Users' guides to the medical literature: XX. Integrating research evidence with the care of the individual patient. Evidence-Based Medicine Working Group

Abstract

Clinicians can use research results to determine optimal care for an individual patient by using a patient's baseline risk estimate, clinical prediction guidelines that quantitate an individual patient's potential for benefit, and published articles. We propose that when clinicians are determining the likelihood that treatment will prevent the target event (at the expense of adverse events) in a patient that they also incorporate the patient's values. The 3 main elements to joint clinical decision making are disclosure of information about the risks and benefits of therapeutic alternatives, exploration of the patient's values about both the therapy and potential outcomes, and the actual decision. In addressing the patient's risk of adverse events without treatment and risk of harm with therapy, clinicians must recognize that patients are rarely identical to the average study patient. Differences between study participants and patients in real-world practice tend to be quantitative (differences in degree of risk of the outcome or responsiveness to therapy) rather than qualitative (no risk or adverse response to therapy). The number needed to treat and number needed to harm can be used to generate patient-specific estimates relative to the risk of the outcome event. Clinicians must consider a patient's risk of adverse events from any intervention and incorporate the patient's values in clinical decision making by using information about the risks and benefits of therapeutic alternatives. JAMA. 2000;283:2829-2836