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Evidence-Based Medicine ( EBM )

Evidence-Based Medicine ( EBM ). = Médecine Factuelle. C- EBLM (IFCC-LM) (Cochrane, …). Evidence-Based Nursing,. Evidence-Based Health-Care, …. Evidence-Based Management,. Evidence-Based Policy, …. Evidence-Based S ociology,. Evidence-Based History, …. X. Evidence-Based Mathematics , ….

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Evidence-Based Medicine ( EBM )

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  1. Evidence-Based Medicine (EBM) =Médecine Factuelle

  2. C-EBLM(IFCC-LM)(Cochrane, …)

  3. Evidence-Based Nursing, Evidence-Based Health-Care, …

  4. Evidence-Based Management, Evidence-Based Policy, …

  5. Evidence-Based Sociology, Evidence-Based History, …

  6. X Evidence-Based Mathematics, …

  7. (EB)M = chaque décision médicale se fonde sur: 1) niveaux de preuve (les plus élevés) 2) expertise clinique (professionnelle/scientifique) 3) choix des patients

  8. Prejudice-, Belief-, Faith-, Tradition-, Ideology-, Authority-, Anarchy-Based Medicine, …

  9. Prejudice-based Medicine Fowler FJ Jr, McNaughton Collins M, Albertsen PC, Zietman A, Elliott DB, Barry MJ. Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer.JAMA 2000;283:3217-22.

  10. The quality of health care delivered to adults in the United StatesMcGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA.N Engl J Med 2003 Jun 26;348(26):2635-45.

  11. Study Design - 439 indicators of quality of care for 30 acute and chronic conditions, and preventive care - Telephone survey - Informed consent to examine their medical records + interview - Random sample of 6712 adults from 12 metropolitan areas

  12. Recommended care received

  13. Recommended care received 85%:Influenzae vaccination >65y 45%:MI-beta-blockers 38%: Colorectal cancer/FOBT 24%:HbA1c X3/y

  14. Conclusions • patients received 54.9%(54.3-55.5) of recommended care • strategies to reduce these deficits are warranted

  15. Strategies?EBM?

  16. Niveaux de preuve? I - Randomised Trials II - Non -randomised Trials, Cohort studies III - Case-control studies, case-reports IV –Expert opinion

  17. Annual biomedicalliterature: 17 000 books +2 000 000 articles(in Medline:200 000 articles)

  18. “The medical literature can be compared to ajungle. It is fast growing, full of dead wood, sprinkled with hidden treasure, and infested withspiders and snakes”

  19. Systematic Reviews (Revues Méthodiques) = la pierre angulaire de l’EBM

  20. Systematic Review (Introduction/) Question(s) (focussed) Materials et Methods (objectivity)  Search (systematic) (EB-librarianship) Inclusion / Exclusion / Quality assessment Results - Discussion (limitations) (Conclusion/) Answer(s) - balance benefits/harms (probabilités)

  21. Meta-analysis - results of primary studies combined quantitatively and statistically - statistical power

  22. Trial (Year) Mortality results from 33 trials of beta-blockers in secondary prevention after myocardial infarction. Adapted from Freemantle et al BMJ 1999 Barber (1967) Reynolds (1972) Wilhelmsson (1974) Ahlmark (1974) Multicentre International (1975) Yusuf (1979) Andersen (1979) Rehnqvist (1980) Baber (1980) Wilcox Atenolol (1980) Wilcox Propanolol (1980) Hjalmarson (1981) Norwegian Multicentre (1981) Hansteen (1982) Julian (1982) BHAT (1982) Taylor (1982) Manger Cats (1983) Rehnqvist (1983) Australian-Swedish (1983) Mazur (1984) EIS (1984) Salathia (1985) Roque (1987) LIT 91987) Kaul (1988) Boissel (1990) Schwartz low risk (1992) Schwartz high risk (1992) SSSD (1993) Darasz (1995) Basu (1997) Aronow (1997) 0.80 (0.74 - 0.86) Overall (95% CI) 0.1 0.2 0.5 1 2 5 10 Relative risk (95% confidence interval)

  23. Cumulative meta-analysis of 33 trials of beta-blockers in secondary prevention after myocardial infarction Calculated from Freemantle et al BMJ 1999

  24. Publication bias All studies conducted All studies published Grey literature All studies reviewed

  25. Systematic reviews↓Levels of evidence

  26. (EB) Guidelines↓Levels of evidence (I-IV) CONSENSUS JUDGMENT ↓Strength of recommendation (A-D)

  27. JUDGMENT /CONSENSUS I → A I → D IV → D II/III/IV → A

  28. Cancer colorectaldépistage de masse - FOBT

  29. 12 guidelines

  30. 8 revues systématiques dont 3 publiées en 2006-2007

  31. Heresbach D, Manfredi S, D'halluin PN, Bretagne JF, Branger B. Review in depth and meta-analysis of controlled trials on colorectal cancer screening by faecal occult blood test. Eur J Gastroenterol Hepatol 2006; 18:427-433 • Méta-analyse de 4 essais contrôlés (336 000 pts) (France, UK, USA, Danemark) • Réduction de la mortalité par CCR (RR= 0.79-0.94), pendant la durée du dépistage uniquement (10 ans)

  32. Moayyedi P, Achkar E. Does fecal occult blood testing really reduce mortality? A reanalysis of systematic review data. Am J Gastroenterol 2006; 101:380-4 • Méta-analyse de 3 essais contrôlés randomisés (245 000 pts)(UK, USA, Danemark) • Réduction de la mortalité par CCR (RR= 0.80-0.95) • Augmentation de la mortalité non liée au CCR (RR= 1.00-1.04, p=0.015) [Hypothèse: FOBT = vaccin anti-cancer?]

  33. Hewitson P, Glasziou P, Irwig L, Towler B, Watson E. Screening for colorectal cancer using the faecal occult blood test, Hemoccult.Cochrane Database Syst Rev 2007 Jan 24;(1):CD001216. Revue systématique + méta-analyse de 4 essais contrôlés randomisés(UK, USA, Danemark, Suède) • Réduction de la mortalité par CCR (RR= 0.78-0.90) • Augmentation de la mortalité non liée au CCR (RR= 1.00-1.03, non significatif)

  34. Hewitson P, Glasziou P, Irwig L, Towler B, Watson E. Screening for colorectal cancer using the faecal occult blood test, Hemoccult.Cochrane Database Syst Rev 2007 Jan 24;(1):CD001216. Effets bénéfiques du dépistage de masse: • Réduction modeste de la mortalité par CCR • une possible reduction de l’incidence du CCR • potentiellement, une chirurgie moins invasive Effets délétères du dépistage de masse: • faux-positifs: conséquences psycho-sociales • complications des colonoscopies, des faux négatifs • possibilité de sur diagnostic (investigations ou traitements inutiles et leurs complications)

  35. 9 YES: JUDGMENT: benefits outweighs harms VALID judgment, provided both benefits and harms are mentioned in guidelines

  36. 3 NO(UK, Scotland, New-Zealand): JUDGMENT: benefits may or may not outweigh harms, but the structure of health-system does not allow to recommend for mass-screening VALID judgment too

  37. CONCLUSION 1) niveaux de preuve (balance bénéfices/risques) 2) expertise professionnelle (multi-disciplinarité) 3) choix des patients 38%

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