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Evidence-Based Practice in Primary Care Practice in Primary Second Edition Evidence-Based Second edition Evidence-based Practice in Primary Second edition Care In the Royal Society of Medicine Journal review of the first edition of this book, David Seamark wrote: “Evidence-based medicine provokes reactions from enthusiasm to loathing. Silagy and Haines’ well laid out book seeks to reconcile the two extremes by explaining why evidence-based medicine is relevant to daily practice in primary care and by asking primary care professionals to regard themselves as learners and not just practitioners.” Hence the text is split into two sections, the first dealing with the way primary care workers can begin to understand and practise in an evidence-based way, the second addressing the broader issue of engendering a more evidence-based culture in their practice. Contributions from leading practitioners around the world ensure that the discussions are relevant internationally. Evidence - based In this second edition each chapter has been thoroughly revised in the light of changes both in attitudes to and practice of evidence-based medicine. Emphasis is given to the need for continuing medical education using effective searching and critical appraisal, and to Practice in integrating research findings into practice. As with the first edition, this revised text will be an invaluable guide for anyone in primary Primary Care health care, providing authoritative and thoughtful information on this important development in clinical practice. www.bmjbooks.com Edited by Chris Silagy Silagy and Haines and Andrew Haines Evidence – based Medicine / Primary Care 1403 Evid Based Pract 20/6/1 3:16 pm Page i CHAPTER TITLE Evidence-based Practice in Primary Care Second edition i This Page Intentionally Left Blank 1403 Evid Based Pract 20/6/1 3:16 pm Page iii CHAPTER TITLE Evidence-based Practice in Primary Care Second edition Edited by Chris Silagy Professor and Director, Institute of Health Services Research, Monash University, Australia and Andrew Haines Professor of Public Health and Primary Care and Dean, London School of Hygiene and Tropical Medicine, London, UK iii 1403 Evid Based Pract 20/6/1 3:16 pm Page iv CRITICAL CARE FOCUS: ANTIBIOTIC RESISTANCE © BMJ Books 2001 BMJ Books is an imprint of the BMJ Publishing Group All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. First published in 1998 Reprinted 1999 Second edition 2001 by BMJ Books, BMA House, Tavistock Square, London WC1H 9JR www.bmjbooks.com British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0 7279 1568 1 Typeset by FiSH Books Ltd. Printed and bound by Selwood Printing Ltd., West Sussex iv 1403 Evid Based Pract 20/6/1 3:16 pm Page v Contents Contributors vii Preface to the second edition ix 1 Evidence-based practice in primary care: an introduction 1 Chris Silagy and David Weller PART 1 – EVIDENCE-BASED HEALTH CARE AND THE INDIVIDUAL PATIENT 2 Getting started: how to set priorities and define questions 15 Paramjit Gill and Margaret Lloyd 3 Tracking down the evidence 23 Chris Del Mar 4 Critical appraisal 38 Tim Lancaster and Michael Weingarten 5 Applying the evidence with patients 49 Trisha Greenhalgh and Gavin Young 6 Screening and diagnostic tests 67 J André Knottnerus and Ron A G Winkens 7 How to assess the effectiveness of applying the evidence 83 Richard Baker and Richard Grol PART 2 – STRATEGIES TO DEVELOP A CULTURE OF EVIDENCE-BASED HEALTH CARE IN PRIMARY CARE 8 An overview of strategies to promote implementation of evidence-based health care 101 Andrew D Oxman and Signe Flottorp v 1403 Evid Based Pract 20/6/1 3:16 pm Page vi 9 Identifying and using evidence-based guidelines in general practice 120 Jeremy Grimshaw and Martin Eccles 10 Role of information technology 135 Michael Kidd and Ian Purves 11 Continuing medical education as a means of lifelong learning 142 Dave Davis and Mary Ann O’Brien 12 Integrating research evidence into practice 157 Andrew Haines and Stephen Rogers Appendix 1 Using MEDLINE to search for evidence (Ovid software): some background information and sample searches 175 Barbara Cumbers and Reinhard Wentz Appendix 2 Some further sources of information and resources that facilitate evidence-based practice 190 Index 197 vi 1403 Evid Based Pract 20/6/1 3:16 pm Page vii Contributors Baker R, Clinical Governance Research and Development Unit, Department of General Practice and Primary Health Care, University of Leicester, UK Cumbers B, Library, Central Middlesex Hospital NHS Trust, London, UK Davis D, Office of Continuing Education, Faculty of Medicine, University of Toronto, Canada Del Mar C, Centre for General Practice, University of Queensland Medical School, Australia Eccles M, Centre for Health Services Research, University of Newcastle upon Tyne, UK Flottorp S, Health Services Research Unit, National Institute of Public Health, Oslo, Norway Gill P, Department of Primary Care and General Practice, University of Birmingham, UK Greenhalgh T, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, UK Grimshaw J, Health Services Research Unit, University of Aberdeen, UK Grol R, Centre for Quality of Care Research, Universities of Nijmegen and Maastricht, The Netherlands Haines A, London School of Hygiene and Tropical Medicine, London, UK Kidd M, Department of General Practice, The University of Sydney, Australia Knottnerus JA, Netherlands School of Primary Care Research, University of Maastricht, The Netherlands Lancaster T, Department of Primary Health Care, Oxford University, Oxford, UK vii 1403 Evid Based Pract 20/6/1 3:16 pm Page viii EVIDENCE-BASED PRACTICE IN PRIMARY CARE Lloyd M, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, UK O’Brien MA, Chedoke–McMaster Hospitals, Hamilton, Canada Oxman A, Health Services Research Unit, National Institute of Public Health, Oslo, Norway Purves I, Sowerby Centre for Health Informatics, University of Newcastle upon Tyne, UK Rogers S, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London, UK Silagy CA, Institute of Health Services Research, Monash University, Australia Weingarten M, Department of Family Medicine, Sackler School of Medicine, Tel Aviv University, Israel Weller D, Department of General Practice, University of Edinburgh, Edinburgh, UK Wentz R, Imperial College Library, Chelsea and Westminster Hospital, London, UK Winkens RAG, Transmural and Diagnostic Centre, Maastricht, The Netherlands Young G, The Surgery, Barn Croft, Temple Sowerby, Penrith, Cumbria, UK viii 1403 Evid Based Pract 20/6/1 3:16 pm Page ix Preface to the second edition During the last decade, the concepts of evidence-based practice have stimulated wide-ranging interest amongst health professionals as one of the central foundations underpinning the organisation and provision of health care services. Some people have suggested evidence-based practice represents a new paradigm whilst others argue it is nothing more than a repackaging of old concepts wrapped in new jargon. Irrespective of these divergent views, there is little doubt that the ideas embraced by evidence- based practice are beginning to impact on most health care disciplines, including general practice. Although there are other books on various aspects of evidence-based practice, many of these have focused on the acquisition of specific skills, such as critical appraisal, or on the wide implications for the health system of systematically using research evidence to influence health policy and practice. However, there has been a paucity of information targeting the relevance of evidence-based approaches specifically to general practice. General practice is, by its very nature, a highly complex discipline that has been characterised by a high proportion of less well-differentiated problems that frequently highlight the interplay between biological, psychological and social factors. Through trying to confront and unravel these factors, we became increasingly aware of the need for a book which specifically addressed the relevance and place of evidence-based practice for primary care practitioners. We have elected to use the term “general practitioner” although we are, of course, aware of the different terminology employed to describe primary care doctors around the world. In addition, we recognise the importance of a multidisciplinary approach to involving the primary care team in activities to promote effective practice. This book is not intended to be a step by step “how to do it” guide. For general practitioners who are interested in developing a detailed knowledge and skills in this area, a list of further reading and other resources is provided. There are also a growing number of short courses on evidence- based practice which are being offered by academic institutions and professional societies throughout the world. Instead, it informs those general practitioners and primary care teams who wish to gain an overview of the topic. ix 1403 Evid Based Pract 20/6/1 3:16 pm Page x EVIDENCE-BASED PRACTICE IN PRIMARY CARE The book is organised into two separate parts. The first deals with the approach to utilising an evidence-based approach to the care of individual patients. It begins with how to ask and refine a good clinical question, then track down the necessary evidence and critically appraise it. Subsequent chapters deal with how to apply the evidence, the latter of the two having a specific focus on the application of evidence relating to screening and diagnostic tests. The final chapter in Part 1 deals with how to evaluate the impact of applying the evidence. In the second part of the book, the focus is on the strategies required at professional and disciplinary level in order to develop an ongoing culture of evidence-based practice within primary care.
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