EVIDENCE BASED MEDICINE A new approach to clinical care and research

1. EVIDENCE BASED MEDICINEA new approach to clinical care and research

2. OBJECTIVES OF THE SESSION • Recognize the concepts and principles of EBM. • Identify the important of EBM as an essential part of clinical practice. • Discuss the Skills needed for EBM practice. • Recall the five steps approach to EBM practice. • Identify the application of EBM in clinical practice. • Discuss the barriers to practice EBM • Provide some examples of EBM practice

3. Pause for ThoughtFor three minutes • Why this session is important? • What is EBM • What are the • Benefits ?? First alone then 2-3 in group

4. a test…1st ?

5. WHAT IS THE BASIS OF YOUR MEDICAL PRACTICE? (Check all that apply) • Training, clinical experience and consultation with other professionals • Convincing evidence (non-experimental) from articles, case reports, product literature, etc. • Preferences of the patient • Active search of Randomized Controlled Trials, Systematic Reviews, Meta-Analysis Reports

6. WHAT IS THE BASIS OF YOUR MEDICAL PRACTICE? • EXCELLLENT! • Training, clinical experience and consultation with other professionals • Convincing evidence (non-experimental) from articles, case reports, product literature, etc. • Preferences of the patient • Active search of Randomized Controlled Trials, Systematic Reviews, Meta-Analysis Reports

7. BUT… Past knowledge and practice might be outdated or inadequate Up to date Knowledge Clinical skills and Experience Graduate Medical School Practiced Physician

8. WHAT IS THE BASIS OF YOUR MEDICAL PRACTICE? • FANTASTIC! • Training, clinical experience and consultation with other professionals • Convincing evidence (non-experimental) from articles, case reports, product literature, etc. • Preferences of the patient • Active search of Randomized Controlled Trials, Systematic Reviews, Meta-Analysis reports

9. BUT… This evidence may be biased, outdated, incorrect, or not applicable to your patient JOURNALS (1987 to present) ARTICLES ADVERTISEMENTS

10. WHAT IS THE BASIS OF YOUR MEDICAL PRACTICE? • WONDERFUL! • Training, clinical experience and consultation with other professionals • Convincing evidence (non-experimental) from articles, case reports, product literature, etc. • Preferences of the patient • Active search of Randomized Controlled Trials, Systematic Reviews, Meta-Analysis reports • Mutual Respect + Shared Goals = • Better Cooperation and Compliance

11. The patient should be involved in • all important decisions • But this is NOT always an easy task! • And conflicts WILL occur!

12. No salt? Lose weight? Forget it! Just give me a pill! I WON’T take that medicine… The side effects are INTOLERABLE! But doctor, I DO want to have children! • And conflicts WILL occur!

13. No salt? Lose weight? Forget it! Just give me a pill! I WON’T take that medicine… The side effects are INTOLERABLE! But doctor, I DO want to have children! Education about current alternatives and risks is often needed… for both the Patient and the Doctor!

14. Wow… I never knew that high blood pressure could be so dangerous at my age! Yes, I’d like to try that new medication! I’ll discuss those risks with my husband. Education about current alternatives and risks is often needed… for both the Patient and the Doctor!

15. An important rule in Evidence Based Medicine… It STARTS with the patient and ENDS with the patient. The patient’s preferences MUST be considered!

16. WHAT IS THE BASIS OF YOUR MEDICAL PRACTICE? • WOW!!! SUPERB!!! • Training, clinical experience and consultation with other professionals • Convincing evidence (non-experimental) from articles, case reports, product literature, etc. • Preferences of the patient • Active search of Randomized Controlled Trials, Systematic Reviews, Meta-Analysis reports

17. In the practice of Evidence Based Medicine, it is the physician’s duty to find the best and most current information and apply it judiciously for the benefit of the patient.

18. But… A practice based exclusively on science and math is effective only if your patients are robots or clones! • Don’t forget to allow for individual human differences • and personal preferences!

19. WHAT IS THE BASIS OF YOUR MEDICAL PRACTICE? • If you checked all 4 items… • Training, clinical experience and consultation with other professionals • Convincing evidence (non-experimental) from articles, case reports, product literature, etc. • Preferences of the patient • Active search of Randomized Controlled Trials, Systematic Reviews, Meta-Analysis reports

20. CONGRATULATIONS! You are practicing EVIDENCE BASED MEDICINE! • Training, clinical experience and consultation with other professionals • Convincing evidence (non-experimental) from articles, case reports, product literature, etc. • Preferences of the patient • Active search of Randomized Controlled Trials, Systematic Reviews, Meta-Analysis reports

21. EVIDENCE BASED MEDICINEA new approach to clinical care and research Definition of EBM Basic Steps Trials, Studies and Reports Pros, Cons and Limitations EBM Library Advanced EBM

22. “What is Evidence Based Medicine?” “And where did it come from?”

23. A BRIEF HISTORY 1980’s: McMasters University in Ontario, Canada Dr. David Sackett and colleagues proposed Evidence Based Medicine (EBM) as a new way of teaching, learning and practicing medicine. Dr. Sackett defines EBM as: “…The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

24. "Evidence-based medicine is the integration of best research evidencewithclinical expertise andpatient values."Sackett, D. L. (2000). Evidence-based medicine: How to practice and teach EBM(2nd ed.). Edinburgh; New York: Churchill Livingstone.

25. Clinical expertise: the clinician’s cumulated experience, education, and clinical skills • Patient values: The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. • Best Research Evidence: usually found in clinically relevant research that has been conducted using sound methodology

26. Evidence Based Medicine It is a change in the way physicians practice medicine, teach and learn, and handle research. Clinical practice: Based on the best current evidence (not necessarily on how it’s always been done) Patient Care: Compassionate, patient-oriented (less authoritarian) Learning & Teaching: Problem-based, problem-solving more investigative, less know-it-all-by-yesterday Research: More stringent approach, better proof criteria (more demanding of proof, less room for error)

27. THREE MAJOR COMPONENTS of EBM PATIENT Question or Problem PHYSICIAN INFORMATION

28. THE ADDED DETAILS PATIENT Values, Concerns Preferences, Expectations Life predicament EBM PHYSICIAN Training & Experience Current Expertise Continued learning Demand for proof INFORMATION Clinically relevant Proven by research Best up-to-date evidence

29. “Isn’t this the way we have always practiced medicine?” “Aren’t these just the same old ingredients tossed into a new recipe?” When am I supposed to find the time to do that?

30. The basic steps of EBM

31. THE FIVE BASIC STEPS OF EBM Clinical Question Patient-focused, problem-oriented 2. Find Best Evidence Literary Search 3. Critical Appraisal Evaluate evidence for quality and usefulness 4. Apply the Evidence Implement useful findings in clinical practice 5. Evaluate The information, intervention, and EBM process

32. THE FIVE BASIC STEPS OF EBM Clinical Question Patient-focused, problem-oriented 2. Find Best Evidence Literary Search 3. Critical Appraisal Evaluate evidence for quality and usefulness 4. Apply the Evidence Implement useful findings in clinical practice 5. Evaluate The information, intervention, and EBM process

33. THE FIVE BASIC STEPS OF EBM Clinical Question Patient-focused, problem-oriented 2. Find Best Evidence Literary Search 3. Critical Appraisal Evaluate evidence for quality and usefulness 4. Apply the Evidence Implement useful findings in clinical practice 5. Evaluate The information, intervention, and EBM process

34. THE FIVE BASIC STEPS OF EBM Clinical Question Patient-focused, problem-oriented 2. Find Best Evidence Literary Search 3. Critical Appraisal Evaluate evidence for quality and usefulness 4. Apply the Evidence Implement useful findings in clinical practice 5. Evaluate The information, intervention, and EBM process

35. THE FIVE BASIC STEPS OF EBM Clinical Question Patient-focused, problem-oriented 2. Find Best Evidence Literary Search 3. Critical Appraisal Evaluate evidence for quality and usefulness 4. Apply the Evidence Implement useful findings in clinical practice 5. Evaluate The information, intervention, and EBM process

36. THE FIVE BASIC STEPS OF EBM Clinical Question Patient-focused, problem-oriented 2. Find Best Evidence Literary Search 3. Critical Appraisal Evaluate evidence for quality and usefulness(validity and relevance) 4. Apply the Evidence Implement useful findings in clinical practice Making a decision, by integrating the evidence with your clinical expertise and the patient’s values. 5. Evaluate The information, intervention, and EBM process

37. The Clinical Question The FIRST step The HARDEST step The MOST IMPORTANT step!

38. FACT: We all have informational needs! That is not a problem!

39. Problems arise • if we fail to recognize those needs • if we fail to bridge the information gap • if we fail to ask the right questions

40. Asking good questions is a skill to be learned. Hmmm… Is he about to give me a BONUS? Or is he about to FIRE me? Lee, exactly how much time did you spend on that big project? It will make life easier for you... And also for others around you!

41. Lee, can you give me an accounting of the extra time you spent on that project so that I can charge it back to the client? Oh sure! I’ll have it on your desk by tomorrow! • A GOOD QUESTION… • Is focused and relevant • Provides clear communication • Clarifies your goal or need • Will reduce the amount of time needed to obtain the answer

42. Asking Questions Foreground Questions Background Questions Expert Novice

43. The Question • Background • Anatomy and Physiology • Pathophysiology • Pharmacology and Toxicology • Differential diagnosis • Diagnostic testing • Treatment • Textbooks, reviews, lectures, experts

44. The Clinical Question • Foreground • Detailed information • Patient focus • Evidence-based process

45. WHEN PRACTICING EBM, a good question must also: • Be specific Identify the problem, clarifiy the clinical issue • Be answerable through the literature • Contain multiple aspects (patient, options, comparisons, etc) It should NOT involve a question of Personal Preference or Local Concern.

46. EBM QUESTION: Should include multiple factors • (Examples) • P PATIENT type of patient or population • Ex: 47 yr male w/DM2 and cellulitis toe, 25 yr female w/DVT and chest pain • E EXPOSUREenvironmental, personal, biological • Ex: TB, tobacco, drug, diet, pregnancy or menopause, MRSA, allergy • I INTERVENTIONclinical intervention • Ex: medication, procedure, test, surgery, radiation, drug, vaccine • C COMPARISONcompare alternative treatment • Ex: other prior, new or existing therapy • O OUTCOME clinical outcome of interest • Ex: Reduced death rate in 5 yrs, decreased infections, fewer hospitalizations

47. Scenario and Question • A healthy adult presents to the clinic inquiring about the aspirin that it might prevent heart attack ?

48. The Question “In an asymptomatic adult and no risk factors, would the use of aspirin reduce the incidence of cardiovascular events?

49. 1. Patient population. 2. Intervention. 3. Comparison intervention. 4. Outcomes. Asymptomatic adults with no risk factors Aspirin and Primary Prevention Aspirin Placebo Incidence of CV events “In asymptomatic adults no risk factors, would the use of aspirin reduce the incidence of cardiovascular events?

50. Scenario and Questions (Cont’d) Scenario A 32-year-old man, single, teacher in primary school, known to have IBS for last 3 years with no response to conventional medication. I decided to search for effect of TCA in patients with IBS.