Getting research findings into practice: Using research findings in clinical practice

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Abstract
Asking answerable clinical questions Formulating clear, focused clinical questions is a prerequisite to answering them. Four components of the question must be specified: the patient or problem being addressed; the intervention being considered (a cause, prognostic factor, or treatment); another intervention for comparison, when relevant; and the clinical outcomes of interest.4 The intervention could be from a clinical trial (for example, a drug) or from nature (for example, sex or age). To illustrate how many questions may arise in the treatment of one patient consider a 65 year old man with a history of cirrhosis and ascites secondary to alcohol abuse who presents to accident and emergency with haematemesis. The patient is taking a diuretic. On examination he is disoriented and looks unwell but is afebrile. His blood pressure is 90/60 supine and 70/50 while seated; his heart rate is 100 beats per minute while supine. In addition to spider naevi and gynaecomastia he has ascites. Bowel sounds are present. Steps necessary in practising evidence based medicine Convert the need for information into clinically relevant, answerable questions Find, in the most efficient way, the best evidence with which to answer these questions (whether this evidence comes from clinical examination, laboratory tests, published research, or other sources) Critically appraise the evidence for its validity (closeness to the truth) and usefulness (clinical applicability) Integrate the appraisal with clinical expertise and apply the results to clinical practice Evaluate your performance Dozens of questions may arise in treating this patient; some are summarised in the box opposite. The questions cover a wide spectrum: clinical findings, aetiology, differential diagnosis, diagnostic tests, prognosis, treatment, prevention, and self improvement.4 Given their breadth and number, and knowing that clinicians are likely to have only about 30 minutes in a week to address any of them,5 it is necessary to pare the questions down to just one. This can be done by considering the question that would be most important to the patient's wellbeing and balancing it against a number of factors including which question appears most feasible to answer, which question is most interesting to the clinician, and which question is most likely to be raised in subsequent patients and could provide information for them. For this patient the question becomes: in a patient with cirrhosis and suspected variceal bleeding does treatment with somatostatin decrease the risk of death? Questions to be asked in treating patient with cirrhosis and haematemesis Clinical findings Which is the most accurate way of diagnosing ascites on physical examination: fluid wave or shifting dullness? Aetiology Can gastrointestinal bleeding cause confusion in a patient with cirrhosis and ascites? Differential diagnosis In a patient with cirrhosis and ascites which is most likely to cause gastrointestinal bleeding, variceal haemorrhage or peptic ulcer disease? Diagnostic tests In a patient with suspected alcohol abuse is the use of the CAGE questionnaire specific for diagnosing alcohol abuse?6 Prognosis Does gastrointestinal bleeding increase the risk of death in a patient with cirrhosis? Treatment Does treatment with somatostatin decrease the risk of death in a patient with cirrhosis and variceal bleeding? Prevention Does treatment with a β blocker decrease the risk of morbidity and mortality in a patient with cirrhosis, ascites, and varices? Self improvement To improve my understanding of the pathophysiology of ascites would I gain more from spending an hour in the library reading a textbook or spending 15 minutes on the ward computer looking at the CD ROM version of the same textbook?