Muchos de nosotros a la hora de tomar decisiones sobre la salud de nuestros pacientes nos encontramos con dudas sobre el mejor tratamiento. A veces consultamos a colegas, que con su experiencia o conocimientos nos pueden ayudar. En cambio otras veces probamos bajo nuestro propio criterio cosas nuevas pero, ¿hacemos siempre lo mejor para nuestros pacientes?. Al menos seguro que lo intentamos, pero hay un sistema llamado podología basada en la evidencia que nos ayuda a hacer siempre lo mejor en función al conocimiento científico actual.
¿QUÉ ES LA PODOLOGÍA BASADA EN LA EVIDENCIA?
Es la utilización consciente, explicita y juiciosa de la mejor evidencia científica disponible a la hora de tomar decisiones sobre el trataminto de los pacientes, procedentes de la investigación válida y fiable.
La evidencia la obtenemos a través de la búsqueda fiable de información científicamente comprobada y aplicable a la práctica, cuyo principal representante son las revisiones sistemáticas.
Los orígenes de este tipo de práctica clínica hay que situarlos en los años 80 en la Universidad de McMaster, dónde se acuñó este término.
Los motivos que justifican esta práctica son múltiples:
- Variabilidad en los estilos de práctica clínica.
- Necesidad de especificar criterior de idoneidad.
- Variación en la utilización de recursos.
- Incertidumbre respecto al beneficio de las nuevas tecnologías y de las ya adoptadas.
- Necesidad de una gestión más eficiente de los recursos.
- Exceso de información científica.
- Existencia de influencias de base científica no demostrada.
- Falsas presunciones fisiopatológicas: hipótesis no contrastadas mediante estudios científicos de elevado rigor metodológico.
- Aumento creciente de la demanda de servicios sanitarios.
Imaginemos: a mi paciente con fascitis plantar, ¿cómo le puedo sanar con el menor coste? ¿Me da información real su patrón de presiones plantares? ¿Es mejor infiltrarle u operarle? ¿Factores de crecimiento o Traumeel?
INVESTIGACIÓN SECUNDARIA
Los centros de investigación secundaria generan evidencia. Es decir, cogen multitud de artículos con un alto valor científico mediante revisiones sistemáticas sobre un tema concreto y sacan conclusiones válidas y extrapolables a la práctica clínica habitual.
¿Cuál es una que podamos usar todos? Por ejemplo la Biblioteca Cochrane, a la cual estamos todos suscritos desde España, pagado por el Ministerio de Sanidad. Además de esta hay más, como Fisterra, UptoDate…. Algunas de pago y otras no.
Un momento, aclaremos términos.
Una revisión sistemática es un estudio pormenorizado, selectivo y crítico que trata de analizar e integrar la información esencial de los estudios primarios de investigación sobre un problema de salud específico.
«Una guía de práctica clínica es el conjunto de recomentaciones desarrolladas de manera sistemática para ayudar a los clínicos y a los pacientes en el proceso de la toma de decisiones sobre cuáles son las intervenciones más adecuadas para resolver un problema de salud específico en unas circunstancias sanitarias específicas» (Institute of Medicine, 1990).
¿Y que son esas cosas de números y letras que nos encontramos a veces?
Es la clasificación de los NIVELES DE EVIDENCIA. Este que pongo aquí no es el único (CEBM), también existe el sistema SIGN y el sistema GRADE, pero son menos usados.
| NIVEL DE EVIDENCIA | TIPO DE ESTUDIO |
| 1a | Revisión sistemática con ensayos clínicos aleatorizados, con homegeneidad. |
| 1b | Ensayo clínico aleatorizado con intervalo de confianza estrecho |
| 1c | Práctica clínica (“todos o ninguno”) |
| 2a | Revisión sistemática de estudios cohortes, con homogeneidad |
| 2b | Estudio de cohortes o ensayo clínico aleatorizado de baja calidad. |
| 2c | “Outcomes research”, estudios ecológicos |
| 3a | Revisión sistemática de estudios casos control homogéneos |
| 3b | Estudio caso – control |
| 4 | Serie de casos o estudios de cohortes y caso – control de baja calidad |
| 5 | Opinión de expertos sin valoración crítica explícita o basados en la fisiopatología. |
| GRADO DE RECOMENDACIÓN | SIGNIFICADO |
| A | Extremadamente recomendable |
| B | Recomendación favorable |
| C | Recomendación favorable pero no concluyente |
| D | No se recomienda ni se desaprueba |
Es posible que tratamientos concretos de podología no aparezcan en estas bases de datos. En tal caso se puede hacer una investigación en bases de datos que nos pueden dar artículos ordenados sobre una búsqueda en concreto, eso sí, sin tratar por una persona experta en ellos.
BASES DE DATOS BIBLIOGRÁFICOS
La principal base de datos a nivel mundial es Pubmed, así mismo ENFISPO es la base de datos de la faculta de Podología de la Universidad Complutense. TESEO es un buscador de tesis doctorales a nivel nacional y EMBASE es otra base de datos europea, que junto a Pubmed podríamos encontrar un artículo de cualquier parte del mundo.
LIMITACIONES EN PODOLOGÍA
La limitación más importante que encuentro en nuestro ámbito científico es que tratamientos ortopodológicos raramente están incluidos en las guias clínicas o revisiones sistemáticas. ¿Por qué? PORQUE TENEMOS UNA VARIABILIDAD ENORME. Es decir, unos hacen plantillas duras, otros blandas, otros aletas mediales, otros cuñas supinadoras intrínsecas, otros almendas, barras, descargas selectivas. Hacemos de todo, somos pocos y muchas cosas funcionan, pero con poca evidencia. La más baja que hay, el nivel 5.
¡¡¡A buscar e investigar!!!
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