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E-B Pain Relief

E-B Pain Relief. E-B Pain Relief Distribute the promotion of EBM password. Life long learning with EBM. Prof Eiad Al- Faris MD, MSc , MMEd , MRCGP Consultant Family Medicine Prof. King Saud University Supervisor -King Saud University chair for medical education. Outline.

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E-B Pain Relief

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  1. E-B Pain Relief • E-B Pain Relief • Distribute the promotion of EBM password

  2. Life long learning with EBM • Prof Eiad Al-FarisMD, MSc, MMEd, MRCGP • Consultant Family Medicine • Prof. King Saud University • Supervisor -King Saud University chair for medical education

  3. Outline • Introduction • Definition of EBM • Steps of EBM • Practical search • Conclusion • Closure

  4. INFORMATION EXPLOSION ?250,000 100,000 10,000 MEDICAL JOURNALS 1900 1990 2000

  5. Rule 31 – Review the World Literature Fortnightly* 5,000? per day 1,260 per day 55 per day

  6. Clinical Scenario • Ibrahim is a 60 years old teacher, he is known case of hypertension. He presented to the ED with severe chest pain for the last two hours. • In addition to hitory/ exam and ECG, you wonder should you request for the timely diagnosos: troponin or creatinekinase- MB or both?

  7. When confronted with a clinical question, whom usually you consult?

  8. Colleagues- experts • A great source of information. • Quick, affordable and accessible. • But potentially very biased: Variability Not updated

  9. Textbooks • Rapidly out-of-date (2-4y). • They are a good source of background information (pathophysiology), • but a poor source of information for most foreground questions (clinical).

  10. Burn your traditional textbooks

  11. What is EBM?

  12. EBM is The integration of the current best evidence (from research) with our clinical expertise and patient’s values.

  13. Three (Es)- EBM Components

  14. Controlled trials The “Evidence Transfer Gap” Clinical Practice

  15. Rules of Evidence All evidence is not created equal. Values always influence decisions. Evidence alone never makesclinical decisions.

  16. Hierarchy of Evidence Meta-analysis of RCTs Multi-centric large RCTs Single Centre RCT Observational studies patient-important outcomes Clinical experience Basic research test tube, animal, human physiology

  17. Patient dilemma Process of EBP Act & Assess Ask Acquire Principles of evidence-based practice Appraise Hierarchy of evidence Apply Evidence alone does not decide – combine with other knowledge and values

  18. 5 As to practice EBM Acquirethe Evidence(s) Appraisethe Evidence(s) Applythe best Evidence Assessyour Performance Askfocused Question(s)

  19. 6 As to practice EBM Assess your patient Ask clinical questions Acquire the Evidence(s) Appraise the evidence(s) Apply The best evidence to patient Assess Yourself

  20. Assess Your Patient History Physical examination Objective data – labs, x-rays • Formulate differential diagnosis • Pretest probability of disease

  21. 6 As to practice EBM Assess your patient Ask clinical questions Acquire the Evidence(s) Appraise the evidence(s) Apply The best evidence to patient Assess Yourself

  22. To answer a clinical question effectively, First, turn your scenarios into 'well-built' clinical Q. Four domains:PICO 1) the patient (problem) 2) the intervention or exposure 3) the comparison (intervention) 4) the clinical outcomes

  23. For healthy adults is it worthwhile to give aspirin as prophylaxis to reduce MI and or stroke ?

  24. 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?

  25. Ask Clinical Questions (PICO) Patient/ Population Outcome Intervention/ Exposure Comparison does early treat- ment with a statin decrease cardio- vascular mortality? In patients with acute MI compared to placebo what is the accuracy of exercise ECHO In women with suspected coronary disease compared to exercise ECG for diagnosing significant CAD? does hormone replacement therapy In post- menopausal women compared to no HRT increase the risk of breast cancer? Components of Clinical Questions (PICO)

  26. Types of clinical questions • Therapy and harm: how to select treatments to offer patients that do more good than harm • Diagnostic tests: how to select and interpret diagnostic tests, in order to confirm or exclude a diagnosis • Prognosis: how to estimate the patient's likely clinical course over time

  27. Prefiltered Sources: Secondary sources ACP Journal Club (www.acpjc.org) Cochrane Library (www.update-software.com/cochrane) Up-to-Date (www.uptodate.com) Clinical Evidence (www.evidence.org) InfoRetriever (www.infopoems.com) Ovid (www.ovid.com) MD Consult (www.mdconsult.com) Medscape (www.medscape.com) Dynamed (www.dynamed.com) Unfiltered Sources MEDLINE (www.pubmed.gov) Google (www.google.com Acquire the Best Evidence • We need to focus and familiarize yourself with few of them

  28. Developments (4 s) that facilitate EBM Practice Computer Decision Support System (CDSS) eg. Dynamed “Point of care” EBM journal / ACP j. club Clinical Practice Guidelines Cochrane Library / Systematic Reviews Single RCT in Journal

  29. Cochrane Library http://www.thecochranelibrary.com Up-to-Date www.uptodate.com Clinical Evidence www.clinicalevidence.org Ovid www.ovid.com Pre-filtered Sources:

  30. ACP Journal Clubwww.acpjc.org • InfoRetrieverwww.infopoems.com • MD Consult www.mdconsult.com • Medscapewww.medscape.com • Dynamedwww.dynamed.com

  31. EBM can reduce reading need How much is valid AND relevant? Number Needed to Read is 20+ PROCESS • 120+ journals scanned • 50,000 articles • Is it valid? (<5%) • Intervention: RCT • Prognosis: inception cohort • Etc • Is it relevant? • 6-12 GPs & specialists asked:Relevant? Newsworthy? • < 0.5% selected Number Needed to Read is 200+ www.evidence-basedmedicine.com

  32. Deals with barriers The Challenge – Bridging the gap! • New EBM teaching models • Involves seniors and juniors • EBM Environment

  33. Appraise the Evidence Relevance: It focuses on medical problems common to our practice. patient-oriented evidence Validity: Correctness (likely to be true) Results: Clinically important Can we apply the results to our patient? Applicable in and useful for my patients

  34. Relevance Consider three questions to determine Relevance • Common to practice • Require change of practice • Patient-oriented outcome

  35. POEM Vs. DOE POEM: Patient-oriented evidence that matter mortality, morbidity, quality of life DOE: Disease-oriented evidence pathophysiology, pharmacology, etiology

  36. Comparing DOE and POEM

  37. 40DOE POEM • The cardiac arrhythmia suppression trial. N Engl J Med 1991.

  38. DOE POEM • The cardiac arrhythmia suppression trial. N Engl J Med 1991.

  39. DOE POEM The cardiac arrhythmia suppression trial. N Engl J Med 1991.

  40. 5 journals with highest concentration of POEMS • JAMA-17% • Annals of Internal Medicine-17% • NEJM-16% • Journal of the American Board of Family Practice-16% • Journal of Family Practice-15% Ebell MH et al. J Fam Pract 1999 48: 350-355

  41. Validity In RCT: • Randomization • Blindness • Drop-out • ITT

  42. Results Results clinical importance can be assessed by its: • Magnitude • Precision

  43. Results of a hypothetical randomized trial

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