How do you make sure that the advice you give every day is evidence-based? Dr Shazia Bashir, associate lecturer at UCL, pharmacist and medical writer, and Dr Karolina Dziemidowicz, post-doctoral research fellow at UCL, pharmacist and teaching practitioner (pharmacy), suggest the easiest route to getting this right and keeping informed.
Pharmacists are frequently asked for advice on new therapies and healthcare trends, with the most recent example being topics related to the Covid-19 pandemic.
The dynamic situation in which pharmacists have been forced to operate has, more than ever, required them to keep up-to-date with emerging evidence.
Pharmacists will often need to proactively look for reliable sources of information that can be used in daily practice, long before official guidelines are even issued.
For example, pharmacists are currently playing an important role in informing the general public about the safety and efficacy of the approved vaccines for Covid-19. To do this, it is essential to understand the fundamental science behind the subject, and to be sure that your information comes from reliable, and suitable scientifically-based, sources.
An ideal way of keeping updated is to conduct a quick literature evaluation. This can help to strengthen your knowledge, as well as provide confidence and support when pharmacists are bombarded with questions throughout the working day.
Maintaining and developing professional knowledge is, of course, one of the standards set out by the General Pharmaceutical Council, and every registered pharmacist is expected to use evidence in their decision-making process.1
So, how do you best go about rapidly finding the information you need?
1. Keep up-to-date with current healthcare-related topics
A good way to anticipate healthcare-related enquiries is to follow popular news outlets. Keeping informed by following media channels, such as national newspapers or broadcasters, provides a practical insight into current ‘hot topics’ in healthcare.
Journalistic articles and features are examples of secondary sources of information that are not peer-reviewed and are therefore subject to bias or misinterpretation.2 For this reason, media platforms are only useful as a guidance for further literature searches, focusing on sources that are more reliable.
Skincare is a topic that many pharmacists are often required to offer advice about. While patients will be able to find articles and blogs in the consumer press on skincare that are not scientifically based, there are useful review papers with more reliability that can be easily accessed by the pharmacy team, listing various bioactive ingredients and nutraceuticals that can improve the health of skin3 and reduce the effects of ageing.4
2. Reach out to scientific literature for trustworthy information
When searching for information about a particular theme, a good start is to read some review articles. Similar to journalistic articles, these are secondary sources of information but based on original research articles (i.e. primary sources) that are peer-reviewed and published in reputable journals, leading to reliable and validated claims. They provide a useful summary of current developments in a particular field and provide a wealth of information surrounding the topic. It will consist of a critique and analysis of a collection of publications based on primary research. The citations and references can provide further reading for those curious enough to want to dig deeper.
To look for publications and manuscripts related to health and life sciences, specialised search engines are the next step. Examples include PubMed, Science Direct, and Scopus, and usually require a subscription or access via an institution. For free online access, a very good secondary search engine is Google Scholar and it lists articles from medical and scientific journals from a variety of databases.5 Most researchers will have a favourite online platform that they tend to use, usually depending on their field of research.
When looking for a review article, be mindful of using appropriate key words to streamline the search.
For example, the recent interest in using artificial intelligence (AI) to interpret health data6 has been at the forefront of medical diagnostics during the Covid-19 pandemic. Inputting the terms ‘artificial intelligence’ and ‘review’ into Google Scholar results in over 2 million articles, so to filter the search, add other keywords such as ‘Type 1 diabetes’, ‘diabetic retinopathy screening’ and ‘Covid-19’. In addition, the results can be streamlined further by restricting the search to papers published from 2020, to capture the most significant research that has emerged since the pandemic started. Use of these keywords will still generate 1,330 results, but the first three pages will provide the most relevant studies.
The benefits of probiotics to improve and maintain gut health is now being recognised by consumers and healthcare professionals alike[BS1] .7 However, what is less known is the wider implications of taking probiotic supplements and how the beneficial effects can extend beyond the gut to the rest of the body[BS2] .8
For pharmacists to confidently recommend appropriate probiotic formulations for specific conditions, a quick literature search can be extremely useful to update knowledge and therefore, provide suitable advice that is evidence-based. Inputting keywords into Google Scholar such as ‘community pharmacy’, ‘probiotics’ and ‘review articles’, will generate over 2,000 results. However, to narrow the search output, more specific terms can be added. If, for example, the target patient is a female who is looking for non-drug related treatments to alleviate symptoms of thrush and prevent reoccurrence, then inclusion of the keyword ‘vaginal health’ will narrow the search to a more manageable number and usually, by skimming the list of titles, key papers can be found from which appropriate information can be extracted.
From the several different types of review articles that may be found in a search, the following are the most appropriate for healthcare professionals to obtain evidence-based information:
These type of literature reviews are robust, thorough and comprehensive to obtain a more accurate and evidence-based assessment of a research question. By comparing and contrasting, a large body of data, from a wide range of sources obtained from primary literature, the results are analysed collectively to assess for consistency and replicability in the data. An explicit selection criterion is applied, using pre-determined methodologies, for inclusion within the review, and are typically (although not always) quantitatively analysed for statistical significance. The aim of systematic reviews is to obtain a more balanced overview of medical and clinical interventions and minimise bias and error to determine the overall accuracy with reference to a research question.
Systematic reviews are used in evidence-based medicine to enable practitioners, clinicians and policy makers to make decisions based on rigorous analysis of a collection of different clinical studies, to determine a more balanced and unbiased conclusion of the benefits and risks, before new medical interventions are approved for use in patients and in clinical settings.
The research question is always unambiguous and clear because systematic reviews are designed to clarify and iron out confusion in healthcare-related research.
For example, a recent systematic review investigated the claims that low levels of vitamin D increased the risk and prognosis of Covid-19 infection.9 Although there is evidence in the literature of this link, the published data from individual studies were found to be inconsistent. The systematic review concluded that there was a possibility that low vitamin D status increased the risk of Covid-19 prognosis but further supportive studies were needed.
Cochrane systematic reviews
The Cochrane collaboration is a global organisation that systematically reviews clinical studies with the aim of improving and aiding decision making in healthcare and health policy.10 The reviews are published in the Cochrane Database of Systematic Reviews within the Cochrane Library.
The explicit and rigorous methods applied to the systematic reviews ensure minimal bias in the review process and this makes Cochrane reviews an especially reliable source of clinical and healthcare evidence. Cochrane reviews are updated to reflect current findings and new evidence, therefore this database is reputable, reliable and influential for decision making in clinical settings. Furthermore, the Cochrane database gives open access to the public so patients can be informed about health and medical interventions that may affect their treatment.
An excellent example of a published Cochrane systematic review article is an investigation to assess the diagnostic accuracy of signs and symptoms of Covid-19, to determine if a person presenting in primary care or to hospital outpatient settings (e.g accident and emergency wards), has Covid-19.11 This review was published to aid healthcare professionals in both primary and secondary care, to either rule out the possibility of infection, or to refer for further testing. The first section of the article explains the details of the investigation in ‘plain language’ such that the general public could read, interpret and comprehend the findings of the review.
Narrative reviews are used traditionally in scientific research and consist of a critical analysis of a body of primary literature on a particular topic or theme, to review the current progress and development. There is no particular methodology or system followed when selecting primary sources and are written as scholarly articles to enhance understanding of a subject or identify gaps in research. They are peer-reviewed articles and can be found in reputable scientific journals.
3. Look for short scientific commentaries
Scientific commentaries are highlights written by scientists who are discussing current issues and important developments in a particular field. They are usually popular and well received by readers in scientific journals because they are concise, informative and clear.
An example of a commentary is the recent discussion of a call to begin clinical trials investigating potential risks and benefits of Covid-19 vaccines in pregnant women, and to address the safety issues which are unknown since pregnant women were excluded from the initial clinical trials.12 This type of commentary is always useful for pharmacists and health professionals due to the relevance in patient-facing environments.
4. Original research
These articles report novel research findings where the author is the person who conducted the study and are classified as primary literature. The format of the paper consists of an Abstract, Introduction, Methodology, Discussion regarding the findings and their implications, and a Conclusion.
The abstract is a ‘snap-shot’ of the full study that is being discussed in the manuscript and highlights the most important features of the article. Readers can scan this section and make a decision as to whether the contents of the paper are relevant and worth reading further.
This section of the article is possibly the most important part of the whole paper. If the reader cannot comprehend the meaning of the paper from this concise summary, then it is very unlikely they will continue.
In the academic world, a common practice is to run Journal Clubs – much like a book club where scientists gather to critically analyse recently published articles important to their fields. During such meetings, one person will summarise the article – covering every section– and critically appraise the aims, methodologies and results arising from this work. Such scientific discussion is an effective way to develop one’s critical thinking – rather than accepting published research at face value. Similar concepts are applicable to pharmacists13 and other healthcare professionals, where events are organised to bring together the exchanging and sharing of ideas, novel practices and professional support.
Be armed with knowledge
The ever changing and dynamic landscape underpinning healthcare delivery and the provision of quality services means a well-researched pharmacist is armed with knowledge, confidence (and charm!) to deal with all issues and situations pertaining to their patients’ needs and requirements.
From digital diagnostic techniques, utilising machine learning and artificial intelligence, to a workable understanding of the concept of ‘personalised medicine’ designed to deliver treatment at the ‘right time and right place’, the integration of research in pharmacy practice is the way forward for all those inquisitive pharmacists who are keen to expand their horizons for the sake of making a positive contribution to the public at large.
There’s no time like the present to be well prepared.
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3. Michalak, M., Pierzak, M., Kręcisz, B. & Suliga, E. Bioactive Compounds for Skin Health: A Review. Nutrients. 13, 203 (2021). Available at https://doi.org/10.3390/nu13010203.
4. Misaki, H. Role of anti-oxidants in the skin: Anti-ageing effects. J Dermatol Sci. 58, 85 (2010). Available at http://doi.org/10.1016/j.jdermsci.2010.03.003.
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8. Cunningham, M., Azcarate-Peril, M. A., Barnard, A., Benoit, V., Grimaldi, R., Guyonnet, D., Holscher, H. D., Hunter, K., Manurung, S., Obis, D., Petrova, M. I., Steinert, R. E., Swanson, K. S., van Sinderen, D., Vulevic, J. & Gibson, G. R. Shaping the future of probiotics and prebiotics. Trends Microbiol. 29, 667 (2021). Available at https://doi.org/10.1016/j.tim.2021.01.003
9. Liu, N., Sun, J., Wang, X., Xhang, T., Zhao, M. & Li, H. Low vitamin D status is associated with coranavirus disease 2019 outcomes: a systematic review and meta-analysis. Int J Infect Dis. 104, 58 (2021). Available at https://doi.org/10.1016/j.ijid.2020.12.077
10. Henderson, L. K., Craig, J. C., Willis, N. S., Tovey, D. & Webster, A. C. How to write a Cochrane systematic review. Nephrology (Carlton). 15, 617–624 (2010). Available at https://doi.org/10.1111/j.1440-1797.2010.01380.x
11. Struyf, T., Deeks, J. J., Dinnes, J., Takwoingi, Y., Davenport, C., Leeflang, M. M., Spijker, R., Hooft, L., Emperador, D., Dittrich, S., Domen, J., Horn, S. R. A. & Van den Bruel, A. Signs and symptoms to determine if a patient presenting in primary care or hospital outpatient settings has COVID‐19 disease. Cochrane Database Syst. Rev. 7 (2020). Available at http://doi.org/10.1002/14651858.CD013665.
12. Schaffer, C. Q&A: New trials tackle Covid-19 vaccines in pregnant women. (https://www.the-scientist.com/news-opinion/qa-new-trials-tackle-covid-19-vaccines-in-pregnancy-68494) (2021).
13. Dickerson, R. N., Wood, G. C., Swanson, J. M. & Brown, R. O. Redesigning journal clubs to staying current with the literature. Pharmacy. 5, 62 (2017). Available at http://doi.org/10.3390/pharmacy5040062.