Evidence Based Medicine… The Road ahead: Bridging the gap from theory to Practice

1. Evidence Based Medicine…The Road ahead: Bridging the gap from theory to Practice Amr Nadim, MD. Professor of Obstetrics & Gynecology Ain Shams Faculty of Medicine The QAInc. Advisory Board

2. What happened …? • Over the past decade, the term "evidence-based medicine" (or EBM) has gained considerable currency. • EBM has been described as a "paradigm shift" that will "change medical practice in the years ahead."

3. The medical practice so far… • Based experience gained from clinical practice • Information essentially driven from • The basic science research • Observational studies that are NOT necessarily controlled • Expert opinion • Advocacy

4. So, when faced with a problem, Doctors may… • Reflect on their own clinical experience, • Reflect on the underlying biology, • Go to a textbook, • Ask a local / international expert. • Believe in what they are told by pharmaceutical companies

5. What is the problem any way…? • Bias, bias and bias…

6. Prof. Archibald Leman Cochrane a British medical epidemiologist whose book Effectiveness and Efficiency: Random Reflections on Health Services (1972) and subsequent advocacy caused increasing acceptance of the concept of Evidence Based Medicine The Founding Father (January 12, 1909 - June 18, 1988)

7. The People at McMaster Universityas early as 1992 …introduced Evidence Based Medicine as a Shift of Paradigm

8. What is EBM…? • “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients" • It is about the WISE use of the EVIDENCE to achieve a QUALITY OF PATIENT CARE

9. EBM: The Theory Evidence-based medicine is: the SYSTEMATIC, SCIENTIFIC and EXPLICIT use of current best evidence in making decisions about the care of individual patients.

10. Patient Values…? • The unique preferences, concerns, and expectations each patient brings to a clinical encounter. • They may differ from phase to phase.. from one encounter to another. • These must be integrated into clinical decisions if they are to serve the patient.

11. Clinical Expertise…? Ability to use The clinical skills & past experience to rapidly identify Each patient’s: • Unique health state. • Individual risks/benefits of interventions (Diagnostic or therapeutic). • Personal values and expectations.

12. What is The Best Research Evidence ? Clinically relevant, Patient-centered research about: • Diagnostic tests: To detect the disease • Prognostic markers: To follow up the disease • Therapeutic / preventive regimens: To treat • Harm: That treatments/diagnostic tools may cause.

13. EBM: The Theory A Paradigm Shift…?

14. Paradigm..? • “An entire constellation of beliefs, concepts, values, techniques, and so on shared by the members of a given community"

15. Paradigm Shift…?

16. EBM: The Theory • A Paradigm shift: The medical community is shifting gears Advocacy Inquiry Opinion Evidence Disease-oriented Patient-oriented Intermediate results Final outcomes

17. And in doing so, one should… • Define the problem in the form of an answerable clinical question. • Perform an elaborate search for the best available evidence. • Appraise this evidence for relevance &validity. • Incorporate it in his practice • Become a life-long learner.

18. I have no particular talent…I am merely inquisitive

20. What we used to do…

21. Time spent reading around one’s patients is slim: Self-reports from Oxford : • House Officers: none • S.H.O.’s: 10 minutes • Registrars: 90 minutes • Senior Registrars: 45 minutes • Consultants: • Post 1975: 60 minutes • Pre 1975: 30 minutes

22. What EBM originally advocated…

23. POEM DOE While you are formulating your question… • Alendronate reduces fracture Risk • Alendronate improves • BMD • HRT reduces incidence of Cardiovascular events • HRT Lowers LDL and Increases HDL

24. DOE (intermediate outcomes) • Disease-Oriented Evidence • A test result / A physiological number • POEM (final outcomes)) • Patient-Oriented Evidence that Matters to the Patient • Will I die? Will I suffer? My quality of life?

25. POEM Patient-Oriented Evidence that Matters… To whom? To you …and To your patient

26. And While Doing So You Should Respect The EVIDENCE Hierarchy

27. What we used to do…

28. And in many instances we find ourselves lost in a maze…

29. What EBM is now proposing… Information Mastery Everything is based on the usefulness equation: Usefulness = Relevance x Validity Work

30. Drilling for the evidence Cochrane Library Clinical Evidence Specialty-specific POEMs Best Evidence Textbooks, Up-to-Date, 5-Minute Clinical Consult Usefulness Journals/ Medline

31. Levels of Evidence and Grades of Recommendations

32. Evidence Based Medicine Has Changed the world

33. Source of knowledge is expert opinion Clinical skills are seen as semi-mystical Research is marginal to practice Source of knowledge is systematic review of evidence Clinical skills can be audited and managed Research and evidence go together EBP has changed the world

34. Most of what doctors need to know is in their heads. Most medical care is assumed to be beneficial Doctors must use information tools constantly/ they must constantly be updated and learn new skills. Widespread recognition that the balance between doing good and harm is fine EBP has changed the world

35. Clinical performance is not systematically audited Doctor patient relationship is essentially master/pupil Clinical performance is regularly reviewed and managed Patient partnership is often thought. EBP has changed the world

36. Patients do not have easy access to the knowledge base of doctors The doctor is smartest Patients have as much access to the evidence base of medicine as doctors Often the patient is smarter EBP has changed the world

37. The Pre-internet Patient..

38. The Evidence The Doctor The Patient

42. The Evidence The Doctor The Patient

43. The Clinician of the Future • Learn how to say “I do NOT know” with ease and confidence • Knows then how to find the best available evidence. • Listen to the patient, appreciate his preferences, determine which tests and treatment will do more good than harm by tailoring the best available evidence to the individual’s condition. • Discuss the options with the patient and help him make an informed choice depending on his values and preferences Ahmad Nadim

44. A Doctor More resourceful Aware of the concept of Information Mastery Following Evidence Based Guidelines. Publishing and Appraising Evidence Based Researches and Literature A Patient More Resourceful Aware of his writes Able and willing to take part in the Decision Making process concerning his life Not bluffed by DOEs but essentially with POEMs In few words, EBM changed the medical practice….

45. However…

46. Many Leaks From Research To Practice Paul Glasziou, CEBM, Oxford University The 3rd Asia Pacific Congress on EBM, November 2004

47. Paul Glasziou, CEBM, Oxford University

49. Changing Practice thru the policy (guideline) Set policy (guideline) based on the evidence Get the evidence straight 3 2 1 Practicing Evidence Based Medicine Linking evidence to practice

50. What EBM Did Bring To Our Medical Practice Over The Past Decade? • WHO Medical Eligibility Criteria • WHO Cire • WHO Reproductive Health library • RCOG green top guidelines • The Cochrane Library • Fostering the concept of life-long learning. • CAT Banks • Putting an emphasis on the importance of controlled clinical trials.