base demanded PATIENT-ORIENTED EBP ROME
CJA March 2013
CJA September 2013