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Downloaded from ebmh.bmj.com on March 8, 2013 - Published by group.bmj.comEBMH notebook
Of studies, summaries, synopses, and systems: the “4S”
evolution of services for finding current best evidence
Practical resources to support evidence-based healthcare research evidence had to say about the patient’s problem was
decisions are rapidly evolving. New and better services are being immediately at hand. Furthermore, a short synopsis would be at
created through the combined forces of increasing numbers of the point of first interaction with the user to maximise speed of
clinically important studies, increasingly robust evidence syn- use, but this synopsis would be electronically linked to the syn-
thesis and synopsis services, and better information technology theses, then original studies, on which it was based so that the
and systems. The need for these resources is being spurred by user could go to whatever depth was needed to verify the accu-
demands for higher quality at lower cost from health services, racy, currency, and details of the synopsis.
but the impact of better information resources is being blunted Readily available systems don’t reach this level of perfection,
by noisy pretenders, promising “the earth” but yielding just the but production models exist for parts of such systems. Electronic
dirt. Providers and consumers of evidence-based health care can medical record systems with computerised decision support
help themselves to best current evidence by recognising and rules have been shown in randomised trials to improve the
using the most “evolved” information services for the topic areas process, and sometimes the outcome,2 of care, but these cover a
of concern to them. limited range of clinical problems, are not necessarily based on
Figure 1 depicts a “4S” hierarchical structure, with original current best evidence, and are mainly “homebuilt,” thus not eas-
Studies at the base, Syntheses (systematic reviews) of evidence ily acquired in most practice settings.
just above the base, then Synopses of studies and syntheses next Given that we have some way to go before current best
up, and the most evolved evidence-based information “Systems” evidence is integrated into electronic medical records, some
at the top. Information seekers should begin looking at the excellent, but less developed systems are now available. For
highest level resource available for the problem that prompted example, some electronic textbooks integrate evidence-based
their search. information about specific clinical problems and provide regu-
lar updating. UpToDate (on CD and the internet: http://
Systems www.uptodate.com) for general internal medicine is one of the
A perfect evidence-based clinical information system would leading examples of an evidence-based textbook at present, but
integrate and concisely summarise all relevant and important it is not explicit about the processes it uses to ensure that all rel-
research evidence about a clinical problem, and would evant evidence is reviewed, assessed, and included, and it isn’t
automatically link, through an electronic medical record, a spe- integrated into electronic medical records.
cific patient’s circumstances to the relevant information. The Clinical Evidence (http://www.evidence.org) is a new con-
user would then consult the system—in fact, be reminded by the tender. It has an explicit review process, and integrates evidence
system—whenever the patient’s medical record was reviewed. about prevention and treatment for a broad and rapidly
The information contained in the system would be based on an expanding array of clinical problems in all medical disciplines,
explicit review process for finding and evaluating evidence, and including several chapters on mental health disorders. Thus, it
would be reliably updated whenever important new research provides a model for the 4S approach to building information
evidence becomes available, so that the clinician and patient systems that are firmly based on underpinning studies,
could always have the benefit of the current best evidence. syntheses, and synopses. Clinical Evidence is also available on
The system would not tell the decision maker what to Ovid (http://www.ovid.com) as a separate book title, with
do—these clinical judgments would need to integrate the integration into Ovid’s Evidence-Based Medicine Reviews
system’s evidence with the patient’s circumstances and wishes.1 (EBMR) service promised for 2001.
Rather, the system would ensure that whatever cumulative Although none of these systems is integrated with electronic
medical records, they can be run through the same computers
Examples that run electronic medical records, so that one need not go to
a remote location to find them. Unfortunately, connecting the
Computerised decision
Systems
support systems (CDSS)
right information to a specific patient’s problems requires that
clinicians understand evidence-based care principles, and that
Evidence-based journal they apply some effort and skill in using the resources.
Synopses
abstracts Fortunately, these emerging information systems reduce these
burdens considerably.
Syntheses Cochrane reviews
Synopses
Original published When no evidence-based information system exists for a clinical
Studies
articles in journals
problem, then synopses of reviews or individual studies are the
next best source. What busy practitioner has time to use
Figure 1 “4S” levels of organisation of evidence from research. evidence-based resources if the evidence is presented in its
EBMH notebook www.ebmentalhealth.com EBMH Volume 4 May 2001 37
, Downloaded from ebmh.bmj.com on March 8, 2013 - Published by group.bmj.com
original form or even as detailed systematic reviews? While Studies
these detailed articles and reviews are essential building blocks, If all the other Ss fails (ie, no system, synopses, or syntheses),
they are often indigestible if consumed in whole on the run. The that’s the time to look for original studies. On the web these can
perfect synopsis would provide exactly enough information to be retrieved in a number of ways. Especially if you don’t know
support a clinical action, obviating the need to read the whole which database is best suited to your question, search engines
article or review. The most digestible attempt to do this would be that are tuned for healthcare content can assemble access across
the “one liner” declarative titles for the abstracts that appear in a number of web based services. At least one of these search
Evidence-Based Mental Health (EBMH), such as “virtual reality engines is attentive to issues of quality of evidence, namely,
exposure was as effective as standard exposure for reducing fear SUMSearch (http://sumsearch.uthscsa.edu). Nevertheless, the
of flying” in this issue of EBMH. A more detailed summary from user must appraise the items identified by such a search to
one of EBMH’s sister publications, including the declarative title determine which fall within the “quality rated” schema
plus the essential details on which this is based, appears in the presented here—many will not, especially when convenience of
table. In some circumstances, either of these can provide access is favoured over quality. There are also at least 2 levels of
enough information to allow the decision maker to proceed, evidence-based databases to search directly, specialised and
assuming familiarity with the nature of the intervention and its general. If the topic falls within internal medicine and primary
alternatives. If not, the synopsis should be backed up by more care, then Best Evidence provides a specialised, evidence-based
detail, immediately at hand. The full abstract for this item is in service, because the articles abstracted in this database have
Evidence-Based Medicine and Best Evidence, with an abstract and been appraised for scientific merit and clinical relevance. If the
commentary on 1 full printed page. The synopsis in the table search is for a treatment, then the Cochrane Library includes the
could be easily adopted to wireless palmtop internet devices. Cochrane Controlled Trials Register. SilverPlatter and other
bibliographic database companies have specialised versions of
Medline. Medline itself is freely available (http://
www.ncbi.nlm.nih.gov/PubMed/), and the clinical queries
Syntheses screen provides detailed search strategies that home in on clini-
If more detail is needed, or no synopsis is at hand, then cal content for diagnosis, prognosis, treatment, and aetiology.
databases of systematic reviews (“syntheses”) are available, nota- If none of these services provides a satisfying result, it is time
bly the Cochrane Library, which is available on CD, internet to go to the main search screen in Medline’s PubMed and try
(http://www.updateusa.com/clibip/clib.htm), and in Aries there. If you still have no luck, and the topic is, say, a new treat-
Knowledge Finder (KF) (http://www.kfinder.com) and Ovid’s ment (one that your patients have asked about but you don’t yet
EBMR service. These summaries are based on a rigorous search know about), then try Google (http://www.google.com). It is
for evidence, explicit scientific review of the studies uncovered in incredibly fast and can get you to a product monograph in a few
the search, and systematic assembly of the evidence to provide milliseconds. At least you will find what the manufacturer of the
as clear a signal about the effects of a healthcare intervention as treatment claims it can do, as well as detailed information on
the evidence will allow. Unfortunately, these reviews do not yet adverse effects, contraindications, and prescribing. The Google
extend to clinical topics other than preventive or therapeutic home page allows you to add a Google search window to your
interventions. web browser’s home page. Unless you are a very slow typist, this
Stimulated by the success of the Cochrane Collaboration, the is the fastest way to get to almost any service on the internet,
number of systematic reviews in the medical literature has including all the ones named in this article that are web accessi-
grown tremendously in the past few years; if the Cochrane Library ble.
doesn’t have a review on the topic you are interested in, it is It’s worth emphasising that almost all the resources just
worthwhile looking in Medline. Better still, Ovid EBMR and reviewed are available on the internet. The “value added” of
Aries KF provide one stop shopping for both Cochrane and accessing these services on the web is considerable, including
non-Cochrane systematic reviews. For the example of “clozap- links to full text journal articles, patient information, and com-
ine and schizophrenia,” a search on Ovid’s Best Evidence, plementary texts.
Cochrane, DARE, and Medline databases retrieves 736 items.
Limiting this search to “EBM Reviews” (a check box below the
search window in Ovid) cuts this down to 19 items, all but 2 of
which are individual randomised controlled trials that are linked Is it time to change how you seek best evidence?
to Cochrane Reviews in which they are summarised. Cochrane Compare the ‘4S’ approach with how you usually seek
Reviews are also now indexed in Medline: “clozapine and evidence-based information. Is it time to revise your tactics? If,
Cochrane Review” in PubMed retrieves 6 Cochrane reviews in for example, it surprises you that Medline is so low on the 4S list
which clozapine is considered. of resources for finding current best evidence, then this
A prototype for evidence synopsis for hand-held computers*
Based on: Review: clozapine reduces relapse and symptoms compared with typical neuroleptic drugs in schizophrenia. Evidence-Based Medicine 1997
Nov-Dec;2:182. Abstract of: Essali MA, Rezk E, Wahlbeck K, et al. Clozapine v typical neuroleptic medication for schizophrenia. Cochrane Database Syst Rev
1997;(2): latest version 4 March 1997.
Question Study groups Outcome Weighted EER Weighted CER RRR (95% CI) NNT (CI)
Relapse (n=18 studies) 10.8% 13.5% 41% (19 to 57) 37 (19 to 588)
In patients with schizophrenia, Outcome Weighted EER Weighted CER RBI (CI) NNT (CI)
what is the effectiveness of Experimental: clozapine
clozapine compared with Control: typical Clinical improvement
typical neuroleptic drugs? neuroleptic drugs (n=14 studies) 53.3% 34.1% 50% (33 to 69) 6 (5 to 7)
Conclusion: Clozapine reduces relapse and symptoms and produces clinically meaningful improvement in patients with schizophrenia.
*Abbreviations: EER=experimental event rate; CER=control event rate; RRR=relative risk reduction; RBI=relative benefit increase; NNT=number of patients needed to be treated to prevent 1 addi-
tional bad outcome or to create 1 additional improved outcome.
38 Volume 4 May 2001 EBMH www.ebmentalhealth.com EBMH notebook
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