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Introduction to Evidence-

Based Medicine

Dr. Mazen Ferwana, MD,ABFM, JBFM, PhD


Consultant Family Medicine
Ass. Prof. King Saud Bin Abdul Aziz Medical University
Chairman, Research Committee Residency Training- FM
Director, Cochrane Review Initiative Project
NGCEBM, Task Teams Supervisor
What is EBM?

EBM is the integration of the


current best evidence from
research with our clinical expertise
and patient’s values, preferences
and circumstances.
Clinical Scenario
You are R2 working paediatric out- patient
clinic. A mother comes to see you about her
3-year-old child who she says is always
unwell with coughs and colds. Her child
attends a day nursery as she is working full
time. She is having trouble with her boss at
work as she is always taking time off work to
look after her sick child. In desperation she
has been searching the internet and found
several sites that encourage the use of
immune system boosters in children. In
particular she asks you about probiotics and
hands you an article.
Your answer?

(A) Yes: Good evidence

(B) NO: NO evidence

(C) I Don’t know


If you don’t know

How you
will
answer
your
patient?
1. Read textbooks

2. Ask your senior colleague

3. Search the EBM literature


Clinicians need information

We need it up to 60 times a week (twice


per three patients)
It could affect up 8 decisions a day
We only get 30% of it
Do We Read?

50% had not read a medical


journal article in the last year
Information jungle
WWW – 800 million web sites
MEDLINE has about 400,000 new
entries added each year
To keep ahead by reading everything of
possible importance, need to read
6,000 articles each day!
Why we get it wrong
Our information is out of date !!
Our textbooks are out of date !!
Nobody can read enough journals to keep
up.
Thrombolytic Therapy for Acute MI
Textbook/Review
Cumulative 0.5 1.0 2.0 Recommendations
Year RCTs Pts

Not Mentioned
Experimental
Rare/Never
1 23

Specific
Routine
1960

2 65
1965 3 149 21

4 316 5
1970
7 1793 1 10

10 2544 1 2
11 2651 P<.01
15 3311 2 8
17 3929
22 5452 7
23 5767
1980 8
1
27 6125 12
P<.001
30 6346 M 1 8 4
1985 33 6571 M 7
43 21 059 1 3
M
54 22 051 P<.00001 5 2 2
65 47 185 M 1
67 47 531
M 15 8 1
1990 70 48 154
M 6 1
Odds Ratio (Log Scale)
Favours Treatment Favours Control
Lag time from time of “knowing” to time
of implementation

13 yrs for thrombolytic therapy


Another example

10 yrs for corticosteroids to speed


fetal lung maturity
Are We Failing?

Negative correlation
between our up-to-date
knowledge and the years
since graduation
The
The Slippery
Slippery Slope
Slope

knowledge . ..
of current . . ........ ...
best care .... ...
...
.... ..

r = - 0.54 years since


P < 0.001 graduation
How you get the information?

“Just In Case” Surveillance

“Just In Time” Focused


The
The Usefulness
Usefulness Equation
Equation
Usefulness = Validity x Relevance
of any source Work
Work
Work

The least effort and time to


get the proper information
Validity
Validity

The “Truth”

What we do does more


good than harm.
Relevance
Relevance
POEM: Patient-oriented evidence that
matter
mortality, morbidity, quality of life

DOE: Disease-oriented evidence


pathophysiology, pharmacology, etiology
Comparing DOE and POEM

DOE POEM

Antihypertensive Lowers Blood Decreases


therapy Pressure Mortality
Keeping
Keeping Up
Up
Concentrate on “high yield” journals with
favorable POEM:DOE ratio

Consider three questions to determine


relevance
Patient-oriented
Common to practice
Require change of practice
EBM: 1-2-3-4-5
One goal: improve the quality of care
Two fundamental principles
Three -Es – to define EBM
Four -RVAR- to appraise a paper
Five -As- to practice EBM
One- Goal
Clinical decisions:
Diagnostic test Quality of Care
Therapeutic intervention
Prognosis
Clinical Practice Guidelines

Research
Evidence

Clinical Patient
Experience Expectation
Preference
Two- Fundamental principles
1. Evidence has a hierarchy of
strength

2. Evidence alone is never the sole


basis for decisions
1. 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
2. Evidence alone is not enough

Patients’ values

Would you give a DNR consent for a


terminally ill child in case of arrest, if he is
your relative?
Three (Es)- EBM Components

Evidence Experience

Expectations
Four-RVRA to Appraise The Evidence

1. Relevance: It focuses on medical problems


common to our practice. patient-oriented
evidence

2. Validity: Correctness (likely


( to be true)

3. Results: Clinically important

4. Applicability: Applicable in and useful for my


patients
5 As to practice EBM
Ask clinical
questions

Acquire the Appraise


Evidence(s) the evidence(s)

Apply The Assess


best evidence
Yourself
to patient
Patient care

EBM will hopefully modify individual patient


care

Use of proven therapies and diagnostic tests


only
Institutions

Improve resource utilization


More effective and efficient care
Reduced cost per patient.
The use of EBM clinical practice
guidelines and clinical pathways
Health Care Policy
Health care policy must be reliant on using
the best available evidence to aid funding
decisions.
Screening (cancer, genetics)
Preventative healthcare (cholesterol lowering)
In determining resource distribution within
communities (inpatient vs. community-based
care)
In new health technology assessment.
Medical Education

Worldwide trend toward curricula


Self-directed
Problem-based
Up-to-date physicians