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Evidence-Based Medicine: Tools, Techniques, Results

Evidence-Based Medicine: Tools, Techniques, Results. Balakrishnan S. Motivation: EBM “Successes”. Theophylline and asthma We were doing the wrong thing Littenberg, 1988 Beta blockers and MIs We weren’t doing the right thing Yusuf, 1987. Uses of “EBM”.

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Evidence-Based Medicine: Tools, Techniques, Results

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  1. Evidence-Based Medicine: Tools, Techniques, Results Balakrishnan S

  2. Motivation: EBM “Successes” • Theophylline and asthma • We were doing the wrong thing • Littenberg, 1988 • Beta blockers and MIs • We weren’t doing the right thing • Yusuf, 1987

  3. Uses of “EBM” • Use of empirically-verified treatments in the care of patients • Incorporation of research results into the process of care • Ability to critically appraise research results

  4. What is Evidence-Based Medicine? • “Theintegration of individual clinical expertise with the bestavailable clinical evidence from systematic research.” • David L Sackett, W Scott Richardson, William Rosenberg, R BrianHaynes Evidence Based Medicine--How to Practice and Teach EBM, 1996 • Various definitions

  5. “Clinical Evidence” • Clinical vs physiological outcome • E.g., Sleeplessness rather than O2 saturation • Clinical outcomes: See Outcome Research Institute • Effectiveness vs efficacy • In practice vs biology • Effectiveness: See DARE

  6. “Best Available Clinical Evidence” • Therapy • Double-blind, placebo-controlled, randomized clinical trial • Diagnosis • Independent, blind comparison with a reference standard • Prognosis • Representative and well-defined prospective cohort of patients at a similar point in the course of disease • See Centre for Health Evidence

  7. Levels of Evidences • (I-1) a well done systematic review of 2 or more RCTs • (I-2) a RCT • (II-1) a cohort study • (II-2) a case-control study • (II-3) a dramatic uncontrolled experiment • (III) respected authorities, expert committees, etc.. • (IV) ...someone once told me.... • http://www.phru.org/casp/ • See also AAFP

  8. “Systematic Research” • “Meta-analysis” • “Literature synthesis” • From Michael Scriven

  9. “Integration of Individual Clinical Expertise” • Informal • Formal (Decision analysis)

  10. Questions ARIF

  11. Questions: PICO Centre for EBM: http://163.1.212.5/docs/focusquest.html

  12. Search for the Best Evidence • Review articles • Community/professional standards • Systematic reviews • Original results

  13. What are the Sources of Good Evidence? www.welch.jhu.edu

  14. Cochrane Website

  15. TRIP Database Website (75 resources…) www.tripdatabase.com

  16. Getting to PubMed

  17. PubMed Response

  18. PubMed Clinical Query www4.ncbi.nlm.nih.gov/PubMed/

  19. Question Context Subject matter PubMed, Clinical Query, cont’d Website

  20. Click on “Details”-- ((("atrial fibrillation"[MeSH Terms] OR atrial fibrillation[Text Word]) AND (((randomized controlled trial[PTYP] OR "drug therapy"[Subheading]) OR "therapeutic use"[Subheading:noexp]) OR (((((((((((((((((((((((((((((((((((((((((((((((((((((random[WORD] OR randomaly[WORD]) OR randoman[WORD]) OR randomand[WORD]) OR randombred[WORD]) OR randombreds[WORD]) OR randomdigit[WORD]) OR randomdot[WORD]) OR randome[WORD]) OR randomed[WORD]) OR randomely[WORD]) OR randomer[WORD]) OR randomezed[WORD]) OR randomic[WORD]) OR randomicity[WORD]) OR randomil[WORD]) OR randomily[WORD]) OR randomingly[WORD]) OR randomisation[WORD]) OR randomisations[WORD]) OR randomise[WORD]) OR randomised[WORD]) OR randomisees[WORD]) OR randomisely[WORD]) OR randomises[WORD]) OR randomising[WORD]) OR randomisly[WORD]) OR randomiz[WORD]) OR randomizable[WORD]) OR randomizadely[WORD]) OR randomizado[WORD]) OR randomization[WORD]) OR randomizations[WORD]) OR randomize[WORD]) OR randomized[WORD]) OR randomizedly[WORD]) OR randomizely[WORD]) OR randomizer[WORD]) OR randomizes[WORD]) OR randomizing[WORD]) OR randomlike[WORD]) OR randomly[WORD]) OR randomlyselected[WORD]) OR randommess[WORD]) OR randommized[WORD]) OR randommobility[WORD]) OR randomnes[WORD]) OR randomness[WORD]) OR randomomized[WORD]) OR randoms[WORD]) OR randomsource[WORD]) OR randomyl[WORD]) OR randomyly[WORD]) OR randomzied[WORD]))) AND notpubref[sb])

  21. Controlled Vocabulary for Subject Matter

  22. UpToDate Website

  23. CISMeF Website www.chu-rouen.fr/cismef/

  24. Dynamic Meta-Searching Website sumsearch.uthscsa.edu/searchform45.htm

  25. Clinically Appraised Topic Websites

  26. CAT Content

  27. CAT Synthesis

  28. Washington University: PedsCCM Website pedsccm.wustl.edu/EBJ/EB_Resources.html

  29. Details Website • Therapy/prevention • Diagnostic test • Prognosis • Harm • CPG • Systematic review • Economic analysis • Outcomes research www.med.ualberta.ca/ebm/ebm.htm

  30. Therapy Website

  31. Apply the Evidence to the Individual

  32. Evidence-Based MEDICINE • Do you tell what you know? • Does the patient want to participate? • What is the emotional impact of what you have to say? • What is the meaning to the patient of this evidence?

  33. Should a 30-year-old woman with recurrent uncomplicated lower UTIs be advised to drink cranberry juice to prevent reinfection? For a 63 year old woman with Type 2 diabetes, is gabapentin superior to amitriptyline as first-line therapy for painful peripheral neuropathy? Problems

  34. Task • Well formulated question? • Discuss sites to go…everyone takes one • Formulate the query • Report back to your group on your success • The whole group reports back at the and of 30 min

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