In message <[log in to unmask]>, padmanabhan
badrinath <[log in to unmask]> writes
>Dear All,
>
>Greetings from Al-Ain the oasis city. I just returned from OMAN (our
>neighbouring country) where I acted as a facilitator in the just concluded
>EBM workshop which was well attended. We had experts from both sides of the
>atlantic (Oxford & McMaster) as facilitators.
>
>I got the impression that now there is a move to move towards preprocessed
>information (Cochrane, Clinical evidence, ACP journal club and Up to date).
>Please see http://bmj.com/cgi/content/full/320/7240/954
>
>Although I agree with this in principle I am of the opinion that as all
>these resources have to be paid for (by some one) it may not be easily
>available to all. Hence I feel that sources in the public domain (clinical
>query in PubMed, National guideline clearing house and possibly others)
>should still be an option when looking for evidence.
>
There are two issues here:

1) should preprocessed evidence be the main source of information for
EBM?

2) how should it be made available (and indeed how should primary source
information be made available?)

So far as 1 is concerned I personally tend to use the Cochrane Library
in particular in most cases because of the clarity and tight definition
of the questions and the ease with which one can access summaries of the
numerical values of outcomes studied. Of course one has to depend on the
quality of the review in the first place (which is usually at worst
acceptable) and take it on trust that the figures reported are valid.
Clinicians do not have the time to critically appraise all studies in a
systematic review, so validity cannot be assessed in detail from a
Cochrane review - however since we are usually concerned with
applicability, and the reviewers usually make helpful comments, this is
not a problem in practice.

However there are situations where your queston is not addressed by a
Cochrane review and you need to do a Medline search. Many treatments are
still used that are justified by tradition and expert opinion. For
example a patient came to see me with an exacerbation of Meniere's
disease and told me that her consultant years ago had prescribed
Naftidrofuryl Oxalate which had worked well. I did a Medline search and
found only one or two small trials, apparently of poor quality and a
couple of expert reviews that mentioned it as one of the treatments for
Meniere's. I was not able to access the full texts and could only
conjecture that there was not strong evidence to support the
intervention. So what do you do then? (I prescribed it and asked her to
come back and let me know if it worked in a very informal n-of-1 trial)

This partly bears on 2. It is now technicaly possible for all clinicians
to have online access not only to the Cochrane Library, but to textbooks
and full texts of original papers. However (with the noble exception of
the BMJ) most journals charge for online access and it is beyond the
means of many clinicians to pay for the access. I believe that the WHO
should encourage governments around the world to pay for access to
online evidence and make this available free of charge to clinicians in
all countries (and indeed to the general public). In comparison with
other government expenditure this would be laughably cheap, yet would be
of great value for health care. Certainly it would seem more effective
than expecting each health care organisation to make its own
arrangements (with much of the funding ultimately coming from
governments anyway). Here the UK has made a good start with the National
Electronic Library for Health and the NICE website.

best wishes to all

Toby
--
Toby Lipman
General practitioner, Newcastle upon Tyne


Tel 0191-2811060 (home), 0191-2437000 (surgery)

Northern and Yorkshire Evidence-Based Practice Workshops

http://www.eb-practice.fsnet.co.uk/