In the past chiropractors relied almost exclusively on their experience, intuitions, theories, systemized rules, or the findings of a celebrated teacher to guide their clinical decisions. With the explosion of information and communication in the 21st century, research evidence now figures in a larger portion of the decision process.
While research evidence is necessary, by itself it is not sufficient to make good health decisions. Expertise can be defined as the ability to interpret and integrate research evidence, clinical experience, patient preferences and values, and the situational context to formulate recommendations and good courses of action.
How to start using research evidence?
It all starts with asking a clinical question. To ask a well-informed question the PICO framework is commonly used. The PICO model is as follows:
P = Patient, Population, or Problem: What are the most important characteristics of the patient; include the primary problem, disease, or co-existing conditions.
I = Intervention: What do you want to do for the patient?
C = Comparison: Are you trying to decide between two or more treatments or diagnostic tests? You do not always have to have a specific comparison.
O = Outcome: What do you hope to accomplish, measure, improve for the patient? What are you trying to do to affect the patient positively?
What studies are more reliable?
Not all studies are equal in validity. Internal validity is the degree that the study has a low risk of bias. External validity is how well the study’s findings are generalizable to the public at large and to your patient specifically. Therefore, not all “best” studies are best for the individual patient under your care.
In Evidence-Based Practice (EBP), research evidence is ranked from the most internally valid to the least. Here are the 3 broad categories of study designs and reviews of the evidence. From the highest to the lowest quality:
- Critically Reviewed or Filtered Sources: Practice Guidelines, Meta-Analysis, and Systematic Reviews.
- Experimental Studies: Randomized controlled trials and non-randomized controlled trials.
- Observational Studies: Cohort Studies, Case-control Studies, Cross-sectional studies, Case Series, and finally Case reports.
How to find the best available evidence?
There are several sources to find research evidence relevant to your clinical question. The main ones are Journals, Presentations, Guidelines, and Point-of-Care Tools.
Journals: A time-honored way of vetting and disseminating research findings. With thousands of medical journals published, it’s important to choose quality journals and avoid those which are considered questionable, pseudo-journals, or predatory. While there is no specific procedure to determine the quality of a journal, you can ask the following questions to find the quality of a journal:
- Does the Journal have a dedicated website and have transparent editorial, publication and review policies available?
- Who are the Editorial board members? Are they known as established experts in the field related to the aim and scope of the journal?
- Is it peer reviewed and do they have a transparent peer review process?
- Are they selective or do they accept and publish almost all submissions, or charge article processing (or publication) fees?
- Are they indexed in major journal indexing agencies, such as Google Scholar, Scopus, PubMed, and DOAJ?
- What is the journal’s Impact factor and other rankings?
- Do they have membership in and endorse guidelines and best practices with COPE (Committee on Publication Ethics) or another recognized organization?
- Is the journal, the publisher of the journal, and the societal organization that sponsors the journal highly regarded from your colleagues and colleges?
- What is the business model of the journal?
More thorough resources and checklists can be found at: http://thinkchecksubmit.org, and Beall’s list of predatory publishers & journals. https://beallslist.net
Presentations: These are continuing education seminars, webinars, and poster presentations. High quality presentations usually have been selected and screened by an accredited educational institution, professional association, and approved by licensing boards.
Guidelines and Best Practices: Clinical practice guidelines (CPG) are recommendations intended to optimize patient care. They are formed by expert reviewers who perform a systematic review of evidence, and an assessment of the benefits and harms of alternative care options. “Best Practices” are clinical decisions informed by the best evidence available, and balanced by patient complexity and provider experience.
Point-of-care tools: are those research and reference resources that a clinician can utilize immediately at the point-of-care with a patient. They are often easy to use and contain filtered information. These tools should include the best and most recent evidence-based research, provide summaries, link to relevant articles and guidelines, are updated regularly, and are easy to search
Should clinicians read individual research studies?
In general, probably not. A practitioner’s focus and training are on applying research findings to their patient care. They often do not have the skills or time to critically evaluate individual studies. Most should start by utilizing filtered sources of information, namely practice guidelines, systematic reviews, and meta-analyses. Since these sources give recommendations that are generalizations, clinicians can further research unfiltered information for findings that may help their individual patient.
In the end, all research data are tools, not rules to make better clinical decisions for better patient care.
About the Author:
Dr. David Graber is nationally known presenter on chiropractic technique and is a member of the ANJC board of directors. He maintains a private practice in Parsippany, NJ. He blogs on chiropractic and clinical topics at: drgraber.wordpress.com. He can be reached at: DrDavidGraber@gmail.com.
Published originally in the ANJC Journal: NJ Chiropractor, Spring 2023
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