Systematic Reviews in Surgical Decision Making: Unpacking the Data
Clifford Chacha Mwita1, 2
Moi University School of Medicine, Eldoret
Research and Evidence, Afya Research Africa, Nairobi
Correspondence to: Clifford C. Mwita, , P. O. Box 4606-30100, Eldoret, Kenya.
The practice of surgery has always involved a process of trying to understand the pathophysiology of surgical conditions and introducing interventions to alter their course. With time, numerous interventions have become available and contemporary surgical practice warrants that surgeons possess skills in utilizing the best available high-quality evidence for patient care. Such evidence is afforded by systematic reviews. Utilizing such reviews involves a process of reading and interpretation in which the surgeon attempts to determine whether a sensible clinical question was addressed, the search for relevant literature was exhaustive, assessment of identified studies was reproducible, reported results were properly summarized and whether any recognized benefits are worth the potential risks and costs of the intervention. This process aids the surgeon when making recommendations regarding treatment and it must incorporate patient values and preferences.
Keywords: Systematic Reviews, Evidence-Based Surgery
Ann Afr Surg. 2017;14(1): 40-43.
© 2017 Annals of African Surgery. This work is licensed under the Creative Commons Attribution 4.0 International License.
Since its inception, the practice of surgery has involved a process of trying to understand the pathophysiology of surgical disease, introducing an intervention to alter this pathophysiology and observation of the results thereafter (1). However, with time, it has become apparent that the translation of basic physiological principles to patient care does not always lead to improved outcome thereby creating a need for more rigorous methods of evaluating the effects of available treatment options. Modern surgical practice is awash with numerous new interventions and technologies. Most of these are reported to be beneficial to the patient although it is often unclear whether the observed outcomes are due to the intervention itself or due to chance since inherent differences in patients may lead to an observation of effect even where there is none (1, 2). For this reason, it is important that surgeons are equipped with the skills necessary for the identification, evaluation, and utilization of research findings. This review introduces the notion of evidence-based surgery (EBS) with a particular focus on the utilization of systematic reviews by practicing surgeons.
Sackett and colleagues define evidence-based medicine (EBM) as the “...conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” (3). This definition encompasses five key and interrelated ideas that are central to the practice of evidence-based surgery (1). One, as surgeons, we must base our decisions on the best available evidence. Second, whatever evidence we seek must be based on the problems we encounter in our practice. Third, for the purpose of reducing bias, identification of best evidence should involve employing epidemiological and biostatistical ways of thinking. Four, evidence that has been identified and critically appraised is only useful if applied to patient care and/or decision making in healthcare. Finally, our performance in the process of generating and utilizing the best evidence must be constantly re-evaluated. Herein lies the value of surgical audit in evidence-based surgery.
EBS affords us little room (if any) for basing decisions on expert opinion or anecdotal experience. However, the application of best evidence to patient care involves the integration of clinical acumen and incorporation of patient preferences and values in decision making (1, 3, 4). Further, we must remember that EBS is dependent on context. As an example, the advantages of laparoscopic cholecystectomy are well known and documented. However, in low resource settings, the absence of surgeons with skills in laparoscopy as well as lack of the requisite equipment means that only open cholecystectomy can be performed. Further, even if both surgeons and equipment were available, patients may be unable to afford the procedure. Nonetheless, even in such a context, there are best evidence practices regarding open cholecystectomy that should be adhered to.
The steps involved in applying EBS have been outlined by Rosenberg and Donald (5). First, one must clearly identify and articulate a question arising from surgical practice. Second, there should be a focused search of the literature relevant to the question with subsequent critical appraisal of the identified literature. Finally, there must be an implementation of the new knowledge of the surgical practice. As such, the necessary elements of EBS are the production and dissemination of high-quality evidence on which to base surgical decisions (1).