Evidence summaries and synthesis: necessary but insufficient approach for determining clinical practice of integrated medicine?

The heart of evidence-based practice is in fact to be found in the use of evidence gained from systematic reviews or more correctly in the synthesis of evidence from systematic reviews. But just as studies vary in the quality of the design so do systematic reviews, and it is therefore necessary for those wishing to make clinical decisions based on this evidence to evaluate the evidence summaries and synthesis themselves. This article examines the criteria available for evaluating the quality of the evidence summary and synthesis. It provides a set of questions for doing this: who did the review; w hat was the objective of the review; how was the review done? Together these questions allow us to determine the trustworthiness of the review. However, that by itself is insufficient for making clinical decisions. The article suggests that this occurs because the very studies that improve the quality of reviews, that is, the randomized controlled trials, deal with efficacy and not effectiveness. Because they tend to be conducted under ideal conditions, they seldom provide the type of information needed to make a decision vis-à-vis an individual patient. The article suggests that observation studies provide much better information in this regard. The challenge here, however, is to develop standards for judging quality observation studies. In conclusion, systematic reviews and syntheses of evidence are a necessary but an insufficient method for making clinical decisions.