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EDITORIALS: Simon R J Maxwell Evidence based prescribing BMJ 2005; 331: 247-248 [Full text]

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Rational and Evidence based Presribing

Sethuraman K Raman   (29 July 2005)

Hospital and Primary Care Trust formularies restricts evidence-based practice

Joseph Kwan   (30 July 2005)

Evidence Based Prescribing and Primary Care

Dr. Chandrakant Madgaonkar   (3 August 2005)

Rational and Evidence based Presribing 29 July 2005
Sethuraman K Raman, Director-Professor of Medicine JIPMER, Pondicherry 605006 India Send response to journal: Re: Rational and Evidence based Presribing	Senior clinicians would cite several instances of prescriptions that were rational but not based on solid evidence. Rationality and strength of evidence base are two facets of mindful and prudent practice. It is an ideal prescription that is rational and based on strong evidence. It is acceptable to be rational without adequate evidence. However, one should avoid evidence based irrationality and empiricism that is irrational as well. Competing interests: None declared
Hospital and Primary Care Trust formularies restricts evidence-based practice 30 July 2005
Joseph Kwan, Specialist Registrar in Geriatric Medicine University of Southampton Send response to journal: Re: Hospital and Primary Care Trust formularies restricts evidence-based practice	Editor - I read with interest the editorial by Simon Maxwell, called "Evidence based prescribing" [1]. I agree with Dr Maxwell that evidence- based prescribing is indeed complex and requires a combination of clinical experience, common sense and some basic knowledge about clinical pharmacology. Working as a medical SpR in a hospital environment, the medications that I can prescribe are governed primarily by a strict hospital formulary, and in some cases, the PCT formulary. In the formulary, there are often very limited number of drugs (often just a single drug) that can be prescribed for each class, and the choice of those drugs is often determined not by evidence but cost per tablet (and not even longer-term cost-effectiveness). This kind of restriction is often defended by policy-makers using the "class effect" argument, which cannot possibly be true for every drug class. The necessity of the hospital to slash the drug budget has led to some very good drugs being excluded from the formulary even though their use is supported by class A evidence and even national clinical guidelines. As clinicians, we are encouraged to practice evidence-based medicine, and many of us spend hours every week familiarising ourselves with the latest research evidence about our relevant specialist fields. What is the point of doing all this when we have no power to prescribe the drug that we believe to be the best choice for our patients? Furthermore, why should pharmaceutical companies spend millions of pounds in supporting research and developing new and better drugs when the NHS urges drug formularies to include only those drugs which are the cheapest and not primarily those which are supported by good evidence? What will happen to our clinical and prescribing autonomy in the future as medical practice in the UK moves further towards being purely protocol-driven? Over the past few years, I have personally seen true evidence-based practice being steadily eroded within the NHS. If it is to thrive again or even survive, I urge policy-makers to re-consider the impact of their ever -increasingly restrictive prescribing policy. Reference: [1] Maxwell SRJ. Evidence based prescribing. BMJ 2005;331:247-248. Competing interests: None declared
Evidence Based Prescribing and Primary Care 3 August 2005
Dr. Chandrakant Madgaonkar, Family Physician J C nagar; Hubli - 580020; India Send response to journal: Re: Evidence Based Prescribing and Primary Care	It is evident that “Enthusiasm for evidence based prescribing is welcome and should lead to safer and more effective use of medicines. But it also poses some real problems for prescribers” (1) – especially so in primary care / general practice, wherein “evidence has to be interpreted in the light of variables such as patients' co morbidities…” (1) The essential components of Evidence Based Medicine (EBM) that must be considered for it to be more meaningful and effective in primary care setting may be summarized as follows: Essentials of EBM in primary care – • Since family practice is a broad-based specialty, it necessarily requires the physician to manage a broad range of conditions, which are typically presented in an ill defined manner, incorporating therein not just physical aspects of illness, but also mental, social, environmental circumstances. • Clinical guidelines may be based on evidence, which is applicable to general practice. A rigid protocol would be inappropriate for the complexities of conditions presenting in general practice and may therefore not improve health outcomes. • To be relevant for general practice, EBM needs to broaden its approach. It should incorporate alternative methodology to assess the effectiveness of management options, which cannot be evaluated with qualitative date from randomized clinical trails. • It is crucial that the skills and judgments of physicians in the practical setting are respected and enhanced by EBM. • It is important that clinical guidelines formulated on the basis of assessed evidence are developed by practicing physicians in such a way as to provide useful assistance in practical settings rather than merely as a ‘recipe’ for intervention. • It is essential that the use of evidence-based guidelines is evaluated by physicians in a general practice setting to identify use, limitations and benefits. • Increasingly many physicians will practice in a multidisciplinary context, and where appropriate, clinical guidelines should be constructed in a multidisciplinary environment so that they are able to promote effective teamwork in relevant practice settings. Finally, the term EBM was developed to encourage practitioners and patients to pay due respect – no more no less – to current best evidence in making decisions. An alternative term that may find more appealing is, “Research enhanced Health care”. (2) References: 1 - Simon R J Maxwell- Editorial- Evidence based Prescribing - BMJ 2005;331:247-248 (30 July), 2 - Haynes R B et al. Physicians’ and patients’ choice in evidence based practice. BMJ 2002, 324:1350 Competing interests: None declared