Evidence-based case reports

Professor Jennifer Bolton, PhD, MA (Ed)^*

Anglo-European College of Chiropractic

Bournemouth, UK

Clinicians love to read case reports because they tell a good story (and who doesn’t like a good story?), they are relevant to their day-to-day practice and, by implication, they are interesting and informative. In some cases they have quickly alerted clinicians and the general public to unsafe practice, as was the case in the use of thalidomide in early pregnancy in the 1960s, and new cases of disease, such as HIV/AIDS in the 1980s. Yet, case reports are considered very weak evidence in the hierarchy of research evidence, not least because the information they provide has not been tested by rigorous scientific means. However, we might take issue with this stand in that not only are case reports informative, but they are particularly relevant to clinical practice from whence they came.

Since the shift towards evidence-based practice (EBP) in the 1990s¹, there has been continuing debate on the relevance of findings from research studies, most often based on group data, in the management of an individual patient. Increasingly, the RCT has become divorced from normal patient populations by its insistence on the inclusion of patients defined by narrow criteria and absence of co-morbidities. Moreover, the original definition of EBP that included clinician experience and characteristics of individual patients as well as sound research evidence in the decision-making process has been slowly hijacked over the years to the extent that ‘evidence-based practice’ is now synonymous with ‘research evidence-based practice’ and perhaps more alarmingly, only that evidence generated by the hallowed RCT. We need to get back to a model of EBP that is not only inclusive of all types of evidence, but one that is patient-centred and that can be used in the management of an individual patient. The fault in narrow interpretations of EBP lies not with the model itself, but with uninformed, misinformed and biased interpretations of it.

As part of the postgraduate Masters programmes at AECC in Bournemouth, UK² we run a distance-based course in EBP that fosters the combination of research findings with clinician experience, and the application of this synthesis in the management of an individual patient. It seems to us that this is the essence of EBP in any clinical discipline, including chiropractic.

As part of our EBP course, students are required to produce an evidence-based case report (EBCR). This requires the student to adopt a systematic and evidence-based approach to case management. In the EBCR, the student describes a patient presentation in much the same way as in a traditional case report. Out of this, the student articulates a structured clinical question in a format that generates key terms that can be used to search the research evidence base. In the EBCR, unlike the traditional case report, the search strategy is described so that the reader can decide whether a comprehensive search has been conducted, much in the same way as for a systematic review. Once the relevant evidence has been identified and appraised, it is synthesised together with the clinician’s experiential knowledge to inform a management plan for the patient.

It seems to us that the EBCR encompasses all the steps of an evidence-based approach to practice, in particular appreciating the role of clinician experience in EBP. Sometimes, there is no research evidence, or what there is may not be good enough so that patient management is based entirely on clinician experience. What is not acceptable however, is that when there is good research evidence, then this is either ignored or dismissed.

EBCRs remain interesting reading for clinicians while at the same time informing clinicians of the available research evidence (if any), and perhaps more importantly how the research evidence can be applied to the care of an individual patient. This gap between clinical research and clinical practice is arguably as wide today as it has ever been; the EBCR is just one way of bridging this gap. Of course, the EBCR is not a new concept. EBCRs are published by the British Medical Journal³ among others. Now we need to see more EBCRs in our chiropractic journals.