Evidence based clinical practice: an introduction for urologists
Authors:
P. Dahm
Published in:
Urol List 2008; 6(4): 70-77
Overview
Introduction:
Evidence-based clinical practice (EBCP) has been defined as the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients and refers to a broad set of principles and methods intended to ensure that medical decisions, guidelines and health policy are based on well designed studies of therapeutic effectiveness and benefit.
Methods:
This article reviews the principles and practice of EBCP using examples from the urology literature. It further provides a guide to currently available web-based EBCP resources and guidelines for urologists.
Results:
EBCP integrates a hierarchy of evidence and patient's values with the practitioner's judgment to guide decision-making for the individual patient. Important steps in the EBCP process include the formulation of an answerable question and a systematic search of the literature. In absence of pre-appraised evidence or disease-specific guidelines, the practice of EBCP relies heavily on the evaluation of the primary literature by the individual urologist. Depending upon the question domain (therapy/prevention, etiology/cause/harm, diagnosis or prognosis) and study design a given study is critically appraised for its validity, impact and applicability. Evidence is then integrated with clinical judgment and a patient's individual circumstances and preferences. Finally, the practice of EBCP includes a self-assessment of the provider's performance.
Conclusion:
Knowledge, practice, and documentation of EBCP are of increasing importance to every urologist. Urologists should embrace EBCP principles by acquiring the necessary skills to critically appraise the literature for the best evidence to apply to patient care.
Key words:
evidence-based medicine, research methodology, clinical trials, bias
Sources
1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ 1996; 312: 71.
2. Shaneyfelt T, Baum KD, Bell D, Feldstein D, Houston T.K, Kaatz S. et al. Instruments for evaluating education in evidence-based practice: a systematic review. JAMA 2006; 296: 1116.
3. Guyatt GH, Rennie D. User's Guide to the Medical Literature, 4 ed. Chicago IL: AMA Press 2002: 706.
4. Sackett DL. Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest 1986; 89: 2S.
5. Brighton B, Bhandari M, Tornetta P, 3rd, Felson DT. Hierarchy of evidence: from case reports to randomized controlled trials. Clin Orthop Relat Res 2003; 413: 19.
6. Hatala R, Keitz S, Wyer P, Guyatt G. Tips for lear-ners of evidence-based medicine: 4. Assessing heterogeneity of primary studies in systematic reviews and whether to combine their results. CMAJ 2005; 172: 661.
7. Scales CD Jr, Norris RD, Keitz SA, Peterson BL, Preminger GM, Vieweg J et al. A critical assessment of the quality of reporting of randomized controlled trials in the urology literature. J Urol 2007; 177(3): 1090.
8. Schulz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995; 273: 408.
9. Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elbourne D et al. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med 2001; 134: 663.
10. Greenhalgh T. Papers that summarise other papers (systematic reviews and meta-analyses). BMJ 1997; 315: 672.
11. Wilt TJ, Howe RW, Rutks IR, MacDonald R. Terazosin for benign prostatic hyperplasia. Cochrane Database Syst Rev 2002; CD003851.
12. Mansson W. Evidence-based urology--a utopia? Eur Urol 2004; 46: 143.
13. Albert X, Huertas I, Pereiro II, Sanfelix J, Gosalbes V, Perrota C. Antibiotics for preventing recurrent urinary tract infection in non-pregnant women. Cochrane Database Syst Rev 2004; CD001209.
14. Guyatt G, Haynes B, Jaeschke R, Cook D, Greenhalgh T, Meade M et al. Introduction: the philosophy of evidence-based medicine. In: Users' guide to the medical literature. Edited by G. Guyatt and D. Rennie. Chicago, IL: American Medical Association Press 2002: 3-12.
15. Thompson I.M, Goodman PJ, Tangen CM, Lucia MS, Miller GJ, Ford L G et al. The influence of finasteride on the development of prostate cancer. N Engl J Med 2003; 349: 215.
16. Petrisor BA, Bhandari M. Principles of teaching evidence-based medicine. Injury 2006; 37: 335.
17. Guidelines on Prostate Cancer: European Urological Association, 2005.
18. Practice Guidelines in Oncology – v.1.2005 –Prostate Cancer Early Detection National Cancer Center Network, 2005.
19. Guyatt G, Vist G, Falck-Ytter Y, Kunz R, Magrini N, Schunemann H. An emerging consensus on grading recommendations? ACP J Club 2006; 144: A8.
20. Brosnahan J, Jull A, Tracy C. Types of urethral catheters for management of short-term voiding problems in hospitalised adults. Cochrane Database Syst Rev 2004; CD004013.
21. Rafalsky V, Andreeva I, Rjabkova E. Quinolones for uncomplicated acute cystitis in women. Cochrane Database Syst Rev 2006; 3: CD003597.
22. Ilic D, O'Connor D, Green S, Wilt T. Screening for prostate cancer. Cochrane Database Syst Rev 2006; 3: CD004720.
23. Devereaux PJ, Yusuf S. The evolution of the randomized controlled trial and its role in evidence-based decision making. J Intern Med 2003; 254: 105.
24. Davis JW, Chang SS, Schellhammer PF. Clinical Trials Methodology. AUA Update Series 2004; 23: 138.
25. Devereaux PJ, Manns BJ, Ghali WA, Quan H, Lacchetti C, Montori VM et al. Physician interpretations and textbook definitions of blinding terminology in randomized controlled trials. JAMA 2001; 285: 2000.
26. Scales CD Jr, Norris RD, Peterson BL, Preminger GM, Dahm P. Clinical research and statistical methods in the urology literature. J Urol 2005; 174: 1374.
27. Breau RH, Carnat TA, Gaboury I. Inadequate statistical power of negative clinical trials in urological literature. J Urol 2006; 176: 263.
28. Sur RL, Scales CD Jr, Preminger GM, Dahm P. Evidence-based medicine: a survey of American Urological Association members. J Urol 2006; 176: 1127.
29. Barratt A, Wyer PC, Hatala R, McGinn T, Dans AL, Keitz S et al. Tips for learners of evidence-based medicine: 1. Relative risk reduction, absolute risk reduction and number needed to treat. CMAJ 2004; 171: 353.
30. Dellabella M, Milanese G, Muzzonigro G. Randomized trial of the efficacy of tamsulosin, nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi. J Urol 2005; 174: 167.
31. Montori VM, Kleinbart J, Newman TB, Keitz S, Wyer PC, Moyer V. et al. Tips for learners of evidence-based medicine: 2. Measures of precision (confidence intervals). CMAJ 2004; 171: 611.
32. Bhandari M, Zlowodzki M, Cole PA. From eminence-based practice to evidence-based practice: a paradigm shift. Minn Med 2004; 87: 51.
33. Horton R. Surgical research or comic opera: questions, but few answers. Lancet 1996; 347: 984.
34. Howes N, Chagla L, Thorpe M, McCulloch P. Surgical practice is evidence based. Br J Surg 1997; 84: 1220.
35. Young J, Harrison J, White G, May J, Solo-mon, M. Developing measures of surgeons' equi-poise to assess the feasibility of randomized controlled trials in vascular surgery. Surgery 2004; 136: 1070.
36. Solomon MJ, McLeod RS. Should we be performing more randomized controlled trials evaluating surgical operations? Surgery 1995; 118: 459.
37. EBM: unmasking the ugly truth. BMJ 2002; 325: 1496.
38. Timmermans S, Mauck A. The Promises and Pitfalls of Evidence-Based Medicine. In: Health Affairs 2005; vol. 24: 18–28.
39. Evans CP. Evidence-based medicine for the urologist. BJU Int 2004; 94: 1.
40. Sand PK. Urogynecology: the death of dogma. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12: 1.
41. Jones RS, Brown C, Opelka F. Surgeon compensation: “Pay for performance,"” the American College of Surgeons National Surgical Quality Improvement Program, the Surgical Care Improvement Program, and other considerations. Surgery 2005; 138: 829.
42. Miller DC, Wei JT, Montie JE, Hollenbeck BK. Quality of care and performance-based reimbursement: the contemporary landscape and implications for urologists. Urology 2006; 67: 1117.
43. Miller SH. American Board of Medical Specialties and repositioning for excellence in lifelong learning: maintenance of certification. J Contin Educ Health Prof 2005; 25: 151.
Labels
Paediatric urologist UrologyArticle was published in
Urological Journal
2008 Issue 4
Most read in this issue
- Male pelvic pain syndromes and sexual dysfunction
- Priapism
- Peyronie´s disease
- Osteopenia and osteoporosis in young men presenting with infertility or sexual dysfunction - clinical experience