One of the criticisms levelled against evidence from systematic reviews of
controlled clinical trials relates to the generalisability of the results. Were
the patients typical of those seen in real practice or not? Can we achieve the
same results in day-to-day practice as the Trialists who had the resources to
carry out the study?

In order to test whether trial evidence could be translated into our daily
family-doctor practice in the UK, we devised a strategy based on the results of
a Cochrane review assessing the efficacy of antibiotic prescribing for children
with ear infections. There is widespread concern about excessive prescribing of
antibiotics, but changing practice is not easy due to fears of complications,
increased workload and patient dissatisfaction. We considered the barriers
faced by doctors and parents in making a change in practice and wrote a handout
summarising the evidence. We also offered a deferred prescription for the
antibiotic, and compared our antibiotic usage with a control practice.

We found that it was possible to change practice and reduce antibiotic usage in
the midst of a busy working practice, and our experience now is that parents
are no longer phoning for an appointment for the child the moment they complain
of earache. Like the ripples on a pond this change in practice has spread to
local practices, and then after publication in the BMJ to other practices
across different countries. The paper was presented to the National Pediatric
Infectious Disease Group in Aspen Colorado in August 1999 and was voted the top
infectious disease article of the year and the approach using a deferred
prescription was successfully adopted in a trial in the USA, which was
published in 2003.

This year the American Academy of Pediatrics and the American Academy of Family
Physicians guideline has been revised to include deferring antibiotics for
children with ear infections who are not unduly ill, and have cited the
Cochrane review, the BMJ paper from the UK and the follow-up study in the USA.

I will present the experience that we had in using evidence to empower patients
and doctors to change practice, and the lessons that we learnt in the process.