Evidence in Clinical Practice

Question 1

What is the best source of evidence to support clinical practice?

Answer 1

Clinical guidelines

Question 2

If clinical guidelines are not found, what is the next best source of evidence to support clinical practice?

Answer 2

Evidence summaries

Question 3

If evidence summaries are not found, what is the next best source of evidence to support clinical practice?

Answer 3

Systematic reviews

Question 4

If systematic reviews are not found, what is the next best source of evidence to support clinical practice?

Answer 4

Primary research

Question 5

Why are secondary sources of information used over primary sources, when looking for evidence to support clinical practice?

Answer 5

A single study is rarely enough to provide robust, unbiased evidence to influence a guideline change

Question 6

What is an example of a clinical guideline source?

Answer 6

NICE

Question 7

What is an example of an evidence summary source?

Answer 7

BMJ

Question 8

What is an example of a systematic review source?

Answer 8

Cochran Library

Question 9

When searching for a primary source, what can be used to target the right type of study?

Answer 9

Methodological filters in a bibliographic database

Question 10

How do clinical guidelines go a step further than evidence summaries?

Answer 10

They develop recommendations for clinical practice from available evidence and expert opinion

Question 11

What drives the systematic literature reviews which help form clinical guidelines?

Answer 11

Need for information, regardless of the type or quality of evidence

Question 12

Give four characteristics of clinical guidelines which make them the highest quality source of evidence for supporting clinical practice

Answer 12

They include a systematic review of evidence, including economic analysis
They consider several clinical questions, so the entire disease management pathway is covered
The guidelines evaluate confidence and certainty of the evidence
They engage stakeholders about whom the guidelines concern

Question 13

What is the GRADE tool used for?

Answer 13

To assess confidence in the results of evidence summaries, when forming clinical guidelines

Question 14

What information does the GRADE table present?

Answer 14

The number, type and quality of studies for each clinical outcome

Question 15

Why must each clinical outcome be considered separately when using the GRADE tool?

Answer 15

Because the quality of evidence can vary for different clinical outcomes

Question 16

What are the five domains which make up the GRADE tool?

Answer 16

Risk of bias
Imprecision
Inconsistency
Indirectness
Publication bias

Question 17

How is the rating of each domain determined in the GRADE tool?

Answer 17

According to how close the size of the effect estimated by the evidence is to the trust effect seen in practice

Question 18

How is risk of bias assessed in the GRADE tool?

Answer 18

Using the evidence hierarchy and critical appraisal of individual studies used

Question 19

How is imprecision assessed in the GRADE tool?

Answer 19

Based on the width of confidence intervals

Question 20

How is inconsistency assessed in the GRADE tool?

Answer 20

Based on the similarity between the results of individual studies
Whether confidence intervals overlap or not

Question 21

How is indirectness assessed in the GRADE tool?

Answer 21

Based on the applicability of evidence to the population
Base on the setting of interest

Question 22

How is publication bias assessed in the GRADE tool?

Answer 22

Based on the potential effect that excluding studies from the review would have on the estimate of the effect

Question 23

When evidence is turned into recommendations, who is input required from?

Answer 23

MDT guideline group
Stakeholders

Question 24

When evidence is turned into recommendations, what does the strength of recommendation depend on?

Answer 24

Strength and certainty of evidence
Size of the effect relative to adverse effects
The cost of the intervention, both monetary and training hours
Whether patient preferences are in agreement or not

Question 25

If guideline recommendations are weak, what is essential before they are implemented?

Answer 25

Shared decision making

Question 26

What three components make up the appraisal of guidelines?

Answer 26

Validity
Clinical relevance/applicability
An appraisal tool (AGREE II)

Question 27

What does a validity appraisal of guidelines ask?

Answer 27

Whether the guidelines are up to date and trustworthy or not

Question 28

What does a clinical relevance appraisal of guidelines involve?

Answer 28

Whether guidelines are applicable to patients and the clinical context

Question 29

What does AGREE II stand for?

Answer 29

Appraisal of Guidelines for REsearch and Evaluation II

Question 30

How many domains are in the AGREE II checklist?

Answer 30

6

Question 31

What do domains 1, 3 and 5 of the AGREE II tool (the CASP style domains) check?

Answer 31

Purpose, rigour of development and applicability of the guidelines

Question 32

What do domains 2, 4 and 6 of the AGREE II tool check?

Answer 32

Engagement of stakeholders
Clarity of recommendations

Question 33

What are clinical guidelines used for (three examples)

Answer 33

Facilitate shared decision making between practitioners and patients, especially if the evidence is poor
Facilitate sharing of the evidence base for clinical practice between practitioners
As a tool for quality assurance activities

Question 34

Give three quality assurance activities which clinical guidelines can be used for

Answer 34

Care pathways
Performance indicators/measures
Clinical audits and review criteria

Question 35

What are three overarching distinguishing features of guidelines?

Answer 35

Comprehensive literature searchers driven by information need rather than evidence type or quality
Grading of certainty of evidence for each clinical outcome
Development of recommendations for practice