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Evidence-Based Medicine (EBM)

Evidence-Based Medicine (EBM). Arnuparp Lekhakula Department of Internal Medicine Faculty of Medicine Prince of Songkla University. Scope of Presentation. Wh y EBM? Wh at is EBM? How to use and practise EMB Application of EBM Limitations of EBM. Why EBM ?.

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Evidence-Based Medicine (EBM)

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  1. Evidence-Based Medicine (EBM) Arnuparp Lekhakula Department of Internal Medicine Faculty of Medicine Prince of Songkla University

  2. Scope of Presentation • Why EBM? • What is EBM? • How to use and practise EMB • Application of EBM • Limitations of EBM

  3. Why EBM?

  4. Negative correlation betweenknowledge of hypertensionandthe years since graduation from the medical school

  5. Why EBM? • Paradigm shift • Evidences create frequent, major changes • in the way of patient care • Both our up-to-date knowledge and our • clinical performance deterioratewith time • Quality of health care • Second opinion • Patient education • Cost of health care • Third party

  6. Why EBM? • Eyepatches for corneal abrasion • Anti-arrhythmic agent : • Encainide and flecainide - suppress • ventricular arrhythmia • Steroids in prematurity No benefit Higher mortality rate than control ?Outcome Beneficial effect

  7. What is Evidence-Based Medicine?

  8. Evidence-Based Medicine The practice of EBM is the integration of • individual clinical expertise with the • best available external clinical evidence from systematic research and • patient’s values and expectations

  9. Assumption of the Old Paradigm • Clinical experiences are a valid way for • clinical practice • Pathophysiologic principles are adequate • guides for clinical practice • Assessment of evidence is adequate • through thorough traditional medical • training plus the use of common sense • Experts are authority who should be • consulted in solving clinical problems

  10. Solving Problems under Old Paradigm • Reflect on own clinical experiences • Reflect on underlying pathophysiology • Consult an updated textbook • Ask content experts • Read introduction and discussions of • journals

  11. Assumption of the New Paradigm • Clinical experiences are of limited values • in decisions about clinical practices • Pathophysiologic principles can lead to • inaccurate judgement about clinical • practices because of incomplete • understandings of all related principles

  12. Assumption of the New Paradigm • Assessment of evidence requires • knowledge of rules of evidences in • addition to training and common sense • Experts should be challenged to produce • evidence on which their recommendations • are based

  13. Solving Problems with EBM • Define a patient problem • Convert the problem into answerable • questions • Search literature for the best evidence • Critically appraise that evidence for its • validity (closed to the truth) and • usefulness (clinical applicability) • Apply the results back to the patient • Evaluate our performance

  14. Evidence-Based Medicine Clinical problem Building a good question Carrying out an efficient, thoughtful search of evidence Applying the evidence to the patient Choosing the best evidence from the search output Critically appraising the evidence

  15. How to use and practise EBM?

  16. Clinical Questions Arise from : • Clinical findings • Etiology • Differential diagnosis • Diagnostic test • Prognosis • Clinical prediction • Therapy • Prevention • Economics

  17. Building a Good Question ‘PICO’ Patient I ntervention C omparison Outcome

  18. Weighing the Evidence • Validity(Is it good and true?) • Importance(Is it worth attention?) • Relevance • (Is it worth putting in practice?)

  19. Two Key Components of EMB • Hierarchy of evidences • Clinical research • Physiological studies involving • animals & non-clinical outcomes • Clinical experiences • Decision making • Application of evidences • Determinants of actions

  20. Nature of Evidences • Clinical Experiences • Unsystematic observations • Varying degree of bias • Physiologic Evidences • Highly systematic & strict scientific rules • Limited generalization and inference • Different from clinical outcomes • Clinical Research • Systematic clinical observation • Strategies to deal with bias

  21. Systematic Review Meta-Analysis RCT Cohort Case-Control Cross-sectional Case Reports Hierarchy of Evidence

  22. Learning how to practise EBM • Seeking and applying evidence-based • summaries generated by others • Accepting evidence-based practice • protocols developed by colleagues Three EBM Strategies for Keeping Up-to-date

  23. 3 Different Modes of Practice • “Searching & appraising” • provides E-B care, but is expensive in time and resources • “Searching only” • much, quicker, and if carried out among E-B resources, can provide E-B care • “Replicating” the practice of experts • quickest, but may not distinguish evidence-based from ego-based recommendations

  24. Patients can benefit • Even if <10% of clinicians are capable of practicing in the “searching & appraising” mode (5% of GPs) • As long as most of them practice in a “searching” mode within high-quality evidence sources (70-80% of GPs): • Cochrane Library, E-B Journals, E-B Guidelines, etc

  25. Cochrane Systematic Reviews (522; another 500 in preparation) Database of Abstracts of Reviews of Effectiveness (1895) Registry of Randomised Controlled Trials (218,355)

  26. EBM in Medical Training • Encourage learning • Challenging • Decreased the knowledge gap between • trainee and their teachers • Increased the trainees’ confidence and • fostering life-long self-directed learning

  27. Limitation of Evidence-Based Medicine

  28. The Limits of Evidence • RCT gives average probability and not • the possible ranges of outcomes • Patient’s choices informed by facts but • influenced by personality and preference • Bias in research in posing questions and • getting answers • Bias in publication

  29. Incomplete and contradictory evidence • Population effectiveness versus • individual effectiveness • Difficulty of searching evidence in • emergency • Force feeding by EBM may antagonize • many The Limits of EBM

  30. EBM ignores clinical experience and • clinical intuition • Understanding of basic investigation • and pathophysiology plays no part in • EBM • EBM ignores standard aspects of • clinical training, such as history taking • and physical examination Misapprehensions about EBM

  31. Evidence-Based Medicine • is not“everybody already is doing it” • is notsubject matter in the textbook • will notproduce new findings • will notproduce better evidence • is not“cook-book” medicine • is notrestricted to randomized trials and • meta-analysis

  32. Filter of EBM Patient’s preference Clinical knowledge, experience and guts Best Evidence Clinical decision

  33. “Absence of evidence” is not “Evidence of absence”

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