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 Se
Evidence-based Practice in Primary Care Second edition

co
nd
ed
iti
In the Royal Society of Medicine Journal review of the first edition of this book,

on
David Seamark wrote:

“Evidence-based medicine provokes reactions from enthusiasm to loathing.

Silagy and Haines’ well laid out book seeks to reconcile the two extremes by
explaining why evidence-based medicine is relevant to daily practice in primary
care and by asking primary care professionals to regard themselves as learners
and not just practitioners.”

Hence the text is split into two sections, the first dealing with the way primary care workers
can begin to understand and practise in an evidence-based way, the second addressing the
broader issue of engendering a more evidence-based culture in their practice. Contributions

Evidence - based
from leading practitioners around the world ensure that the discussions are relevant
internationally.

Practice in
In this second edition each chapter has been thoroughly revised in the light of changes both
in attitudes to and practice of evidence-based medicine. Emphasis is given to the need for
continuing medical education using effective searching and critical appraisal, and to
integrating research findings into practice.

As with the first edition, this revised text will be an invaluable guide for anyone in primary
health care, providing authoritative and thoughtful information on this important
Primary Care
development in clinical practice.

www.bmjbooks.com Silagy and Haines

Edited by Chris Silagy
and Andrew Haines
Evidence – based Medicine / Primary Care
 CHAPTER TITLE

Evidence-based Practice in
Primary Care
Second edition

i
This Page Intentionally Left Blank
 CHAPTER TITLE

Evidence-based
Practice in
Primary Care
Second edition

Edited by
Chris Silagy
Professor and Director, Institute of Health Services Research,
Monash University, Australia
and

Andrew Haines
Professor of Public Health and Primary Care and Dean, London School
of Hygiene and Tropical Medicine, London, UK

iii
CRITICAL CARE FOCUS: ANTIBIOTIC RESISTANCE

© BMJ Books 2001

BMJ Books is an imprint of the BMJ Publishing Group

All rights reserved. No part of this publication may be reproduced, stored in a

retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording and/or otherwise, without the prior written
permission of the publishers.

First published in 1998

Reprinted 1999
Second edition 2001
by BMJ Books, BMA House, Tavistock Square,
London WC1H 9JR

www.bmjbooks.com

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

ISBN 0 7279 1568 1

Typeset by FiSH Books Ltd.

Printed and bound by Selwood Printing Ltd., West Sussex
iv
Contents

Contributors vii

Preface to the second edition ix

1 Evidence-based practice in primary care: an introduction 1

Chris Silagy and David Weller

PART 1 – EVIDENCE-BASED HEALTH CARE AND THE

INDIVIDUAL PATIENT

2 Getting started: how to set priorities and define questions 15

Paramjit Gill and Margaret Lloyd

3 Tracking down the evidence 23

Chris Del Mar

4 Critical appraisal 38
Tim Lancaster and Michael Weingarten

5 Applying the evidence with patients 49

Trisha Greenhalgh and Gavin Young

6 Screening and diagnostic tests 67

J André Knottnerus and Ron A G Winkens

7 How to assess the effectiveness of applying the evidence 83

Richard Baker and Richard Grol

PART 2 – STRATEGIES TO DEVELOP A CULTURE OF

EVIDENCE-BASED HEALTH CARE IN PRIMARY CARE

8 An overview of strategies to promote implementation

of evidence-based health care 101
Andrew D Oxman and Signe Flottorp

v
 9 Identifying and using evidence-based guidelines
in general practice 120
Jeremy Grimshaw and Martin Eccles

10 Role of information technology 135

Michael Kidd and Ian Purves

11 Continuing medical education as a means of lifelong learning 142

Dave Davis and Mary Ann O’Brien

12 Integrating research evidence into practice 157

Andrew Haines and Stephen Rogers

Appendix 1 Using MEDLINE to search for evidence

(Ovid software): some background information
and sample searches 175
Barbara Cumbers and Reinhard Wentz

Appendix 2 Some further sources of information and resources that

facilitate evidence-based practice 190

Index 197

vi
Contributors

Baker R, Clinical Governance Research and Development Unit,

Department of General Practice and Primary Health Care, University of
Leicester, UK
Cumbers B, Library, Central Middlesex Hospital NHS Trust, London,
UK
Davis D, Office of Continuing Education, Faculty of Medicine, University
of Toronto, Canada
Del Mar C, Centre for General Practice, University of Queensland
Medical School, Australia
Eccles M, Centre for Health Services Research, University of Newcastle
upon Tyne, UK
Flottorp S, Health Services Research Unit, National Institute of Public
Health, Oslo, Norway
Gill P, Department of Primary Care and General Practice, University of
Birmingham, UK
Greenhalgh T, Department of Primary Care and Population Sciences,
Royal Free and University College Medical School, London, UK
Grimshaw J, Health Services Research Unit, University of Aberdeen, UK
Grol R, Centre for Quality of Care Research, Universities of Nijmegen
and Maastricht, The Netherlands
Haines A, London School of Hygiene and Tropical Medicine, London,
UK
Kidd M, Department of General Practice, The University of Sydney,
Australia
Knottnerus JA, Netherlands School of Primary Care Research, University
of Maastricht, The Netherlands
Lancaster T, Department of Primary Health Care, Oxford University,
Oxford, UK

vii
EVIDENCE-BASED PRACTICE IN PRIMARY CARE
Lloyd M, Department of Primary Care and Population Sciences, Royal
Free and University College Medical School, London, UK
O’Brien MA, Chedoke–McMaster Hospitals, Hamilton, Canada
Oxman A, Health Services Research Unit, National Institute of Public
Health, Oslo, Norway
Purves I, Sowerby Centre for Health Informatics, University of Newcastle
upon Tyne, UK
Rogers S, Department of Primary Care and Population Sciences, Royal
Free and University College Medical School, London, UK
Silagy CA, Institute of Health Services Research, Monash University,
Australia
Weingarten M, Department of Family Medicine, Sackler School of
Medicine, Tel Aviv University, Israel
Weller D, Department of General Practice, University of Edinburgh,
Edinburgh, UK
Wentz R, Imperial College Library, Chelsea and Westminster Hospital,
London, UK
Winkens RAG, Transmural and Diagnostic Centre, Maastricht, The
Netherlands
Young G, The Surgery, Barn Croft, Temple Sowerby, Penrith, Cumbria,
UK

viii
Preface to the second
edition

During the last decade, the concepts of evidence-based practice have

stimulated wide-ranging interest amongst health professionals as one of the
central foundations underpinning the organisation and provision of health
care services. Some people have suggested evidence-based practice
represents a new paradigm whilst others argue it is nothing more than a
repackaging of old concepts wrapped in new jargon. Irrespective of these
divergent views, there is little doubt that the ideas embraced by evidence-
based practice are beginning to impact on most health care disciplines,
including general practice.
Although there are other books on various aspects of evidence-based
practice, many of these have focused on the acquisition of specific skills,
such as critical appraisal, or on the wide implications for the health system
of systematically using research evidence to influence health policy and
practice. However, there has been a paucity of information targeting the
relevance of evidence-based approaches specifically to general practice.
General practice is, by its very nature, a highly complex discipline that has
been characterised by a high proportion of less well-differentiated
problems that frequently highlight the interplay between biological,
psychological and social factors. Through trying to confront and unravel
these factors, we became increasingly aware of the need for a book which
specifically addressed the relevance and place of evidence-based practice
for primary care practitioners. We have elected to use the term “general
practitioner” although we are, of course, aware of the different terminology
employed to describe primary care doctors around the world. In addition,
we recognise the importance of a multidisciplinary approach to involving
the primary care team in activities to promote effective practice.
This book is not intended to be a step by step “how to do it” guide. For
general practitioners who are interested in developing a detailed knowledge
and skills in this area, a list of further reading and other resources is
provided. There are also a growing number of short courses on evidence-
based practice which are being offered by academic institutions and
professional societies throughout the world. Instead, it informs those
general practitioners and primary care teams who wish to gain an overview
of the topic.

ix
EVIDENCE-BASED PRACTICE IN PRIMARY CARE
The book is organised into two separate parts. The first deals with the
approach to utilising an evidence-based approach to the care of individual
patients. It begins with how to ask and refine a good clinical question, then
track down the necessary evidence and critically appraise it. Subsequent
chapters deal with how to apply the evidence, the latter of the two having
a specific focus on the application of evidence relating to screening and
diagnostic tests. The final chapter in Part 1 deals with how to evaluate the
impact of applying the evidence. In the second part of the book, the focus
is on the strategies required at professional and disciplinary level in order
to develop an ongoing culture of evidence-based practice within primary
care. These include clinical practice guidelines, use of computerised
decision support systems and continuing medical education strategies.
Contributors have been drawn from six countries. This is reflected in the
diversity of writing styles and examples which are used to illustrate the
relevance of evidence-based health care to general practice throughout the
world.The experience of the contributors is largely in primary medical care
in industrialised countries but the underlying concepts discussed are also
relevant to primary care in other nations. Some topics, such as the
performance of diagnostic and screening tests, are covered more than once
in the book at different levels of detail. We have allowed them to remain in
the text so that individual chapters are complete in themselves, but have
cross referenced where relevant to other chapters.
The success of the first edition prompted us to prepare this second
edition. We wish to thank all the contributors for their patience and
cooperation in complying with our requests for revisions and rewrites, Drs
Trisha Greenhalgh, Paul Glasziou, Linda Geron, Anita Berlin, and Jane
Russell who kindly reviewed parts of the manuscript and provided
extremely helpful comments and suggestions which greatly improved the
end product; Ms C O’Connor and Ms R Burnley who assisted in the final
preparation of the manuscripts; and Ms Mary Banks from BMJ Books who
provided support and encouragement throughout the preparation of the
book. Finally, we also wish to thank our respective families for their
tolerance and patience when the time that should have been theirs was spent
preparing this book.

Chris Silagy and Andrew Haines

x
1: Evidence-based
practice in primary care:
an introduction
CHRIS SILAGY AND DAVID WELLER

Introduction
This book aims to explore the concept of evidence-based practice (EBP) in
terms of its relevance and applicability to general practice. We recognise
that neither is EBP a new concept, nor is its application in general practice
a straightforward task. Indeed, some argue that the culture of EBP is too
narrow and overly prescriptive to be made relevant to the complexities and
uncertainty of general practice.
The task of this book is not to dismiss potential barriers to applying EBP
in general practice, but rather to examine methods of integrating and
promoting the uptake of EBP in such a way that it takes account of the
complexities of the discipline. Indeed, with the growing demand for public
accountability in health care and the increased availability of information
to users of health care services, it is likely that EBP will be a central theme
in general practice and the organisation of care for many years to come.

The need for an evidence-based approach to

decision-making in general practice
The core of general practice is the relationship between the doctor and
patient.1 One of the central aspects of this relationship is the process of
decision-making, which can range from the simple clinical types of decision
(this patient has a sore throat; it’s red but there is no pus – should
antibiotics be prescribed?, or, this patient has complained of frontal
headaches, for two weeks, which are present on waking – should a CT scan
be carried out?) to decisions at a practice level about how services should
be organised (for example, is the establishment of a specialised,
multidisciplinary mini-clinic within the practice likely to result in improved
care for diabetic patients?). In each case, the decisions ought to involve a
negotiated arrangement which occurs in the context of a partnership
between the health care professional and patient (or between the team of

1
EVIDENCE-BASED PRACTICE IN PRIMARY CARE
primary health care professionals and their practice population), and takes
account of factors such as patient need, preferences, priorities, available
resources and evidence of the effects of providing different forms of care
(Figure 1.1).

Evidence Other
from randomised necessary
controlled trials evidence

Needs Effects of care

MAKING POLICIES AND

TAKING DECISIONS
professionals and providers
service users and purchasers
researchers and funders

Resources Priorities

Fig 1.1 Evidence on the effects of care: essential, but not sufficient, for improving
policies and decisions in health care and research. (Cochrane Collaboration
brochure 1995.)

Both the doctor and patient require access to reliable and valid
information about each of these factors, which they can then consider
applying to the situation where a decision is required. Evidence based
medicine is the phrase used to describe such an approach and entails (from
the doctor’s perspective) “the conscientious, explicit and judicious use of
current best evidence in making decisions about the care of individual
patients”.2
Evidence based health care has never been promoted as a total substitute
for clinical experience. General practitioners acquire proficiency, wisdom
and judgement through their clinical experience; this expertise produces

2
 AN INTRODUCTION
clinical skill and acumen in detecting physical signs and symptoms, as well
as a greater understanding of individuals’ “predicaments, rights and
preferences in making clinical decisions about their care”. Clinical
experience is therefore an important component of decision-making in
general practice as it is the means by which research evidence can be put
in context and individualised to specific clinical encounters. On the other
hand, overreliance on clinical experience can be misleading, giving rise to
false impressions of the benefit or harm from interventions.3
Many general practitioners would argue that they have always tried to
take account of evidence when making clinical decisions, and find it
difficult to understand what all the fuss is about with the recent
emergence of interest in evidence-based medicine. In responding to this
view, it is important to emphasise that evidence-based approaches build
on and support, rather than directly challenge, the traditional values of
health care practice. In particular, there have been a number of
developments during the past few decades which make it much easier to
adopt an evidence-based approach to health care decision-making.4 These
include the availability of better research methods for assessing the validity
of evidence of effectiveness through to improved techniques for collating
evidence in a systematic way. These changes have been accompanied by a
gradual shift within health care from an authoritarian culture to a more
authoritative culture. This shift has occurred as a direct result of placing
greater emphasis and value on the doctor’s ability to access and
appropriately use knowledge rather than on any historical position of
power and influence.

The distinction between evidence-based

medicine and evidence-based health care
It is useful to distinguish at this point the difference between the terms
evidence-based medicine and evidence-based health care (EBHC). The
former is a conceptual approach that health care professionals (particularly
doctors) can use in making decisions about the care of individual patients.
By contrast, EBHC is a somewhat broader concept that incorporates
improved approaches to understanding patients’, families’ and
practitioners’ beliefs, values and attitudes (often through qualitative
research methods). EBHC also takes account of evidence at a population
level (such as the burden of disease and implications for resource
utilisation) as well as encompassing interventions concerned with the
organisation and delivery of health care (including that provided by health
care professionals other than doctors). There is little value in debating
whether there is a clear line to divide the two approaches, and for the
purposes of this book we have decided to focus on the broader definition
of EBHC since it encompasses the general practitioner’s responsibility to

3
EVIDENCE-BASED PRACTICE IN PRIMARY CARE
their practice population as well as to individual patients. To avoid conflict
relating to terminology we have chosen to use a more neutral term,
evidence-based practice (EBP), throughout the text. This terminology also
highlights the use of evidence both in individual patient care and in the
organisation of services for the practice population.

The gap between research and practice

One of the major reasons why there has been so much interest in evidence-
based approaches to health care is the growing number of examples where
current medical practice has lagged significantly behind the available
research evidence. For example, despite strong evidence during the 1970s
that treatments such as thrombolytic therapy and aspirin were effective in
the treatment of acute myocardial infarction, it took almost a further
decade before these treatments were being recommended routinely.5
Similarly, there are examples of widely (and sometimes excessively) used
practices, such as dilatation and curettage for dysfunctional uterine
bleeding, where for a number of years there has been evidence of lack of
effectiveness.5 The reason for this apparent gap between the available
scientific research evidence and its application in practice is complex. In
some instances, it reflects upon the lack of rigour which has been applied
to synthesising results of primary research in a systematic manner. In other
instances, it reflects the inability of the available research evidence to
provide the relevant information that consumers and health care
professionals need to make decisions. At a broader level, it reflects upon the
lack of appropriate frameworks, systems and strategies for effectively
influencing professional behaviour.

The complexity of general practice

It is widely acknowledged that skills necessary for general practice go well
beyond diagnosis and treatment of illness; other important elements
include aspects of sociology, pastoral care, or even mythology. Patients
present in general practice with multiple and ill-defined problems – single,
discrete problems are rare. As a result, general practitioners are often faced
with difficulty in identifying a clear diagnosis and formulating an explicit
plan of management. More often than not there will be unanswered
questions following a consultation; some issues will be addressed
immediately, others will require time to either develop or resolve. The
complex nature of general practice means that often individuals seek help
in aspects of illness for which there may be no convincing evidence of the
effectiveness of any intervention.6
This complexity and lack of evidence should not be seen as a reason
for jettisoning the use of evidence in those areas where it does exist, and
is an argument for continually seeking to develop and refine our capacity
4
 AN INTRODUCTION
to collect new evidence, in a rigorous manner, in those areas where it
does not exist. In fact, a report by Gill et al.,7 based on a retrospective
analysis of a consecutive series of doctor–patient encounters, found that
a high proportion (81%) of interventions in general practice could be
supported by evidence from randomised controlled trials and/or
convincing nonexperimental evidence. Although there have been
methodological criticisms of the study, it does highlight the potential of
using evidence to inform a considerable proportion of decision-making in
general practice.
There is still a need to refine how evidence can be incorporated into the
complexity of the doctor–patient relationship in general practice. For
example, currently a major research effort is being undertaken to develop
methods of incorporating the weighted preferences of patients into models
of decision analysis.8 This may ultimately represent an important advance
in creating a useful resource for decision-making in general practice. As we
begin to understand more about the contribution of other aspects of the
decision-making process, such as the importance of information sharing
and the ethical values held by the doctor and patient, it is likely that
methodologies for understanding and applying an evidence-based
approach will continue to be refined and improved.

How to get started: a five-step process for

using an evidence-based approach in general
practice
How should busy general practitioners get started if they want to embrace
an evidence-based approach as part of their practice? The McMaster
University Evidence Based Medicine Resource Group have identified a
five-step approach that individual health care professionals need to follow:9

(1) define the problem;

(2) track down the information sources you need;
(3) critically appraise the information;
(4) apply the information with your patients;
(5) evaluate how effective this application of information is.

These five steps are reviewed briefly in this chapter and discussed in more
detail in later chapters.

Step 1: defining the problem

In every consultation decisions need to be made. Many of these are done
almost subconsciously, with little or no formal critical evaluation.
Questions frequently arise, such as the pros and cons of using a particular

5
EVIDENCE-BASED PRACTICE IN PRIMARY CARE
form of therapy, the value of having a particular diagnostic test or screening
procedure, the risk or prognosis of a particular disease, or the cost (and
cost-effectiveness) of a potential intervention. Rather than relying solely on
our memories to answer such questions (which may not represent the most
up-to-date summary of the available clinical information), an evidence-
based approach would be to pause and recognise that there is a clinical
problem for which you are unsure of the evidence and to make a decision
to investigate it further.
Clearly, it is not possible within a busy general practice to embark on a
detailed search of the scientific evidence for every question that arises.
Establishing a system for prioritising and refining questions will be
addressed in Chapter 2.

Step 2: tracking down the information sources needed

General practitioners face difficulties above and beyond their specialist
colleagues in gaining access to research findings.10 The body of medical
literature which can assist in providing answers to the questions raised in
clinical practice is broadly scattered; journals of ear, nose and throat or
mental health, specialist general practice and family medicine journals and
government reports all contain information which may be of relevance.
The challenge (which is discussed further in Chapter 3) is to identify what
is available and accessible through a variety of means, including searching
electronic databases, consulting research synthesis journals and
communicating with colleagues. An increasingly common scenario that
can facilitate tracking down relevant information involves patients arriving
at the surgery having completed literature searches of their own.

Step 3: critically appraising the information

Having decided which journal articles to read, it is important to read them
carefully as not all published information is of equal value. Critical
appraisal of articles is a process which involves carefully reading an article
and analysing its methodology, content, and conclusions. The key question
to keep in mind is: “Do I believe these results sufficiently that I would be
prepared to adopt a similar approach, or reach a similar conclusion, with
my own patients?”
The skill of being able to critically appraise articles needs to be learned
and practised like any other clinical skill. There are a range of different
approaches to critical appraisal, depending on the type of question being
asked; this will be addressed further in Chapter 4.

Step 4: applying the information with your patients

The fourth step in the process of using an evidence-based approach to the

6
 AN INTRODUCTION
practice of health care is to decide how to apply the information obtained
to the particular circumstances of your patient. This is probably the most
crucial step in the process, as well as the most complex, and will be
examined in detail in Chapters 5 and 6.
It is necessary to decide whether there are any methodological issues
raised about the evidence which might prompt you to reject it outright.
Assuming there are no such issues involved, there is a need to assess the
trade-offs between any adverse and beneficial effects as well as decide how
to take into account an assessment of the patient’s stated (and perceived)
needs, the resources available and the priorities that may be placed by the
patient on different treatment options. This process requires a partnership
between the doctor and patient. If at the end of that process the decision is
made not to apply the available research evidence, that decision should be
a mutual and conscious one.

Step 5: evaluating how effective it is

The final step in using an evidence-based approach (which is discussed in
Chapter 7) is to evaluate the effect of the evidence as applied to specific
patients. This is an important step in “closing the loop”, to gauge whether
the expected benefits that arose from using a particular item of evidence
were consistent with the observed benefits. If the observed benefits are less
than had been expected from the evidence, it may well generate the need
for further research to identify why some patients have not responded in
the expected manner and what can be done to rectify this.

There is nothing particularly conceptually difficult about these five steps;

they can be readily taught at an undergraduate level and then reinforced at
a postgraduate level. The practical problem in the “real world” facing busy
general practitioners is having sufficient time to apply these steps routinely
in their daily practice.

Supporting a framework for evidence-based

practice within general practice
The second part of this book describes the challenges and responsibilities
facing general practitioners as professionals that need to be addressed if an
evidence-based approach is to flourish. Such a framework needs to be built
around ensuring that the evidence required to inform decision-making is
available, accessible, acceptable and applied by general practitioners, as
well as putting in place strategies to thoroughly evaluate the impact of
applying the evidence. For example, there is an overwhelming amount of
research evidence available, with over two million new articles added to the
world’s medical literature each year.11 Even in the primary care literature
there are probably now five times as many randomised controlled trials as
7
EVIDENCE-BASED PRACTICE IN PRIMARY CARE
there were about 20 years ago.12 Keeping up to date with all of this is a
daunting task, particularly since the evidence (even when limited to a single
discipline) is published across a wide range of journals and is of variable
quality and relevance. General practitioners have little hope of coming to
grips with this body of material unassisted – they lack time and often do
not have access to the necessary skills or resources to undertake searching,
critical appraisal and assessment of relevance to general practice.
Several initiatives have recently emerged internationally which aim to
produce systematic summaries of literature, thereby relieving a great deal
of the burden associated with trying to practise EBP. Good examples are
the Cochrane Library (a database of high quality systematic reviews
covering all fields of health care, including general practice) and the
journals of secondary publication, such as the AGP Journal Club, Evidence
Based Medicine and Clinical Evidence, which undertake the task of
scanning the medical literature and compiling summary commentaries
together with structured abstracts on particular topics, after a process of
critical appraisal and quality assessment of material (see Appendix 2, p 190
for further details).
At a more local level, there are a growing number of networks being
established around the world amongst general practitioners who wish to
share the tasks of searching for and appraising evidence.13 Some of these
networks meet face to face whilst others concentrate on electronic media
for communicating. Support mechanisms such as these can allow busy
clinicians to devote their scarce reading time to “selective, efficient, patient-
driven searching,” and incorporation of the best available evidence in order
to practise evidence-based health care.
A natural extension of this process is to apply evidence-based protocols
and guidelines, developed by our colleagues, in clinical practice. Systematic
reviews may provide a sound basis for the development of clinical
guidelines.
Two other important features of evidence which affect whether it is likely
to be implemented in clinical practice are its acceptability and applicability.
There is little value in gaining access to evidence if it is not relevant to the
GP’s patients, or if the health intervention it examines is not acceptable or
available in a particular practice setting. In the absence of these features
which are discussed further in Chapter 8, exposure to evidence from the
literature is likely to have little effect on clinical practice.
To examine the question of whether exposure to research evidence can
change practice behaviour, Oxman et al. reviewed 102 randomised
controlled trials in which changes in physician behaviour were attempted
through means such as continuing medical education workshops and
seminars, educational materials, academic detailing and audit and
feedback.14 Each produced some change, but the authors concluded that
a multifaceted strategy was called for, using combinations of methods.

8
 AN INTRODUCTION
Chapter 9 examines the specific role of clinical practice guidelines in
supporting clinical decision-making; Chapters 10 and 11 discuss the role
of information technology and continuing education respectively in
helping practitioners keep up to date with the sheer volume and rapidly
changing knowledge base, while Chapter 12 discusses factors affecting the
integration of evidence into practice via these and other methods that are
used to promote change.
There is growing interest in individualising the results of research
evidence and developing co-ordinated strategies which can take into
account factors such as the strength of evidence, methodological
limitations, relative trade-offs between adverse and beneficial effects (after
adjustment for patient’s baseline risks) as well as evidence of patient beliefs,
attitudes and values.15
Finally, there must be the capacity to evaluate the uptake of EBP in
general practice. Critics of EBP in general practice often argue that uptake
of evidence-based health practises is difficult or impossible to evaluate.
Why promote the concept of EBP if we can never be sure that decision-
making in general practice has been influenced by the process? (as
discussed in Chapter 7). In theory, evidence-based health practises should
lead to improvements in health outcomes, but not all general practice
interventions can be linked directly to health outcomes. Furthermore, in
many aspects of health care there are long lag times; for example, in cancer
or cardiovascular disease, the time between the GP’s health interventions
and any measurable outcomes may be considerable.There is a concern that
a strong adherence to EBP may lead to a focus on those health
interventions in general practice for which outcomes are easily and
immediately measured.
Other than measurable health outcomes, there are a number of proxy
measures which can be used to establish whether or not health care in
general practice is evidence-based. These include case-note audit for
process measures, level of usage of evidence-based clinical practice
guidelines and access to decision support systems. Furthermore, wide-
spread adoption of EBP in general practice should lead to measurable
reductions in variability between GPs, practices, or geographical regions in
areas such as prescribing and ordering of investigations.16 Monitoring such
changes is complex and requires highly specialised systems that are capable
of tracking large amounts of data on patients across different health care
sectors. Developing such systems will need to be an important priority in
the future development of EBP.

Summary
In this chapter we have described what EBP is, how it is applied to general
practice, and what frameworks are required if general practitioners (as

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