Evidence – Based Medicine

1. Evidence – Based Medicine

2. What do you think about EBM

3. HISTORY • MIDDEL 19 CENTURY IN FRANCE MEDICAL SCHOOL • EBM WAS CREATED M.C MASTER UNIVERSITY 1980

4. 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. 

5. Why EBM • Daily 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 • Inadequate sources of information because of out of date (textbooks)- frequently wrong (experts) ineffective (didactic CME) or too overwhelming in their volume and variable in their validity for practical use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 performance • Inability to spend much time to find out the diagnosis

6. EBM - definition • Integration of best research evidence with clinical expertise and patient values . • What is research evidence? clinically relevant & patient centered Patient centered evidence? Evidence about accuracy of diagnostic tests, power of prognostic markers, efficacy and safety of therapeutic-rehabilitative-preventive regimen Clinical expertise? The ability to use clinical skills and past experience to identify patient’s problem and present appropriate solution

7. DEFINITION • INTEGRATION OF CLINICAL EXPERIENCE WITH THE BEST EVIDENCE PROVIDED BY SYSTEMATIC AND OBJECTIVE – ORIENTED RESEARCH EBM MODEL BEST EVIDENCE Clinical expertise Patient values

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

9. EBM OBJECTIVES • KEEPING YOUR SKILLS UP TO DATE -MEMORY DECREASE -NEW TREATMENT METHODS • SAVING TIME • SAVING LIVES • SUPPLEMENTING CLINICAL JUDGEMENT(EBM MODEL)

10. Why EBM? • Caring for patients creates the need for clinically important information • Diagnosis….Therapy….Prognosis • Knowledge deteriorates with time: Practitioners practice what they learned during residency training • EBM: goal of life-long self-directed learning • New evidence often changes clinical practice • Prospective 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

12. Minimum reading to keep up-to-date with pediatrics • Pediatrics – 40 articles x 12 months • New England Journal of Medicine – 5 articles x 52 weeks • Lancet - 6 articles x 52 weeks • Journal of Pediatrics – 18 articles x 12 months • Pediatric Infectious Disease Journal - 15 articles x 12 months • JAMA 8 articles x 12 months • BMJ 10 articles x 52 months • Archives of Pediatric and Adolescent Medicine – 10 articles x 12 months • 1694 article per year= 5 articles per day

13. مزايايEBM • قابل آموزش به پزشكان در سطوح مختلف • پر كردن شكاف بين تحقيقات باليني و بكارگيري نتايج آنها • تقويت آ‌موزش مستقل و خود محور • تقويت بحث گروهي • روز آمد كردن اطلاعات پزشكان • درك عميق روش تحقيق توسط متخصصين باليني

14. مزايايEBM • افزايش اعتماد به نفس پزشكان باليني در اخذ تصميم باليني • افزايش توانائي پزشكان در جستجوي اطلاعات • عادت به مطالعه را در پزشكان مي افزايد • امكان توجيه منطقي تصميمات درماني را براي بيماران فراهم مي كند. • طراحي دستور العمل مشترك براي تصميمات باليني توسط متخصصين محلي

15. مضراتEBM • آموزش و بكارگيري EBMدر بالين وقت گير است • هزينه فراهم سازي امكانات زياد است • كاهش اعتماد به نفس پزشكان در مقابل اطلاعات جديد و اقدامات فعلي آنها

16. EBM Method Assess your patient Ask clinical questions Acquire the best evidence Appraise the evidence Apply evidence to patient care

17. EBM PROCESS • PATIENT PROBLEM • CLINICAL QUESTION • SEARCH FOR EVIDENCE • CRITICAL APPRAISAL OF THE EVIDENCE • APPLYING THE RESULTS INTO PRACTICE (CURRENT PATIENT)

18. Domains of EBM • TREATMENT • PROGNOSIS • DIAGNOSIS • ETIOLOGY/CAUSATION/HARM

19. FORMULATING CLINICAL QUESTION(well built Question) • In daily practice,there is 1 question per 4 patients • Direct observation by covell DG,et al.AnnInt Med 1985;103:596-9 Revealed : • 2 questions per 3 patients • 15 questions per shift • 2/3 of questions left unanswered

20. COMPONENTS OF CLINICAL QUESTIONS • P - patient and problem(population) • I - intervention(treatment,test,prognosis…) • C - comparison • O - outcome

21. Patient/ Population Outcome Intervention/ Exposure Comparison does early treat- ment with a statin decrease cardio- vascular mortality? In patients with acute MI compared to placebo what is the accuracy of exercise ECHO In women with suspected coronary disease compared to exercise ECG for diagnosing significant CAD? does hormone replacement therapy In post- menopausal women compared to no HRaT increase the risk of breast cancer? Ask Clinical Questions Components of Clinical Questions

22. 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

23. 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 ?

24. Question Prognosis • P- In children with Down syndrome • I - Is IQ an important prognostic factor C • O - In predicting Alzheimer’s later in life

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

26. Source of Medical Information • Colleagues • Conferences • Drug Reps • Textbooks • Journals • Internet • Patients

27. Finding the Evidence

28. Finding the Evidence systematic review

29. Finding the Evidence

30. Finding the Evidence

31. Finding the Evidence

32. Finding the Evidence

33. Evidence-Based Answers to Clinical Questions • Clinical Evidence, BMJ Publishing Group • http://www.clinicalevidence.com • Clinical Queries on PubMed • http://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

34. Evidence-Based Summaries of Recent Research • American College of Physicians Journal Club • http://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

35. Practice Guidelines • Agency for Healthcare Research and Quality (AHRQ) • Clinical Guidelines and Evidence Reports • http://www.ahrq.gov/clinic • Canadian Task Force on Preventive Health Care • http://www.ctfphc.org • Effective Health Care Bulletins • http://www.york.ac.uk/inst/crd/ehcb.htm • Institute for Clinical Systems Improvement (ICSI) • http://www.icsi.org • National Guideline Clearinghouse (NGC) • http://www.guideline.gov • U.S. Preventive Services Task Force (USPSTF) • http://www.ahrq.gov/clinic/uspstfix.htm

36. DARE • Database of Abstracts of Reviews of Effects • Structured Abstracts • Provisional Abstracts • Effective health bulletins • Cochrane reviews • National Health Service -- UK • Updated monthly

37. ACP Journal Club • Limitations • individual article summaries may not account for the “big picture” • may have to read multiple items • No “control” over what is covered