Uma Devalapalli

1. Uma Devalapalli Evidence Based Medicine Process - An Introduction

2. Aims & Objectives To know about • What is Evidence Based Medicine (EBM)? • Why is EBM Important? • The steps in EBM process

3. Learning Outcomes By the end of this session you will be able to • Formulate a clinical question • Apply PICO model to identify key concepts

4. What is EBM ? “EBM is theConscientious, explicit and judicious use ofcurrent best evidencein making decisions about the care of the individual patient. -Sackett D. et al., 1996 Thus, the practice of EBM means : Integrating individual clinical expertise with the best available external clinical evidence from systematic research.” “Evidence Based Clinical practice is an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best” -Muir Gray JA., 1997

5. Why is EBMImportant ? • Studies on information seeking habits of physicians: • Practice generated 2 questions for every 3 patients. • Only 30% of physicians' information needs were met during the patient visit, usually by a colleague. • Reasons for not using printed resources included • office textbook collections too old, • lack of knowledge of appropriate resources, and • lack of time to find the needed information. • (Covell, DG. Uman, CG. Manning, PR. Information needs in office practice: • are they being met? Annals of Internal Medicine 103(4):596-599, Oct 1995.)

6. Why is EBM Important ? When actually observed: • About 5 questions for each patient. • 52% of these question could be answered by the medical record or hospital information system. • 25% could have been answered by published information resources such as textbooks or MEDLINE. (Osheroff JA. Forsythe DE. Buchanan BG. Bankowitz RA. Blumenfeld BH. Miller RA. Physicians' information needs: analysis of questions posed during clinical teaching. Annals of Internal Medicine 114(7):576-81, 1991 Apr 1.)

7. Why is EBM Important ? When Clinicians have access to information, it changes their patient caremanagement decisions. (Sackett D, 1998 & Crowley S, 2003)

8. The Steps in the EBM Process • The patient • The question • The resource • The evaluation • The patient • The patient • The question • The resource • The evaluation • The patient

9. Step1 – The Patient • Starts with the patient: a clinical problem/ question arises out of the care of the patient.

10. Step 2 – The Question • Construct a well-built question derived from the case.

11. Clinical Scenario… You are assessing a 65-year-old man who is due to have coronary grafting. Anaesthetist suggests ‘thoracic epidural’, where as Surgeon says that ‘epidurals can be dangerous with full heparinisation’ Now the the team wants to know whether the thoracic epidural prior to induction reduce the post -operative complications…

12. Anatomy of good Clinical Question Does epidural anesthesia reduce post operative complications ? Ask focussed and answerable questions !!! In elderly male patient undergoing cardiac surgery, does epidural anaesthesia reduce the post operative complications?

13. PICO - Finding the evidence P - Patient, Problem or Population I - Intervention C - Comparison (not always relevant) O - Outcome

14. P: Patient, Population or Problem I: Intervention or Exposure C: Comparison (not always relevant) O: Outcome What patient group, population or problem are you interested in? elderly coronary patient What intervention or exposure are you examining? epidural anaesthesia Do you want to make a comparison? general anaesthesia What outcome were you looking for? reduce the post operative complications PICO - Finding the evidence

15. PICO in practice P – In elderly coronary artery graft patients I – does epidural anaesthesia C – compared with general anaesthesia O – reduce postoperative complications?

16. Step 3 – The Resource • Select the appropriate resource(s) and conduct a search

17. Resources available from the library • Databases (subscribed & free) • Cochrane Library, TRIP, Medline, Embase etc • Journals (print & electronic) • Books • Web based resources - (reports, statistics, guidelines)

18. Step 4 – The Evaluation Appraise the evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice)

19. Common Questions… • Are the results of the study valid ? • What are the results ? • Will the results help in caring for my patient ?

20. The Hierarchy of Research Evidence Systematic Review A review in which all available evidence on a particular subject is systematically identified, appraised and summarised. Randomised Controlled Trials A group of patients are randomly allocated to receive different interventions. Outcomes are then compared. Cohort Study Groups of people are selected on the basis of their exposure to a particular agent and followed up. Survey or interview of a sample of the population of interest at one point in time. Cross Sectional Survey A report based on a single subject or patient. Case Report Expert opinion A consensus of experience amongst professionals. Anecdotal Something a bloke told you after a meeting or in the bar.

21. Step 5 - The Patient Return to the patient - integrate the evidence with clinical expertise, patient preferences and - apply it to practice

22. The EBM cycle Identify & Define the problem Formulate a focused clinical question Identify the appropriate resources Search for valid and relevant information Critically appraise/review this information Implement in practice Clinical audit ...