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Evidence based medicine

Evidence based medicine. By: Mohsen Dehghani MSc Student in Epidemiology Isfahan University of Medical Sciences. Trace back to the development of EBM. Evidence based medicine. تلفیق بهترین شواهد بدست آمده از تحقیق با مهارتهای کلینیکی و ارزشهای بیمار. David Sackett, et al. 2000

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Evidence based medicine

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  1. Evidence based medicine By: MohsenDehghani MSc Student in Epidemiology Isfahan University of Medical Sciences

  2. Trace back to the development of EBM

  3. Evidence based medicine • تلفیق بهترین شواهد بدست آمده از تحقیق با مهارتهای کلینیکی و ارزشهای بیمار. • David Sackett, et al. 2000 • استفاده دقیق، روشن و عاقلانه از بهترین شواهد موجود برای تصمیم گیری در مورد مراقبت از یکایک بیماران. Best Evidence Clinical expertise Patient values

  4. Evidence based medicine • Evidene based practice (EBP) • چرا به EBP نیاز داریم؟

  5. Evidence based medicine • Archei cochrane, • British epidemiologist, 1972 • او در سال 1979 نوشت: • ”مطمئنأ انتقادی بزرگ از حرفه ما این است که برنامه ای برای خلاصه کردن منظم و منتقدانه همه کارآزماییهای بالینی مربوط به یک موضوع در رشته های تخصصی و فوق تخصصی مختلف و بازبینی مستمر آنها نداریم.“ • Cochrane center • Cochrane collaboration • Cochrane library

  6. استفاده از کورتیکوستروئیدها در زایمان زودرس • RCT-1972 • 6RCT, 1972 – 89 • Systematic review, 1990 • conclusion

  7. Push, Pull, …ways to deal with too much information Evidence-Based Information Resources

  8. Increasing Knowledge

  9. The steps 1.    answerable questions 2.    Find the best evidence 3.    Critically appraise that evidence for its validity and usefulness 4. Apply the results 5.     Evaluate the performance

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

  11. Where Clinical Questions Arise From: • Clinical findings • Aetiology: • Differential diagnosis: • Diagnostic tests: • Prognosis: • Therapy: • Prevention:

  12. Question components : PICO • What types of Participants? • What types of Interventions? • What types of Comparison? • What types of Outcomes?

  13. The four elements of well built clinical questions:(PICO)

  14. Best Evidence… • Journal of evidence based medicine. • Encyclopedia of clinical evidence

  15. The Evidence Pyramid Validity/Strength of Inference Time Spent in Critical Appraisal

  16. Finding the Evidence systematic review

  17. Systematic review & Meta-analyses • تاثیر دریافت مواد غذایی در طول زایمان بر پیامد مادری زنان باردار: RCT • ارتباط بین چاقی و سکته مغزی • درمان با انسولین و خطر ابتلا به سرطان

  18. PubMed Clinical Queries

  19. PubMed Clinical Queries

  20. PubMed – Key Features • Clinical Queries • Clinical study by category • Find systematic reviews • MeSH Database • Synonyms (keywords) to use for your searches • Tutorials • Comprehensive Limits Option • “My NCBI” Alert, Storage and Retrieval Option

  21. The Cochrane Collaboration Preparing, maintaining and disseminating systematic reviews of the effects of health care

  22. Cochrane Library • International collaboration • Produces systematic reviews and meta-analyses of individual studies • DARE • Registry for RCT • Updated regularly • Abstracts are free • http://www.cochrane.org

  23. The Cochrane Library Total Records at December 2010

  24. 3.  Critically appraise that evidence for its validity and usefulness • 1- pico مطالعه چیست و آیا کاملأ مشابه pico شماست؟ • 2- مطالعه چقدر خوب انجام شده است؟ • 3- نتایج چه معنی می دهند؟

  25. What is critical appraisal? • Critical appraisal is the assessment of evidence by systematically reviewing its relevance, validity and results to specific situations. Chambers, R. (1998).

  26. Three questions • Valid? Is the methodology appropriate to answer the question. Is it carried out in a sound way, eliminating bias and confounding? • Reliable? Are the results real or because of chance? • Applicable? Will the results help locally?

  27. Dealing with chance error • During design of study • Sample size • Power • During analysis (Statistical measures of chance) • Test of statistical significance (P value) • Confidence intervals

  28. 95% Confidence Interval (95% CI) • 20 out of 100 participants: 20% 95% CI: 12 to 28 • 80 out of 400 participants: 20% 95% CI: 16 to 24 • 2000 out of 10000 participants: 20% 95% CI: 19.2 to 20.8

  29. Quality assessment tools • Checklist : the components are evaluated separately and do not have numerical scores attached to them • Scale: each item is scored numerically and an overall quality score is generated.

  30. 4. Apply the results • آیا تست یا درمان مورد نظر در بیماران مرکز طبابت من قابل انجام است؟ • آیا بیماران من متفاوت از افرادموجود در مطالعه است که منجر به عدم کاربرد نتایج میشود؟ • آیا روش دیگری در دسترس است؟ • آیا فواید بالقوه درمان بیش از زیانهای بالقوه آن برای بیمار من است؟ • بیمار من در این مورد چگونه فکر میکند؟

  31. Think اگر دانشجوییم وظیفه ما جستجوی علم و رعایت ادب و احترام استاد و ... وظیفه ما این است که عمل به وظیفه کنیم ” Leonardo Davinchi“

  32. References • Paul glasziou, Chris Del Mar. Evidence-Based Practice workbook. University of Oxford; 2008 • Sackett DL, et al. Evidence Based Medicine: How to practice and teach EBM. Edinburge; 2000 • Glasziou P. Evidence based case report: Twenty year cough in a non-smoker. British Medical Journal 2006. • http://www.cvidene-evidence-based medicine.com • http://www. Cochrane.org • Bero L, Rennie D. The Cochrane Collaboration. JAMA 2007 ;274:1935–8. • http://www.CONSORT-sratement.org/revisedstatement.htm.Vol.9 No.1, March 2007

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