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ScienceCartoonsPlus.com. e vidence-based medicine (EBM)*: what it is & why its necessary. Rod Jackson 2013. * also called evidence-based practice (EBP). e vidence-based medicine (EBM)*: what it is?.

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  1. ScienceCartoonsPlus.com

  2. evidence-based medicine (EBM)*: what it is & why its necessary Rod Jackson 2013 * also called evidence-based practice (EBP)

  3. evidence-based medicine (EBM)*: what it is? ‘its about how to better inform your clinical decisions with the best up-to-date epidemiological evidence’

  4. core components of ‘traditional’ evidence based decision-making *relied on clinical knowledge or ‘mechanistic evidence’ mainly from: anatomy, physiology, pathology, biochemistry, psychology, etc.

  5. ‘modern’ EBM explicitly emphasises ‘current’ best clinical epidemiological evidence about outcomes directly relevant to people evidence from direct observation, what happens in practice

  6. clinical epidemiological evidence* • how accurate are diagnostic tests? • how strong are prognostic markers? • how effective are interventions? • therapy • Screening • prevention * study of the probability of outcomes in groups of patients

  7. Aristotle (384 – 322 BCE): the first evidence based practitioner? None of the arts (i.e sciences)theorise about individual cases. Medicine,for instance, does not theorise about what will help to cureSocrates, but only about what will help to cure anyor all of a given class of patients. This alone is our business. Individual cases are so infinitely various that no systematicknowledge of them is possible. Aristotle. Rhetoric. book I,chapter 2: 1356b (clinical epidemiology is the science of investigating the probability of outcomes in ‘groups ‘or classes’ of patients’)

  8. evidence-based practice ‘informing decisions more explicitly with the best up-to-date evidence, particularly from epidemiology’ by using this evidence: more efficiently more critically more systematically EBP: informing decisions with the best up-to-date evidence

  9. 5,000? per day 2,000 per day 75 per day why do we need to use evidence efficiently? Articles Per Year EBP: informing decisions with the best up-to-date evidence

  10. clinical evidence increasing so rapidly we need better skills to keep up-to-date more efficiently than previous generations of clinicians more efficiently Bastian, Glasziou, Chalmers PLoS2010 Vol7 | Issue 9 | e1000326

  11. using evidence more critically validity: most articles should be ignored Number Needed to Read to find 1 valid is 20+ EBM Journal Process • 140+ journals scanned • 60,000 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 to find 1 valid & relevant is 200+ more critically EBP: informing decisions with the best up-to-date evidence

  12. but many clinicians cannot tell good from poor quality research BMJ study of 607 reviewers • 14 deliberate errors inserted Detection rates • On average <3 of 9 major errors detected • Poor Randomisation (by name or day) - 47% • Not intention-to-treat analysis - 22% • Poor response rate - 41% Schroter S et al, accepted for Clinical Trials more critically EBP: informing decisions with the best up-to-date evidence

  13. using evidence more systematically Total mortality from trials of β-blockers in 2° prevention after MI. Black square & horizontal line correspond to odds ratio (OR) & 95% confidence interval (CI) for each trial. The size of the black square reflects the weight of each trial. The diamond represents the combined OR & 95 CI, showing a 22% reduction in odds of death Egger, M. et al. BMJ 1997;315:1533-1537

  14. using evidence more systematically Cumulative meta-analysis of total mortality results from trials of oral β-blockers after MI. Size of squares reflect amount of statistical information available at a given point in time Egger, M. et al. BMJ 1997;315:1371-1374

  15. Gets worse with “duration in practice”

  16. what skills will you need to keep up to date with the best evidence? • to find the evidence more efficiently • to appraise the quality of the evidence more effectively • to use good quality evidence more systematically

  17. the steps of practicing EBM 1. ask a focused question. 2. access (systematically search for) epidemiological evidence to help answer question. 3. appraise evidence found for its validity, effect size, precision (ideally all the relevant evidence) 4. apply the evidence in practice: a. amalgamate the valid evidence with other relevant information (values & preferences, clinical/health issues, & system issues) and make an evidence-based decision; and b. act(implement) the decision in practice explicitly improving practice with external evidence from literature

  18. about 1/2 of ‘valid’ evidence today is out of date in 5 years about 1/2 of valid evidence is not implemented ScienceCartoonsPlus.com

  19. the 5th step of EBP = Quality Improvement audit your practice: compare your actual practice with best (evidence-based) practice i.e. the gap between your evidence-based decisions and your actions explicitly improving practice with internal evidence from your practice

  20. GATE: Graphic Approach To Evidence Based Practice- a framework for learning the skills of EBP 1 picture, 2 formulas & 3 acronyms

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