Evidence-based care in gynaecology

CHAPTER 68 Evidence-based care in gynaecology






Evidence-Based Medicine Processes


The practice of EBM involves systematically identifying, appraising and applying contemporaneous research findings as the basis of clinical decisions. This process is often summarized by the four ‘A’s:






A fifth ‘A’ for ‘Audit’ can be added to these steps to take EBM beyond the care of the individual patient (Figure 68.2).




Formulation of a structured question


A well-structured question is essential in order to get the right clinical answer. It also facilitates the process of searching for evidence. A suggested approach uses five components (PICOD: Population, Intervention, Comparison, Outcome(s) and Design), as shown in Table 68.1.


Table 68.1 Components of structured clinical questions



























Component Example 1 Example 2
P: Population, patient or problem In women suffering with heavy menstrual bleeding… In postoperative women with swollen legs…
I: Intervention (test, medical or surgical treatment, or process of care) … would treatment with norethisterone… … would a Doppler ultrasound be accurate…
C: Comparison (placebo, another alternative treatment or the gold standard in a diagnostic accuracy study) … compared with no treatment at all or alternative treatments (e.g. levonorgestrel IUS)… … compared with venography as the gold standard…
O: Outcome(s) … lead to an improvement in their symptoms? … in diagnosing deep venous thrombosis?
D: Ideal design for the study A randomized controlled trial A test accuracy study

IUS, intrauterine system. Produced by Bob Phillips, Chris Ball, Dave Sackett, Doug Badenoch, Sharon Straus, Brian Haynes, Martin Dawes since November 1998. Updated by Jeremy Howick March 2009.


The purpose of this step is to get clarity regarding the clinical question. Writing down the question in free form often makes it possible to break it down into a PICOD format. In practice, this may not always be feasible for all clinical questions, and missing out some elements of PICOD is not necessarily a cause for concern.



Searching the literature


Approximately 17,000 journals collectively publish over 1 million biomedical articles each year. Identifying relevant articles will require the use of apposite keywords (and their combinations) to search appropriate databases. A hierarchical approach to literature searching is recommended (Figure 68.3).



The first step is to look for an up-to-date professional guideline that has been developed on the basis of systematic appraisal of available evidence. Table 68.2 lists some sources of guidelines and evidence summaries. The Royal College of Obstetricians and Gynaecologists (RCOG) has long acknowledged the need to update clinical practice on the basis of research findings. Since 1973, the RCOG has regularly convened study groups to address important growth areas within the specialty. These groups have met, evaluated the results of research and conducted in-depth discussions on a variety of topics. These discussions have shaped the development of clinical recommendations which were initially based on consensus. Over the years, this approach has been modified in order to produce genuine evidence-based guidelines. To be effective and relevant, guidelines must fulfil fthe following three essential criteria.





Table 68.2 Sources of guidelines and evidence summaries (relevant for gynaecology)

























































Sources of guidelines and evidence summaries Website
Royal College of Obstetricians and Gynaecologists (RCOG) www.rcog.org.uk
American College of Obstetricians and Gynecologists (ACOG) www.acog.org
The Society of Obstetricians and Gynaecologists of Canada (SOGC) www.sogc.org
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) www.ranzcog.edu.au
International Federation of Gynecology and Obstetrics (FIGO) www.figo.org
Faculty of Sexual and Reproductive Healthcare (FFPRHC) www.ffprhc.org.uk
British Fertility Society (BFS) www.britishfertilitysociety.org.uk
British Gynaecological Cancer Society (BGCS) www.bgcs.org.uk
British Society for Colposcopy and Cervical Pathology (BSCCP) www.bsccp.org.uk
British Society of Urogynaecology (BSUG) www.rcog.org.uk/bsug
British Society for Gynaecological Endoscopy (BSGE) www.bsge.org.uk
The Association of Early Pregnancy Units (AEPU) www.earlypregnancy.org.uk
The NHS National Library for Health (NLH) www.library.nhs.uk
The National Institute for Health Clinical Excellence (NICE) www.nice.org.uk
Scottish Intercollegiate Guideline Network (SIGN) www.sign.ac.uk
NHS Clinical Knowledge Summaries (NHS CKS; formerly PRODIGY) www.cks.library.nhs.uk
The National Guideline Clearing House (NGC, US) www.guidelines.gov

It is generally anticipated that national guidelines will, in turn, be used as a basis for the development of local protocols and guidelines in conjunction with local commissioners and providers of health care as well as service users. These should take into account the specific needs of local service provision and the preferences of the local population.


In the absence of credible evidence-based guidelines, the next step would be to search for an up-to-date, good-quality, systematic review. Some sources of systematic reviews are given in Table 68.3.


Table 68.3 Sources of evidence


























Systematic reviews
Sources of systematic reviews Website
The Cochrane Library www.cochrane.org/reviews/
The CRD databases (including DARE) www.crd.york.ac.uk/crdweb
The Pubmed Systematic Reviews Search Filter www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml
Bandolier www.jr2.ox.ac.uk/bandolier
The WHO Reproductive Health Library (RHL) www.rhlibrary.com
Health Technology Assessment (HTA) database www.ncchta.org/project/htapubs.asp
































Sources of primary literature
Sources of primary literature Subject matter Website
Pubmed (Medline) Medicine, bioscience www.pubmed.gov
EMBASE Medicine, pharmacology, nursing www.embase.com
CINAHL Nursing and allied health care www.cinahl.com
AMED Allied and alternative health care www.bl.uk (search for ‘AMED’)
BNI (British Nursing Index) Nursing  
HMIC (Health Management Information Consortium) database Health management  

WHO, World Health Organization; CRD, Centre for Reviews and Dissemination; DARE, Database of Abstracts of Reviews of Effectiveness.


Apart from the traditional sources of systematic reviews, such as the Cochrane Library and DARE, MEDLINE and Pubmed have now become a rich source of systematic reviews. Pubmed contains a systematic review filter within Pubmed Clinical Queries (http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml), and MEDLINE has the indexing term ‘reviews, systematic’ as a ‘publication type’.


If no systematic reviews are identified, or if reviews are out-of-date, non-systematic or of marginal relevance to the clinical question, it is necessary to continue the literature search for primary studies. Table 68.3 provides a list of important sources of primary literature.

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Jun 4, 2016 | Posted by in GYNECOLOGY | Comments Off on Evidence-based care in gynaecology

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