Faculty of Health, University of Technology Sydney UTS, Australia.
BMC Med Inform Decis Mak. 2013 Feb 20;13:25. doi: 10.1186/1472-6947-13-25.
There has been increasing emphasis on evidence-based approaches to improve patient outcomes through rigorous, standardised and well-validated approaches. Clinical guidelines drive this process and are largely developed based on the findings of systematic reviews (SRs). This paper presents a discussion of the SR process in providing decisive information to shape and guide clinical practice, using a purpose-built review database: the Cochrane reviews; and focussing on a highly prevalent medical condition: hypertension.
We searched the Cochrane database and identified 25 relevant SRs incorporating 443 clinical trials. Reviews with the terms 'blood pressure' or 'hypertension' in the title were included. Once selected for inclusion, the abstracts were assessed independently by two authors for their capacity to inform and influence clinical decision-making. The inclusions were independently audited by a third author.
Of the 25 SRs that formed the sample, 12 provided conclusive findings to inform a particular treatment pathway. The evidence-based approaches offer the promise of assisting clinical decision-making through clarity, but in the case of management of blood pressure, half of the SRs in our sample highlight gaps in evidence and methodological limitations. Thirteen reviews were inconclusive, and eight, including four of the 12 conclusive SRs, noted the lack of adequate reporting of potential adverse effects or incidence of harm.
These findings emphasise the importance of distillation, interpretation and synthesis of information to assist clinicians. This study questions the utility of evidence-based approaches as a uni-dimensional approach to improving clinical care and underscores the importance of standardised approaches to include adverse events, incidence of harm, patient's needs and preferences and clinician's expertise and discretion.
通过严格、标准化和经过良好验证的方法，越来越强调循证方法来改善患者的结局。临床指南推动了这一过程，并且主要是基于系统评价（SR）的结果制定的。本文通过使用专门构建的综述数据库（即 Cochrane 综述）来讨论 SR 过程，以提供决定性的信息来塑造和指导临床实践，该数据库重点关注一种普遍存在的医疗状况：高血压。
我们搜索了 Cochrane 数据库，确定了 25 项相关的 SR，其中包含 443 项临床试验。纳入的综述标题中包含“血压”或“高血压”一词。一旦入选，两名作者将独立评估摘要，以评估其在告知和影响临床决策方面的能力。第三名作者对纳入的内容进行了独立审核。
在形成样本的 25 项 SR 中，有 12 项提供了明确的结论来指导特定的治疗途径。循证方法有望通过清晰性来协助临床决策，但在我们样本中的高血压管理中，有一半的 SR 强调了证据和方法学上的局限性。有 13 项综述没有结论，其中包括 4 项有明确结论的 SR，也指出缺乏对潜在不良反应或伤害发生率的充分报告。
这些发现强调了对信息进行提炼、解释和综合以协助临床医生的重要性。本研究质疑了循证方法作为改善临床护理的单一维度方法的实用性，并强调了采用标准化方法纳入不良反应、伤害发生率、患者需求和偏好以及临床医生的专业知识和判断力的重要性。
