Applying evidence: What's the next action?

Every fortnight my practice group gathers for an early morning “journal club” where we discuss a paper that we think could change our practice. A large pot of tea, an informal atmosphere, and lively discussions have made the sessions popular. But our interest is not the entertainment of pulling apart papers or curiosity about pathophysiology: our central interest is in clinical practice improvement. As in other journal clubs, we critically appraise the paper, calculate the number needed to treat (NNT), and decide on the clinical bottom line. But most journal clubs end there, assuming that everyone will implement the change. But, as we’ve repeatedly experienced, that assumption is often false. So following the traditional EBM steps, we ask, “So what is the next action?”

The “next action” can be a variety of things. Sometimes the next action is garnering some additional information through another search, writing to the authors, or writing to a local expert. It doesn’t need to be a whole implementation plan, just the next physical action and who is responsible for it. For example, at a recent journal club, we discussed measuring blood pressure in both arms. A useful systematic review of blood pressure differences between arms made us aware of several important facts: (a) the prevalence is high, with around 6% of the adult population having at least a 6 mm Hg difference between arms, (b) the prevalence increases with cardiovascular risk factors such as age, diabetes, and smoking, and (c) the pressure in the higher arm is the “correct” one and more predictive of future risk. So we agreed we should do this but recognised the reality of our time pressure (or laziness): unless this was made easy, we wouldn't really do it. We agreed on 2 things: (i) we would only do this once on current patients with hypertension or those suspected of having high blood pressure, and (ii) we should ask the nurse who runs our blood pressure clinic to do this as part of the hypertension clinic.