Information gathering and the final analysis

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Chapter 42 Information gathering and the final analysis

Chapter contents

Internet portals and gateways 342
Professional journals 342
Websites 345

As first-hand experimental evidence is not likely to be generally available to the normal complementary healthcare professional, it is important to know where to go to find reliable information and how to use it.

Internet Portals and Gateways

These are websites, quite often run by governmental bodies, which allow access to the databases of reliable websites in specialist areas. Entering through these portals and gateways usually ensures you will be accessing relatively reliable information.

Professional Journals

Many of these are available online and in many instances, providing the embargo date has passed, there is free online access to articles. Note: just because a paper is published in a professional journal does not mean it is flawless.

Critical Analysis of Papers

This requires some practice and it is not possible, given the scope of this book, to enter into a detailed discussion on evidence-based medicine or to dissect a scientific paper. However, a brief summary of the important factors should give an appreciation of what might constitute a well-written paper.

How is it Possible to make Sense of the Information Available and Place it in a Clinical Setting?

As a clinician exploring the subject of pharmacology, you will probably come across two main types of paper:

• Evidence-based medicine: a way of bringing together clinical experience with the best available clinical evidence from systematic research.
• Scientific experiment: limited to work in the rigidly controlled environment of a laboratory.

• Evidence-Based Medicine

Evidence-based papers can be:

• Quantitative: involving numbers and statistics.
• Qualitative: more descriptive, giving background to a study such as the participants’ personal feelings or experiences. These are more like reading a story and do not involve statistics.

General Questions to be Asked of an Evidence-Based Paper

• Does the title of the paper reflect the content?
• Is the quantitative or qualitative approach appropriate?
• Was the type of study used appropriate: e.g. if the researcher wanted to examine the relationship between a particular drug and its effects on a group of people over a period of time it is more appropriate to use a cohort study than a randomized controlled trial (see below).
• Have the authors thoroughly justified the methods they used?
• Bias: was the study biased by, for example, the selection of participants or the funding body?
• Was the data that was collected appropriate?
• Had ethical considerations been taken into account?
• Has the data been analysed properly: in the case of evidence-based medicine the statistics should be directly relevant to the clinical situation, e.g. numbers needed to treat (NNT).
• Are statements appropriately referenced?
• Is the research of clinical value?

Both the Critical Appraisal Skills Programme (CASP) and the Scottish Intercollegiate Guidelines Network (SIGN 50) have more detailed work sheets for critical appraisal (p. 347).

Evidence-Based Statistics

These are becoming more user friendly; for example, numbers needed to treat (NNT) gives an idea of how effective a treatment might be, as the fewer the number of patients needed for a response, the more effective the treatment. Details of the statistics associated with evidence-based medicine are available at the websites listed at the end of this chapter.

• Scientific Experiments

These are done in a laboratory environment, which is much easier to control than the conditions under which evidence-based medicine investigations are carried out. However, scientific experimentation is not without its problems. Most serious is that the results of scientific experiments, because of the way the experiments are conducted, are far removed from the conditions encountered in everyday life.

In many cases, at the start of an experiment an assumption is made regarding a drug or an active plant metabolite that might not apply to the normal consumption of that compound. The experiment then proceeds as follows:

• An observation: e.g. crude extracts of a particular species are found to have antibacterial properties.
• The hypothesis: the crude extracts contain several compounds, therefore one, several or all of them are responsible for the antibacterial properties.
• The question: what is the answer to the hypothesis?
• Conduct a literature search: to see what has been done before.
• Testing of the hypothesis: an experiment is constructed to test the hypothesis. All details of the experiment, e.g. material, preparation and process of the experiment, should be included in the experimental description. It is important that the methodology is reproducible; ‘one-off’ experiments are not scientifically valid.
• Presentation of results: quite often tabulated for quick reference.
• Discussion: what conclusions can be drawn e.g. certain groups of compounds in the plant in isolation have an antibacterial effect.

General Comments

The paper should state:

• Why there might be flaws in the research.
• If there is any particular bias: e.g. does the research have any affiliations with an interested group, or was funding derived from an interested party.
• Statistics: are these relevant? A full appreciation of a paper will obviously be enhanced by a proper understanding of statistics.

Types of Paper

• Systematic Reviews or Meta-Analyses

• Very useful for the busy clinician: someone else has taken the time to look through several related articles, commenting on their conclusions and the reliability of the evidence.
• The Cochrane database website (details below) is an example of this and some journals are published with this specific intent in mind.

Disadvantages

• The conclusions drawn by the reviewer might reflect that person’s own opinions, so care does have to be taken when reading reviews to identify any particular bias.

• Randomized Controlled Trials (RCTs)

• Considered the ‘gold standard’ of research and are an intervention approach.
• Patients are randomly allocated into groups. Usually, one is a control group that receives no intervention, e.g. this group is not treated with an active drug.
• The two patient groups selected should be identical in character.

Disadvantages

• Trial subjects do not lead life in a vacuum and will introduce variables into the trial, e.g. dietary habits.

• Cohort Studies

• Prospective studies following a specific disease or characteristic over a period of time to see how a particular condition in a group of patients develops in comparison to a control group.
• This is how smoking was linked to lung cancer; a group of smoking doctors was followed over 50 years.

Disadvantages

• Time taken for study to be completed.
• Influence of lifestyle variables.

• Case-Control Studies

• Retrospective studies looking at what might cause a disease compared with a control group.
• Show associations, e.g. linking thalidomide to limb-bud malformation.

Disadvantages

• Rely on good record keeping or patient’s memory.
• Control groups are difficult to select.

• Cross-Sectional Studies

• Measure of frequency of a disease or risk factor in a carefully selected part of the population.
• Data is collected at a single point in time.
• Data might be retrospective.
• Cross-sectional studies suggested linkages between vitamin A deficiency and cataracts.

Disadvantages

• Cannot establish the cause of a disease.

Websites

UK Portals

• National Electronic Library for Health: http://www.nelh.nhs.uk (This is a virtual library for the NHS.)
• Healthsites: http://www.healthsites.co.uk/index.php (Gives extensive list of medical gateways and portals.)
• Institute of Health and Life and sciences: http://www.intute.ac.uk/healthandlifesciences (Has replaced Organising Medical Network Information, OMNI. It is a database that enables you to be confident of accessing high-quality internet sites covering health and medicine because they have been assessed by specialists in the topics covered. It is possible to use the database to search for a subject or as a gateway to other reliable sites.)
• PubMed: http://www.ncbi.nlm.nih.gov/entrez/PubMed (A service provided by the US National Library of Medicine that includes millions of citations from journals back to the 1950s. There may be abstracts or links to full text articles denoted by an icon. This service is the database most used by scientists and health professionals.)
• The Cochrane Library: http://www.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME?&SRETRY=0 (A collection of databases that contain high-quality information related to healthcare. The residents of the following countries have full access to the Cochrane database through a ‘national provision’: Australia, Denmark, England, Finland, Ireland, New Zealand, Norway, Scotland, Sweden and Wales.)

Reviews of Healthcare Papers

• University of York NHS Centre for Reviews and Dissemination: http://www.york.ac.uk/inst/crd/index.htm (Provides research-based information about the effects of interventions used in health and social care.)

Online Formularies

• MIMS: only available on subscription.
• Australia: Australian Medicines Handbook: subscription only.
• UK: BNF online: http://www.bnf.org/bnf (UK medication: free registration.)
• USA: http://www.ashp.org/ahfs (American hospital formulary service online; see Chapter 5 ‘Nomenclature’, p. 33.)

US Portals

• US Government Science and Technology gateway and portal websites: http://www.science.gov (Sites that pull together information from across government agencies.)

Gateways

• BUBL: http://www.bubl.ac.uk/link/h/healthlinks.htm (A UK-based gateway enabling access to a wide range of websites on a variety of subjects.)
• United States National Library of Medicine: http://www.nlm.nih.gov

Many databases provide an online tutorial for new users to guide you through the process of excluding information you might not want and refining your search.

Evidence-Based Medicine

• Australia

• National Institute of Clinical Studies: http://www.nhmrc.gov.au/nics/asp/index.asp/(Australia’s official body for marrying evidence-based medicine with clinical practice. As with UK NICE, this is a useful site to keep abreast of new medical guidelines.)

• Canada

• Public Health Agency of Canada: http://www.phac-aspc.gc.ca/dpg_e.html (medical guidelines.)
• Faculty of Medicine and Dentistry of the University of Alberta’s evidence-based medicine website: http://www.med.ualberta.ca/ebm/ebm.htm (Provides toolkits to aid the practice of evidence-based medicine.)

• New Zealand

• New Zealand Guidelines group: http://www.nzgg.org.nz (Attempts to link evidence-based medicine with clinical practice. Good links to health issues sites.)

• UK

• Institute for Health and Life Sciences: http://www.intute.ac.uk/useful-websites/evidence-based (See p. 344)
• Centre for Evidence-Based Medicine: http://www.cebm.net (A brief run-down of what evidence-based medicine is, providing links to evidence-based websites.)

• USA

• National Guideline Clearing House: http://www.guideline.gov (Database of evidence-based practice guidelines.)
• Agency for healthcare research and quality: http://www.ahrq.gov

Tools for Performing Analysis on Evidence-Based Medicine

• National Health Service Critical Appraisal Skills Programme (CASP) website: http://www.phru.nhs.uk/Pages/PHD/CASP.htm
• Scottish Intercollegiate Guidelines Network (SIGN 50). Critical Appraisal. Notes and Checklists: http://www.sign.ac.uk/methodology/checklists.html
• National Institute for Health and Clinical Excellence: http://www.nice.org.uk (Provides guidance in the UK for promoting good health and preventing and treating ill health. For orthodox health professions with tools to implement guidelines given by NICE, so a useful site to see changes that are occurring in current thought on the use of orthodox medication.)

Regulatory Agencies for Healthcare Products

These bodies work to ensure the safety of the general public who are taking drugs, herbs or supplements or using medical devices. Although your respective associations should be keeping you informed of changes in the law or guidelines, these website will keep you abreast of any changes.

Quality Control

• Australia

• Therapeutic goods administration of the Australian government: http://www.tga.gov.au/index.htm (Covers orthodox and complementary medicines.)

• Canada

• Canadian government website on drugs and health products: http://www.hc-sc.gc.ca/dhp-mps/index_e.html

• New Zealand

• Medsafe: http://www.medsafe.govt.nz/(New Zealand’s medicines and medical devices safety authority.)

• UK

• Medicines and Healthcare Products Regulatory Agency: http://www.mhra.gov.uk

• USA

• Food and Drug Agency: http://www.fda.gov

Bibliography on Evidence-Based Medicine

Greenhalgh (1997) Greenhalgh T. How to read a paper: getting your bearings (deciding what a paper is about). British Medical Journal. 1997;315:243-246. Online. Available: http://www.bmj.com/cgi/content/full/315/7102/243

Greenhalgh (1997) Greenhalgh T. How to read a paper: assessing the methodological quality of published papers. British Medical Journal. 1997;315:305-308. Online. Available: http://www.bmj.com/cgi/content/full/315/7103/305

Greenhalgh (1997) Greenhalgh T. How to read a paper: papers that summarise other papers (systematic reviews and meta-analyses). British Medical Journal 1997;. 1997;315:672-675. Online. Available: http://www.bmj.com/cgi/content/full/315/7109/672

Greenhalgh (1997) Greenhalgh T. How to read a paper: statistics for the non-statistician. I: different types of data need different statistical tests. British Medical Journal 1997;. 1997;315:364-366. Online. Available: http://www.bmj.com/cgi/content/full/315/7104/364

Greenhalgh (1997) Greenhalgh T. How to read a paper: statistics for the non-statistician. II: ‘Significant’ relations and their pitfalls. British Medical Journal. 1997;315:422-425. Online. Available: http://www.bmj.com/cgi/content/full/315/7105/422

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