A clinical decision on the use of complementary and alternative medicine (CAM) should be made based on evidence-based medicine (EBM) together with practitioner's knowledge and experiences. This chapter describes the process of EBM, including how to address a clinical question, do a systematic search for appropriate evidence with key search terms, appraise the evidence and make a clinical decision on CAM applications. An effective literature search should be performed by using a structured search strategy in searching biomedical and CAM databases, such as the National Center for Complementary and Alternative Medicine (CAM Citation Index). Few standard tools are recommended to evaluate the quality of CAM studies, i.e. the CONSORT extension for herbal interventions and STRICTA for RCTs of acupuncture. Additionally, some guidelines for designing RCTs in Chinese herbal medicine (CHM) can also be adopted to critique CAM literature. A clinical decision on choosing optimal CAM for patient care should be based on the current best evidence emerged from the EBM process.
TopIntroduction
Decision-making on optimising the use of complementary and alternative medicine (CAM) is challenged for clinical practitioners due to a lack of robust clinical evidence. Therefore alternative approaches such as anecdotes or recommendations from others, may be used to rationalise clinical decisions. However, the evidence-based medicine (EBM) process which is employed in western or conventional medicine to facilitate clinical decision making, is an appropriate approach to making a decisions whether to use CAM. Three key components, i.e. clinical expertise, patient’s values and preferences, and the best research evidence, should be integrated into the EBM decision-making process to ensure optimum health outcomes in terms of therapeutic, economic or humanistic impacts.
According to Sackett and team (1996) EBM refers to the conscientious, explicit and judicious use of current best evidence in making decisions about individual patient care. Another definition is ‘the ‘systematic reviewing, critically appraising and using results from clinical studies in order to provide optimal patient care’ (Rosenberg, et al., 1995). The correct concept of evidence source and quality, together with the relevant skills required to retrieve, appraise and apply the best current evidence is the foundation for making an evidence-based clinical decision when choosing CAM. This chapter outlines these processes.
Prior knowledge of best current evidence is the cornerstone to implementing EBM into clinical decision-making. Evidence is generally referred to as a fact or information obtained from clinical or scientific studies using appropriate methodologies, however the quality of evidence varies. Several organisations, e.g. Oxford Centre for Evidence-Based Medicine, or the Scottish Intercollegiate Guidelines Network (SIGN), have endeavoured to categorise the levels of evidence for judging the causal relationship of clinical interventions, i.e. from the highest to the lowest, based on the quality of the clinical studies. To facilitate decision-making when choosing CAM, the category proposed by National Health and Medical Research Council (2009) is often used (Table 1).
Table 1.
Levels of evidence (National Health and Medical Research Council, 2009)
| Level | Study Design |
| I | Systematic reviews of level II studies |
| II | Randomised controlled trials (RCTs) |
| III | Non-RCTs, observational studies, cross-sectional studies |
| IV | Case series, case reports, expert opinions |
| V | Animal studies |