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Evidence - based medicine

Evidence - based medicine. Course: Research in Biomedicine and Health III Lab 3 : Looking for evidence. What is EBM in practice ?. EBM steps Step 1: Formulating questions that can be answered Step 2: Finding best evidence Step 3: Quick critical assessment of the evidence

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Evidence - based medicine

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  1. Evidence-based medicine Course: Research in Biomedicine and Health III Lab 3: Looking for evidence

  2. What is EBM inpractice? • EBM steps • Step 1: Formulating questions that can be answered • Step 2: Finding best evidence • Step 3: Quick critical assessment of the evidence • Step 4: Applying evidence • Step 5: Assessing effectiveness and efficiency of the process

  3. I intervention C Comparison (not always) Be precise! P Patient, problem T Type of study O Outcome Kew words for database search

  4. ACP Journal Club / Cochrane Database of Systematic Reviews Pubmed (MEDLINE) “AND” meta-analysis Metaanalysis ACP Journal Club / Cochrane Database of Systematic Reviews Pubmed (MEDLINE) Clinical Queries (Systematic Reviews) Systematic review ACP Journal Club / Cochrane Central Register of Controlled Trials Pubmed (MEDLINE) Clinical Queries (Therapy) RCT PubMed (MEDLINE) “AND” cohort study Cohort study PubMed (MEDLINE) “AND” case control study Case-control study Case series/case reports PubMed (MEDLINE) “AND” case report

  5. Example – Clinicalscenario • 65 year-old patient is recovering from a stroke. He has narrowing of the left carotid artery confirmed by US. • Would therapy with acetyl-salicilic acid decrease the risk of another stroke?

  6. Type of question: Therapy/prevention Study design: RCT/systematic review Concepts: stroke Acetyl-salicilic acid (aspirin) Systematic reviews or randomized controlled studies Example – What needs to be determined

  7. Stepsinsearch for evidence • First search Cochrane Database of Systematic Reviews. • CDSR can be accessed via OvidSP – link on the web-site of the School’s library. • Choose the database on the front page.

  8. CochraneDatabaseofSystematicReviews (OVID) • Choose “Advanced Search” and check that the search is by “Keywords” • Enter only one term and start “Search” • Enter the second key word and “Search” • Click Search History • If you are using more keywords, link them with OR and then link their sets with AND • Limit the search to “Full Systematic Reviews” • Check the results

  9. PubMed ClinicalQueries • If you want to look for a RCT, choose PubMed or Ovid MEDLINE • PubMed has special interface for clinical questions • At the start page of PubMeda click on Clinical Queries (below PubMed Tools) • Enter keywords, e.g.: probiotics irritable bowel syndrome • Choose the category for your search (e.g. Therapy) i search precision (Broad/Narrow) • Start the search

  10. Limitingresults to RCTs • In the column Clinical Study Categories click on “See all” below search results • When the search results are displayed, click Limits • Choose Randomized Controlled Trial under Type of Article

  11. Practicallab • Define a search strategy according to your PICO(T) questions from day 2.

  12. Example 1: • Your patient has 45 years and complains of frequent migraine headaches. She tried different medications but is afraid of side-effects. She is healthy, except for the history of asthma during childhood. She read in a magazine about bio-feedback and using relaxation as a treatment for migraine. She is asking you for advice.

  13. Example 2: • Your patient has 56 years. He was released from a hospital 6 weeks before, after he was admitted because of slight heart failure. He comes to you for a check up. He feels well but sometime fells that his heart “misses a beat”. ECG confirms atrial fibrillation. The patient wanders if this arrythmia is dangerous and needs a treatment. Preventive anticoagulant warfarine therapy is one possibility but carries a small risk of stroke because of bleeding. You want to check if the risks of such therapy outweigh its benefits.

  14. Example 3: • Parents of your patient want to sue you as her family physician because of malpractice. Their 22 year-old daughter suddenly fainted at home. They took her to ER, where she was pronounced dead on arrival. The ER doctor mentioned a blood clot in her lungs. Local organization “Parents against contraceptives industry” is talking the parents into suing the producer and you because you prescribed the contraceptive about a year ago. You want to check the association between oral contraceptives and thromboembolism.

  15. Example 4: • Your patient takes nicotine replacement therapy as smoking cessation treatment. His friends suggested acupuncture as a quicker therapy. You want to check if this is true.

  16. Example 5: • Your friend asks you if there is evidence for the use of feverfew in the therapy of migraine.

  17. Example 6: • Your patient is middle-aged and is a frequent airplane traveler. He is worried because of the risk of deep vein thrombosis during flight. You want to check whether compression socks would be useful in preventing the problem.

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