Evidence-based Medicine Toolkit

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76 Evidence-based Medicine Toolkit• How can you maximize your time to make sure that your interventionis realistic in your setting?• Do your staff need extra training?• Do you need to do a cost–benefit analysis?• Are you going to audit what you do? Do you need to follow upyour patients?What alternatives are available?There may be different ways of tackling the same disorder, suchas in hypertension, where evidence may be for single or combineddrug effects. Again, dosage and delivery are likely to affect compliance,which in turn may make alternatives more practical.• Have you weighed up the adverse effects of your treatmentagainst those of less helpful treatments? You (or your patient)may feel that a treatment of less benefit which is less harmfulmay be more appropriate.• Is doing nothing an option? This relies on your interpretationof the patient’s benefits and risk of harm, and what the patientthinks.• Is there a class effect? Many trials put down the effect to thespecific drug and not the generic class.• Is your patient on so many drugs that it might be worth stoppingsome or all of them if the adverse effects outweigh the benefits?• Is your patient aware of lifestyle changes which may be ofbenefit?Are the outcomes appropriate to your patient?What does your patient think? Does your patient understand theimplications of the intervention? Some drugs require lifelong adherenceto maintain efficacy. The outcomes which are importantto you are not necessarily the ones which matter most to your patient,particularly where quality of life is affected. Other importantissues to discuss with your patient include:• Some of the adverse effects may not be mentioned in trials, butmay be very relevant to your patient, such as mood disturbances.• How much reassurance would your patient derive from testresults or prognostic estimates?• The invasiveness of a test or procedure may affect your patient’swillingness to participate.• Implications for further testing and/or treatment.
Applying the evidence 77Further readingAltman D. Practical Statistics for Medical Research. Edinburgh: ChurchillLivingstone, 1991.Bloom BS. Daily regimen and compliance with treatment. Br Med J2001;323:647.Sackett DL, Straus SE, Richardson WS, Rosenberg WMC, Haynes RB. Evidence-BasedMedicine: How to practice and teach EBM, 2nd Edn. NewYork: Churchill Livingstone, 2000.
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