Examining the confdence intervals is the easiest

way to assess whether the study sample was too

small and therefore did not have the statistical
power to detect a clinically important diference (as
refected by wide confdence intervals). Even when
a study is positive or shows statistically sig-
nifcant results it is important to consider whether
the fndings are clinically signifcant and applicable
to your practice. !or example if a study showed a
drug reduces the ris" of heart attac" by one in a
million patients we would probably be s"eptical
about its utility. #i"ewise the fndings show ing
that daily borscht reduces fractures its a study
done in $ussian doc"wor"ers may or may not be
applicable in the %nited &tates. 'he acceptability of
an intervention (e.g. electroconvulsive therapy for
depression) may vary. (oreover the ability to
replicate the fndings of a study done in a typi cal
research setting is often reduced in real-world
practice. )n intervention for osteoporosis
re*uiring daily in+ections may be demonstrated to
be e,cacious but in the average practice setting
its efectiveness may be much more limited.
-linicians fre*uently rely on the synthesis of many
studies rather than a single study to change our
practices. &uch reviews can be systematic, in which
rigorous attempts are made to uncover all studies
published and unpublished in English and in other
relevant languages or they may be more limited
reviews that consider only a portion of the
published literature. &ome use formal mathematical
methods to combine the results of studies (i.e. meta-
analysis) and others are qualitative and synthesi.e data
according to an author/s overall +udgment. -ommon
biases to consider related to published reviews
include whether all sources of evidence were
considered0 how disparate results were combined1
whether relevant patient- oriented outcomes were
assessed1 if there was ade*uate attention to the
*uality of the studies and their generali.ability1 and
whether the authors analy.ed why diferences in
outcomes may have occurred based on such
factors as study design population and
intovention. 2ublished reviews including
systematic reviews and clinical guidelines have
become increasingly important tools for the
busy clinician.
-linicians may hone critical appraisal s"ills
through involvement with local +ournal clubs
soothing with the !amily 2hysicians/ 3n*uiries
4etwor" (wwwipin.org). )lthough it is important to
understand basic concepts for interpreting medical
literature sifting through original research studies
can be a tedious impractical process for busy
clinicians. (any practical E5( tools have emerged in
recent years to help physicians *uic"ly access
comprehensive expert reviews of published studies
in the middle of a busy practice ('able 6-7). 'he
ability to criti*ue articles using a structured
approach is facilitated by using widely available
wor"sheets and tools (see 8eb $esources). )lthough
many taxonomies exist for level of evidence two of
the most widely available are the -entre for
Evidence-5ased (edicine (-E 5() and the
taxonomy used in this boo" 'he &trength of
$ecommendation 'axonomy is specifcally tailored
to family medicine (Ebel/ et al.. 9::;).
Using Evidence at the 2oint of -are
2hysicians have many sources of clinical
information from throwaway or non-peer-
reviewed +ournals to evidence- based searchable
databases. Each of these has advantages
disadvantages and diferent methods of access
('able 6-;).
Table8-3 Distinguishing Characteristics of Evidence-Based
Medicme
<escription
Databases are searched and search strategies described.
Concentrates on clinical research that reports patient-oriented
outcomes.
The searches are systematic and thorough so that important evidence
is not missed.
tandardi!ed critical "mportant sources of potential systematic
appraisal and random error are assessed in each
study.
#ierarchy of study design More $eight is given to stronger study
designs.
Designation of levels of Each study is designated $ith respect to the
evidence strength of the study design and its %uality
of evidence.
&rading of accumulated Each recommendation "s graded
recommendations according to the strength oldie evidence
from research studies that support the
recommendation.
'erifiable fi ndings The e(plicitness
of the methods of searching and
critical a ppmisa " allo$s others to verify
)r refute findings and
recommendations.
)ne model to help busy physicians stay clinically
current called information mastery, has been
advocated by &lawson and &haughnessy (=>>>)
Ebel/ and colleagues (=>>>) and -eyman (=:>>).
3n this model physicians see" the answer to
clinical *uestions through secondary sources of
information that have been created
by experts through a review of the
medical literature. &econdary sources
include the following ('able 6-?)0
Evidence-based summaries such
as -ochrane -ollaboration reviews 2atient-
@riented Evidence that (atters (2@Etvls) -linical
3n*uiries and 2riority %pdates from the $esearch
#iterature (2%$3As) as published in the
Journal of Family Practice.
&ystematic reviews including 2ub(ed and
-linical 3n*uiries.
Buidelines written by professional societies
and accessed through sites such as the 4ational
Buideline -learinghouse (wwsv.ngc.gov).
Evidence-based databases such as Essential
Evidence 2lus <ynaCsled and 2E23< 2-2.
'he following example describes the type of
relevant information that a busy clinician can
access using two of these !5( resources.
Case E(ample
* ??-year-old woman sees you because she is
experiencing severe vasomotor symptoms (i.e.
hot fashes). 'hese symptoms are "eeping her
awa"e at night. &he had a total
-haracteristi
c
E(plicit methods
+ocus on patient-
oriented outcomes