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Evidence Based Medicine (EBM)
Evidence Based
Medicine (EBM)
Tim FOME Fakultas Kedokteran Universitas Andalas
Tim FOME
Fakultas Kedokteran Universitas Andalas

Introductory Lecture: Objectives

1. What

What is evidence-based medicine?

What does it look like in practice?

2. How

Formulate Clinical Questions

1. Search for Evidence

2. Appraisal of research

3. Apply to clinical problem

What is evidence-based medicine?

“Evidence-based medicine is the integration of best

research evidence with clinical expertise and patient values

- Dave Sackett

Patient Concerns EBM Best research evidence Clinical Expertise
Patient
Concerns
EBM
Best research
evidence
Clinical
Expertise

What is “EBM” NOT?

What we have always done

“Cookbook medicine”

Only a cost-cutting trick

Only randomized trials

 Only a cost-cutting trick  Only randomized trials Evidence based medicine IS…  Tracking down

Evidence based medicine

IS…

Tracking down the best external evidence with which to answer our clinical questions…

Life long learning

The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not … a medical course, but a life course, for which the work of a few years under teachers is but a preparation.

the work of a few years under teachers is but a preparation. – Sir William Osler

Sir William Osler (1849-1919), from: The Student of Medicine

How do I decide what to do?

How do I make decisions?

• Dogma: “Natural is best”

• Tradition: “We’ve always done it that way”

• Convention: “Everyone does it this way”

Evidence-Based: “Evidence supports this way”

How do I decide what to do?

The answer from EBM…

“…use of current best evidence…”

How do I decide what to do?  The answer from EBM… “…use of current best
How do I decide what to do?  The answer from EBM… “…use of current best

Evidence: systematic observation

Evidence: systematic observation Meta-Analysis Randomized Controlled Trial Uncontrolled Trial Case Series Anecdote

Meta-Analysis Randomized Controlled Trial

Uncontrolled Trial

Case Series Anecdote

Meta-Analysis Randomized Controlled Trial Uncontrolled Trial Case Series Anecdote More systematic observation ►

Meta-Analysis

Randomized Controlled Trial

Uncontrolled Trial Case Series

Anecdote

More systematic observation better evidence

Integrating evidence & practice

Integrating evidence & practice

EBM Cycle

Evaluate Application
Evaluate
Application
EBM Cycle Evaluate Application Patient problems Apply Evidence Clinical Question Critical Appraisal Literature Search

Patient

problems

EBM Cycle Evaluate Application Patient problems Apply Evidence Clinical Question Critical Appraisal Literature Search

Apply

Evidence

Clinical

Question

Critical Appraisal
Critical
Appraisal
EBM Cycle Evaluate Application Patient problems Apply Evidence Clinical Question Critical Appraisal Literature Search
EBM Cycle Evaluate Application Patient problems Apply Evidence Clinical Question Critical Appraisal Literature Search

Literature

Search

The EBM Cycle

1. Assess the patient: A clinical question arises from caring for a

patient.

2. Ask the question: Construct a well-built foreground question derived from the case.

3. Acquire the evidence: Find the answer from the evidence presented in the medical literature and identify the best resource from among the many.

4. Appraise the evidence: Appraisal includes validity (closeness to

truth) and applicability (usefulness in clinical practice).

5. Apply: Communicate the evidence to your patient and integrate the evidence with clinical expertise, patient preference and apply.

6. Self-evaluation: Evaluate the process and outcome.

Clinical Questions

Ask the question: Construct a well-built foreground question derived from the case.

Two Types of Questions are Generated in the EBM Cycle

Background Questions ask about general knowledge relating to a condition, diagnostic test or treatment.

They typically start with who, what, where, when, how, or why.

Foreground Questions ask for specific knowledge to inform clinical decisions for patient care.

Clinical Questions

Background - “What is it?”

General information on a condition or disease

Foreground – “What do I do for this patient?”

Patient

Intervention/Investigation

Comparison Intervention/Investigation

Outcome (Patient-Oriented)

PICO

P = Patient, population or target problem at hand How would you describe a group of patients similar to your own? What is the condition or disease you are interested in?

I = Intervention

What do you want to do to this patient?

Treat, diagnose or observe?

C= Comparison What is the main alternative (gold standard) to compare with the intervention? Your clinical question does not always need a direct comparison.

O= Outcome What can you hope to improve, accomplish, measure or affect? What are the relevant outcomes? (morbidity, death, complications)

Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well-built clinical question: a key to evidence-based decisions. ACP J Club. 1995 Nov-

Dec;123(3):A12-3.

Formulating the Foreground Question

The following formula will help construct the question:

In patients [include significant demographics]

with [specify Target Problem ] does [specify

Intervention] or [specify Comparison, if any]

affect [specify Outcome]?

Clinical Questions - “PICO”

Example:

In a 5 year old child with conjunctivitis (patient) will

topical antibiotics (intervention) compared to no

treatment (comparison) lead to quicker symptom relief (outcome)?

In a 5 year old child with conjunctivitis (patient) will

topical antibiotics (intervention) compared to no treatment (comparison) lead to improved cure rates (outcome)?

Question Domains

Foreground questions fall into general question domains.

Each domain is best answered by particular study types.

Study types are powerful limits to finding best evidence.

Question Domain

Suggested Best Study Types

Diagnosis

RCTs > prospective studies (which make a blind comparison to the gold standard)

Therapy

RCTs > cohort studies > case-control studies

Etiology/Harm

RCTs > cohort studies > case-control studies

Prognosis

cohort studies > case-control studies

Economic Analysis

costs and cost analysis

Literature Search

Acquire the evidence: Find the answer from the evidence presented in the

medical literature and identify the best

resource from among the many.

Should I ask a colleague?

Searching: finding good answers?

Searching: finding good answers?

Searching made easy

Searching made easy 

Finding Evidence-based Answers

Trip Database (http://www.tripdatabase.com/)

Database of Abstracts of Reviews of Effectiveness (http://www.crd.york.ac.uk/crdweb/)

*Subscription required.

Essential Evidence Plus (http://www.essentialevidenceplus.com/)

*Subscription required.

Cochrane Library (http://www.cochrane.org/)

*Subscription for full access, abstracts free.

*Subscription required.

Clinical Evidence (www.clinicalevidence.com/)

*Subscription required.

Critical Appraisal

Appraise the evidence: Appraisal

includes validity (closeness to truth) and

applicability (usefulness in clinical practice).

Rapid Critical Appraisal

It’s peer-reviewed, therefore it must be OK ????

Rapid Critical Appraisal It’s peer -reviewed, therefore it must be OK ????
Rapid Critical Appraisal It’s peer -reviewed, therefore it must be OK ????
Rapid Critical Appraisal It’s peer -reviewed, therefore it must be OK ????

Which resources do I use to answer my question?

Part of the process in answering foreground questions is

understanding how to select resources that yield the best evidence.

Understanding the pros and cons of those resources will lead to information mastery.

The Evidence Pyramid can help determine where to go.

and cons of those resources will lead to information mastery. • The Evidence Pyramid can help

Evidence Pyramid

Synthesized & Evaluated Literature Primary Literature May or May not be Evidence-Based Best Evidence
Synthesized & Evaluated
Literature
Primary Literature
May or May not be
Evidence-Based
Best Evidence

Provided by HealthLinks, University of Washington, http://healthlinks.washington.edu/ebp/ebptools.html

Evidence Pyramid

How do I use the pyramid?

Evidence Pyramid How do I use the pyramid? That depends on the kind of question you

That depends on the kind of question

you are asking.

That depends on the kind of question you are asking. What kind of information are you

What kind of information are you after? A systematic review may not be necessary for every situation.

Start at the bottom and work your way up.

There are more Clinical Reference Texts than Systematic Reviews.

Start Here: Base Resources

Start Here: Base Resources Where do I find them? • Give background information • Help to

Where do I find them?

Give background information

Help to define the PICO elements

Form the basis of foreground questions

Make up the largest percentage of

resources

Library catalog, discovery tool for clinical texts

http://guidelines.gov

“review article” limit in MEDLINE

Top of the Pyramid Resources

Top of the Pyramid Resources How do I find them? • Have the most evidence to

How do I find them?

Have the most evidence to support

their conclusions

Best for answering foreground questions

Less abundant in the literature

But more clinically relevant for decision making

Consult a point-of-care resource such as DynaMed

Search MEDLINE for systematic reviews, meta-analyses or individual study types e.g. RCTs

The “best” evidence depends

on the type of question

Level

Treatment

Prognosis

Diagnosis

I

Systematic

Systematic

Systematic

Review of …

Review of …

Review of …

II

Randomised

Inception

Cross

trial

Cohort

sectional

III

     

Apply Evidence

Apply: Communicate the evidence to your patient and integrate the evidence with

clinical expertise, patient preference and

apply.

Applying to the individual

What do the results mean on average?

What do they mean for

Applying to the individual • What do the results mean on average? • What do they

this individual?

Evaluate Application

Self-evaluation: Evaluate the process and outcome.

In short…

EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

Is keeping up to date Mission Impossible?

Is keeping up to date Mission Impossible? Bluegreenblog 2006

Bluegreenblog 2006

Review the World Literature Fortnightly*

*"Kill as Few Patients as Possible" - Oscar London

5,000? 2500000 per day 2000000 1500000 1,500 1000000 per day 95 per 500000 day 0
5,000?
2500000
per day
2000000
1500000
1,500
1000000
per day
95 per
500000
day
0
Biomedical
MEDLINE
Trials
Diagnostic?
Articles Per YearMedical
Medical Articles per Year

Coping with the overload:

three possible things you might try

with the overload: three possible things you might try A. Read an evidence-based abstraction journal (and
with the overload: three possible things you might try A. Read an evidence-based abstraction journal (and

A. Read an evidence-based

abstraction journal

(and cancel other journals)

B. Keep a logbook of your

own clinical questions

C. Run a case-discussion journal

club with your practice

other journals) B. Keep a logbook of your own clinical questions C. Run a case-discussion journal

What are your clinical questions?

A 35 year old man says his brother recently died of a ruptured cerebral aneurysm. He is worried about whether he might have one and what the chances are that it would rupture.

A 60 year old women worried about her rheumatoid arthritis. She asked whether the rheumatoid arthritis could kill her.

Do patients with rheumatoid arthritis have higher

mortality?

You use methotrexate for rheumatoid arthritis patients. But you are confused is the methotrexate benefit patients?

But you are confused is the methotrexate benefit patients? – Do patients with rheumatoid arthritis benefit

Do patients with rheumatoid arthritis benefit from

methotrexate?

-> PICO Table