Evidence-Based Medicine in

Clinical Practice.

Dr. Harry Gee

Dr. Chisale Mhango

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 "Every intervention is a two-
edged sword."
Iain Chalmers

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 Practice Pradigms
Old paradigm New paradigm

Unsystematic Systematic clinical

clinical experience experience

Pathophysiology Pathophysiology
necessary but not
sufficient

Content expertise
Rules of evidence
& authoritarianism
 Pre-Requisites
• Questioning
– The Knowledge Gap
– Honesty
– Humility
– Discerning
• What is merely custom and
practice?
• Desire for Improvement

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 Our Aims

• Understand EBM
– What is it?
– Why do we need it?
– What are the benefits?
– Who benefits?

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 Our Objectives

The key steps:

– Formulate a clinical question
– Search the literature
• Efficiently
• Confidently
– Appraise the evidence
– Apply the evidence

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 What is EBM?

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 Good Clinical Practice

• Knowledge from best external evidence

based on clinical research
• Judgement from experience.
• Understanding of patient's beliefs &
preferences.
Sackett 1996

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 Who Benefits?

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 Evidence Based Medicine

Conscientious, explicit and judicious

use of current best evidence in
making decisions about the care of
an individual patient

Sackett. BMJ 1996;312:311-2

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 EBM for the Clinician

• Knowledge & Skills

• Proficiency
– Application
– PRACTICE
– Confidence

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 The 5 Steps Towards
Evidence Based Practice
1. Ask the right clinical question:
Formulate a searchable question
2. Collect the most relevant publications:
Efficient Literature Searching
Select the appropriate & relevant studies
3. Critically appraise and synthesize the evidence.
4. Integrate best evidence with personal clinical expertise, patient
preferences and values:
Applying the result to your clinical practice and patient.
5. Evaluate the practice decision or change:
Evaluating the outcomes of the applied evidence in your
practice or patient.

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 Asking the Right Questions

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 Clinical Process and knowledge Research evidence sought from
requirements literature searches

Etiology
knowledge about causation
Etiognostic Research
Patient presentation
knowledge about diagnosis
Testing
•History
•Examination Diagnostic Research
•Investigations

Diagnosis
knowledge about prognosis
Prognostic Research
Therapy
•Changes prognosis
Therapy Research
knowledge about therapeutic effectiveness
Clinical outcome
 The Question - Why is it so
Important?
•A good answerable question will help us focus
on evidence that is relevant to a patient’s
clinical needs, (or your own knowledge needs).
•They can suggest high yield search strategies
•They can suggest the forms that useful answers
might take (i.e. what is best research design to
answer our question)

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 Formulating Clinical
Questions
• There is no right or wrong way to turn a
scenario/knowledge need into a question.

• Just make sure it is concise, clinical and uses

appropriate language (avoid colloquialism, in
favour of technical language).

• Ask one question at a time.

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 PICO(D)

• Population
• Intervention
• Comparison
• Outcome
• (Design)

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 Select best evidence

• Question
– Relevant
– Focussed
• Appropriate Study Type
• Up to Date

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 Research Study Design

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 Research Design
• Diagnostic tests Cross sectional study

• Prognosis Cohort study

• Therapy RCT

• Patients’
Qualitative research
Preferences

BMJ 1997;315:1636
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 What resources could be
searched?

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 Why Should We Be Critical
in Our Reading of the
Literature?

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 Quality of the Medical
Literature

Journal High Quality Articles

N Eng J Med 17%

Ann Intern Med 13%
JAMA 12%
BMJ 9%
Lancet 8%
 What do we mean by
Research Quality?

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 Quality of a Study
The confidence that the study design,
conduct and analysis has minimized
biases in addressing the research
question

The better the quality, the higher is the

likelihood that the results produced in
the study are credible
 Quality of a Study
Validity
– The degree to which the results of an observation are correct
for the patients being studied.

Bias
– A process that tends to produce results that depart
systematically from the true values existing in the study
population.
Fletcher et al, 1988; Murphy, 1976
 Bias

• Conscious
• Unconscious
• Conflict of Interest

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 The Hawthorne Effect

What is it?

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 Hawthorne Effect

• Outcomes changed
• By virtue of doing the study
• Irrespective of the intervention

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 Hierachy of Evidence
 Experimental studies
– Randomized controlled trials

 Controlled Observational studies

– Case-control studies

 Uncontrolled Observational studies

– Case series
– Case reports
Sacks et al. Am J Med 1982;72:233-240;
Cook et al. Chest 1992;102:305s-311s;
Guyatt et al. JAMA 1993;270:2598-2601

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 EBM Basic Skills
• Formulate structured clinical question
• PICO(D)
• Search for evidence
• Systematic
• Select best evidence
• Critically appraise
• GATE Frame
• RAMMbo
• CASP
• CAT maker
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 AT-A-GLANCE
• Acronym
• Title
• Aim
• Groups
• Limbs – Intervention v Comparator
• Absolute Risk Reduction
• Number Needed to Treat (NNT)
• Clinical Conclusion
• Education for patients/carers

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 AT-A-GLANCE
• Acronym: is there a study name? as a mnemonic
• Title: Full title, authors, institute, journal, full reference
• Aim: specific aim of the study and why, what outcomes were used?
• Groups: who were the research subjects, inclusion criteria, exclusion
criteria, who excluded by chance or bias
• Limbs – Intervention v Comparator, ? Versus placebo, ? Blinded, how
randomised,
• Absolute Risk Reduction: What the main results?, what the main
results on the outcomes studied, other main results, ? Side-effects, other
harm events
• Number Needed to Treat (NNT): How many people do you need to treat
to have one beneficial effect? Eg how many people to save a life? How
many treated to have side-effects?
• Clinical Conclusion: What are the main clinical conclusions for you and
the team? Can the results be implemented locally? ? Change in guideline
needed? ? Clinical audit needed?
• Education for patients/carers: How can you explain the results to a
patient/guardian prior to consent and explanation? State what you will
actually say eg “Research has shown that………what do you think?”
 Guidelines

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 Levels of evidence
Level Type of evidence

I Evidence obtained from at least one randomised controlled

trial or from meta-analysis of randomised controlled trials

II Evidence obtained from at least one well-designed controlled

study without randomisation

III Evidence obtained from well-designed non-experimental

descriptive studies, such as comparative studies, correlation
studies and case control studies

IV Evidence obtained from expert committee reports or

opinions and/or clinical experience of respected authorities
 Grading of
recommendations
Grade Recommendation

A (Evidence level I)
Requires at least one randomised controlled trial as part of the body of literature of
overall good quality and consistency addressing the specific recommendation

B (Evidence levels II, III)

Requires availability of well-conducted clinical studies but not randomised clinical
trials on the topic of recommendation

C (Evidence level IV)

Requires evidence from expert committee reports or opinions and/or clinical
experience of respected authorities. Indicates absence of directly applicable studies of
good quality
 To Summarise

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 Summary

Clinical problem

Expertise,
Experience &
Pathophysiology
 Summary

Clinical problem

Develop answerable Expertise,

questions Experience &
Pathophysiology

ETATMBA Module 5
 Summary

Clinical problem

Develop answerable Expertise,

questions Experience &
Pathophysiology

Search and obtain

relevant articles

ETATMBA Module 5
 Summary

Clinical problem

Develop answerable Expertise,

questions Experience &
Pathophysiology

Search and obtain Critical appraisal of

relevant articles evidence

ETATMBA Module 5
 Summary

Clinical problem

Develop answerable Expertise,

Decision making
questions Experience &
about diagnosis &
Pathophysiology
treatment

Search and obtain Critical appraisal of

relevant articles evidence

ETATMBA Module 5
 Summary

Clinical problem

Develop answerable Expertise,

Decision making
questions Experience &
about diagnosis &
Pathophysiology
treatment

Search and obtain Critical appraisal of

relevant articles evidence

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 Performance
• Competence
– Knowledge
– Skills
• Proficiency
– Application
– PRACTICE
– Confidence

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 Are We Together ???

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