Evidence Based Medicine

What do you think about EBM

HISTORYMIDDEL 19 CENTURY IN FRANCE MEDICAL SCHOOL

EBM WAS CREATED M.C MASTER UNIVERSITY 1980

What is Evidence-Based Medicine?Evidence-based medicine (EBM) is an important change in the way physicians practice, teach, and do research.

It was initially proposed by Dr. David Sackett and colleagues at McMasters University in Ontario, Canada.

Why EBMDaily need for valid information about diagnosis, therapy , prognosis..Inadequate sources of information because of out of date (textbooks)- frequently wrong (experts) ineffective (didactic CME) or too overwhelming in their volume and variable in their validity for practical use (journals).Decline of our up to date knowledge and clinical performanceInability to spend much time to find out the diagnosis

EBM -definitionIntegration of best research evidence with clinical expertise and patient values .

What is research evidence? clinically relevant & patient centeredPatient centered evidence?Evidence about accuracy of diagnostic tests, power of prognostic markers, efficacy and safety of therapeutic-rehabilitative-preventive regimenClinical expertise?The ability to use clinical skills and past experience to identify patients problem and present appropriate solution

DEFINITIONINTEGRATION OF CLINICAL EXPERIENCE WITH THE BEST EVIDENCE PROVIDED BY SYSTEMATIC AND OBJECTIVE ORIENTED RESEARCH

EBM MODELBEST EVIDENCEClinical expertisePatient values

DEFINITIONCONSCIENTIOUS,EXPLICIT &JUDICIOUS USE OF CURRENT BEST EVIDENCE IN MAKING DECISIONS ABOUT CARE OF INDIVIDUAL PATIENTS OR THE DELIVERY OF HEALTH SERVICES DAVID SACKETT.

EBM OBJECTIVESKEEPING YOUR SKILLS UP TO DATE -MEMORY DECREASE -NEW TREATMENT METHODSSAVING TIMESAVING LIVESSUPPLEMENTING CLINICAL JUDGEMENT(EBM MODEL)

Why EBM?Caring for patients creates the need for clinically important informationDiagnosis.Therapy.PrognosisKnowledge deteriorates with time: Practitioners practice what they learned during residency trainingEBM: goal of life-long self-directed learningNew evidence often changes clinical practiceProspective learning from reading journals and going to conferences is important, but not sufficient Impossible to prospectively acquire all information necessary to treat all future patients

Minimum reading to keep up-to-date with pediatricsPediatrics 40 articles x 12 monthsNew England Journal of Medicine 5 articles x 52 weeksLancet - 6 articles x 52 weeksJournal of Pediatrics 18 articles x 12 monthsPediatric Infectious Disease Journal - 15 articles x 12 monthsJAMA 8 articles x 12 monthsBMJ 10 articles x 52 monthsArchives of Pediatric and Adolescent Medicine 10 articles x 12 months1694 article per year= 5 articles per day

EBM

EBM .

EBM EBM

EBM Method Acquire the best evidenceAppraise the evidenceApplyevidence to patient careAssess your patientAsk clinical questions

EBM PROCESSPATIENT PROBLEMCLINICAL QUESTIONSEARCH FOR EVIDENCECRITICAL APPRAISAL OF THE EVIDENCEAPPLYING THE RESULTS INTO PRACTICE (CURRENT PATIENT)

Domains of EBMTREATMENTPROGNOSISDIAGNOSISETIOLOGY/CAUSATION/HARM

FORMULATING CLINICAL QUESTION(well built Question)In daily practice,there is 1 question per 4 patientsDirect observation by covell DG,et al. Ann Int Med 1985;103:596-9

Revealed :2 questions per 3 patients15 questions per shift 2/3 of questions left unanswered

COMPONENTS OF CLINICAL QUESTIONS P - patient and problem(population)

I - intervention(treatment,test,prognosis)

C - comparison

O - outcome

Ask Clinical QuestionsComponents of Clinical Questions

Clinical question(scenario) fortreatment P in a child with frequent febrile seizures I would anticonvulsant therapy

C compared to no treatment

O results in seizure reduction

Question for diagnosis P in an otherwise healthy 15 yrs old boy with sore throat I- how does the clinical exam

C- compare to throat culture

O- In diagnosing GAS infection ?

Question Prognosis P- In children with Down syndrome

I - Is IQ an important prognostic factor

C

O - In predicting Alzheimers later in life

Etiology/Harm P -controlling for confounding factors, do otherwise healthy children I -exposed in utero to cocaineC - compared to children not exposedO - have increased incidence of learning disabilities at age six years?

Source of Medical InformationColleaguesConferencesDrug RepsTextbooksJournalsInternetPatients

Finding the Evidence

Finding the Evidencesystematic review

Finding the Evidence

Finding the Evidence

Finding the Evidence

Finding the Evidence

Evidence-Based Answers to Clinical QuestionsClinical Evidence, BMJ Publishing Group http://www.clinicalevidence.com

Clinical Queries on PubMedhttp://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.html

Cochrane Database of Systematic Reviews http://www.cochrane.org

Database of Abstracts of Reviews of Effectiveness (DARE) http://agatha.york.ac.uk/darehp.htm

TRIP (Translating Research Into Practice)http://www.tripdatabase.com

Evidence-Based Summaries of Recent Research American College of Physicians Journal Clubhttp://www.acponline.org/journals/acpjc/jcmenu.htm

Bandolier http://www.jr2.ox.ac.uk/Bandolier

Evidence-Based Practice Newsletter http://www.ebponline.net

InfoPOEMs http://www.infopoems.com

Practice Guidelines Agency for Healthcare Research and Quality (AHRQ)

Clinical Guidelines and Evidence Reportshttp://www.ahrq.gov/clinic

Canadian Task Force on Preventive Health Care http://www.ctfphc.orgEffective Health Care Bulletins http://www.york.ac.uk/inst/crd/ehcb.htm Institute for Clinical Systems Improvement (ICSI) http://www.icsi.orgNational Guideline Clearinghouse (NGC) http://www.guideline.govU.S. Preventive Services Task Force (USPSTF) http://www.ahrq.gov/clinic/uspstfix.htm

DAREDatabase of Abstracts of Reviews of Effects Structured AbstractsProvisional AbstractsEffective health bulletinsCochrane reviewsNational Health Service -- UKUpdated monthly

ACP Journal ClubLimitationsindividual article summaries may not account for the big picturemay have to read multiple itemsNo control over what is covered

1) Our up-to-date knowledge and clinical performance that we all possessed upon completing our residency program definitely deteriorate with time. Sure, we certainly gain experience and some knowledge with practicing medicine, but we tend to lose more than we gain. 2) New types of evidence are generated daily which should create major changes in the way we care for our patients.Also, modern evaluation tools allow dissection, understanding, and objectification of the diagnostic reasoning skills of expert clinicians. In other words we can sort out how skilled doctors think and apply these rigorous systems to training doctors.3) Although we need to use the new research information being generated daily, we usually fail to use it.4) Listserv example of variation in care delivery (PE diagnosis, pneumovax)Whats the evidence that we need it?If we look at the delivery of healthcare, we dont see a well-ordered, knowledge-based system. When health insurers and employers, the people paying for health insurance in America, they dont see a well-ordered, knowledge-based system.We and they see chaos!Now, am I being excessively alarmist or critical?A story in a past Sunday New York Times Magazine has likened unexplained variation to three jumbo jets crashing every two days. Highlight the number of patients killed every year because of missed diagnoses, medication mishaps, and other preventable errors.

Alternative to next slide Structured abstracts Abstracts assessing and summarize published systematic reviews that have met NHS CRD quality criteria Provisional abstracts Short bibliographic references to systematic reviews which may meet the NHS CRD quality criteria and are in the process of being assessed or being written. Effective Health Care Bulletins Brief records giving details of this series produced by the NHS CRD. A link is provided to the full text of the document in most cases. Cochrane Reviews published in journals Bibliographic details of Cochrane Reviews which have been published as a journal article while the full review is available in the Cochrane Database of Systematic Reviews (CDSR). Cochrane "flag" records References to reviews being prepared and maintained by the Cochrane Collaboration. Cochrane Reviews are produced according to the guidelines set out in the Cochrane Handbook and therefore meet the DARE quality criteria, but do not require bibliographic references on DARE because the full text of the original review is readily available in CDSR. This set of records is on the Internet version of DARE but not the Cochrane Library version of DARE. Other records Records from a systematic reviews database maintained by the UK Cochrane Centre prior to 1995. This set of records is no longer updated and have not been assessed by the NHS CRD.