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Evidence Based Medicine_ppt
1. “Half of what you are taught in medical school would in 10 years have
been shown to be wrong. And the trouble is, none knows which half”
Sydney Burwell, MD
Dean of Harvard Medical School
1893-1967
5. Al-Rhazi
900 AD 1780 1840 1967 1980s
Alvan
Feinstein
published his book
Clinical Judgement
James Lind
published review &
clinical trial in
Treatise on Scurvy
Pierre Louis
Developed “numerical
method” and changed blood
letting practice in France
Some milestones in the history of EBM5
David Sackett, Brian
Haynes, Peter Tugwell,
and Victor Neufeld
6. 6
An EBM Approach to Education
• Evidence cart on ward rounds - 1995
• Looked up 2-3 questions per patient
• Took 15-90 seconds to look for evidence.
Dr. David Sackett
6
9. “ The conscientious, explicit, and judicious use of
current best evidence in making decisions about
the care of individual patients.
DEFINITION..9
Sackett DL, et al. BMJ 1996; 312(7023):71-2
12. To improve the quality of clinical care.
1 GOAL
12
HOW??
Improving the health of people through decisions that will maximize their health-
related quality of life.
16. Example:
Alcohol in moderation is protective against heart attacks and stroke. However, in Islam, alcohol is forbidden. It would
be unacceptable to discuss alcohol intake in moderation with a Muslim.
16
The diagnosis of motor neuron disease (amyotrophic lateral sclerosis)
There is definitive evidence from RCTs and meta-analysis indicating that
RILUZOLE can prolong tracheostomy – free life for 3 months if taken regularly
High cost and risk of hepatotoxicity, many neurologists and their patients do not use this. Patients do not
consider it ‘worth it’; however, some patients who can easily afford to take riluzole are prescribed with
this drug.
17. 17
Questions Pre-EBM notions EBM notions
1. Clinical/medical education
Is sufficient to practice EBM Necessary but not sufficient,
needs life-long self directed
learning and reflective practise
2. Clinical experience Sufficient to guide practice Necessary but not sufficient .
Needs to be aware of research
results
3. Textbooks and review articles Are sufficient Needs to refer to systematic
review/original research
4. Medline Source of first resort Medline is a source of last resort
5. Evidence from basic and
animal research
Is adequate to guide clinical
practice
Needs clinical evidence
6. Reading conclusions of paper Is sufficient Needs to read methods and
results
7. Statistical significance p value is sufficient Needs to assess clinical
significance as well
20. 20
The Five-Step Approach to Practicing EBM
▸Step 1- Framing a Proper, Pertinent, Focused and Answerable Question
▸Step 2 - Searching the Literature
▸Step 3 - Critical Appraisal of the Literature
▸Step 4 –Integrating the Evidence with Clinical Expertise and Patient
Values
▸Step 5 – Evaluating the Process
22. 22
Ask Clinical Questions
Patient/
Population OutcomeIntervention/
Exposure
Comparison
Components of Clinical Questions
In patients with
acute MI
In post-
menopausal
women
In women with
suspected
coronary disease
does early treat-
ment with a statin
what is the
accuracy of
exercise ECHO
does hormone
replacement
therapy
compared to
placebo
compared to
exercise
ECG
compared to no
HRT
decrease cardio-
vascular mortality?
for diagnosing
significant
CAD?
increase the
risk of
breast cancer?
23. Clinical Scenario
• A 30 year old male is diagnosed with depression.
• He would prefer to try alternative medicine other than SSRIs.
• You, as his physician believe that his symptoms will be
improved by an SSRI.
• But he wants to know if St. John’s Wort would be as effective
as an SSRI for reducing his symptoms.
23
24. CONCEPTS TO SEARCH
• P (patient problem/population) – DEPRESSION
• I (intervention) – SSRI
• C (comparison) – St John’s Wort
• O (outcome) – IMPROVE SYMPTOMS OF DEPRESSION
24
30. PICO QUESTION CONCEPTS SEARCH TERMS TO BE USED
P (DEPRESSION) DEPRESSIVE DISORDER
I (SSRI) SEROTONIN UPTAKE INHIBITORS
C (St John’s Wort) HYPERICUM “OR” St John’s Wort
O (reduce symptoms)
30
34. Step 3- CRITICAL APPRAISAL
• 1. Are the results valid?
• How strong is the evidence?
• What was the study design and was it appropriate for the question?
• Was there any bias?
• 2.Are the results important?
• How large was the treatment effect?
• Are results clinically significant (and not just statistically significant)
• 3.Will the results be helpful for the patient?
• Is the study’s patient population similar to my patient
34
35. 35
Step 3 - Critical Appraisal of the Literature
1. Screening for internal validity and relevance
2. Determining the consistency of the article
3.Evaluating the significance of information
36. 36
Step 4 - Apply
▸Integrate it with clinical expertise and patient values
▸Decide how to apply in practice
▸The economical/financial status of the parents does not permit
expensive therapies
▸No contraindications for the drug to be administrated
37. 37
Step 5 – Evaluating the Process
▸Able to formulate a focused question?
▸Able to devise a precise search strategy for locating the evidence?
▸Use the most appropriate resource?
▸Were more pertinent resources like practice guidelines available?
▸Did the ‘evidence’ work in our patient?
▸Those of his colleagues should be able develop management protocols
39. 39
Level A: Good scientific evidence suggests that the benefits of the clinical
service substantially outweigh the potential risks.
Level B: At least fair scientific evidence suggests that the benefits of the
clinical service outweighs the potential risks.
Level C: At least fair scientific evidence suggests that there are benefits
provided by the clinical service, but the balance between benefits and risks
are too close for making general recommendations.
Level D: At least fair scientific evidence suggests that the risks of the
clinical service outweighs potential benefits.
40. 40
Who benefits?
Practitioners current knowledge to assist with decision making
Researchers reduced duplication , identify research gaps
Community recipients of evidence-based interventions
Funders identify research gaps/priorities
Policy maker current knowledge to assist with policy formulations
41. 41 Challenges - The research-practice gap
Research Evidence Practice
Diffusion
/Adoption
Information overload
Application to other populations
Lack of consideration of local
community groups, agencies and
governments role and needs
Cultural factors
Economic factors
Social factors
42. Type of Question Suggested best type of Study
Therapy RCT>cohort > case control > case series
Diagnosis
Prospective, blind comparison to a gold
standard
Aetiology RCT > cohort > case control > case series
Prognosis Cohort study > case control > case series
Prevention
RCT>cohort study > case control > case
series
42
Identifying the Best Study
43. ADVANTAGES IN PRACTICING EBM
▸For individuals:
1. Enables clinician to upgrade their knowledge base
2. Improves computer literacy
3. Improves confidence in management decision, makes them more
critical in using data
▸ For patients:
1. More effective use of resources
2. Better communication with patients regarding management
decisions.
43
44. LIMITATIONS OF EBM
UNIVERSAL TO THE PRACTISE OF MEDICINE
i. Shortage of coherent, consistent scientific evidence
ii. Difficulties in applying evidence to the individual patients
UNIQUE TO THE PRACTISE OF EBM
i. The need to develop new skills
ii. Limited time and resources
iii. Paucity of evidence that EBM “works”
44
45. 45
EBM Misconceptions
EBM means appropriately
using the best available
evidence to care for
patients
Clinical judgment must be
used in deciding how to
apply the evidence
•Denigrates clinical expertise
•Ignores patients values and
preferences
•Promotes a cookbook approach to
medicine
•Limited to clinical research
46. CURRENT STATUS OF EBM IN SOUTH ASIA
▸Diversity not only in culture, also in medical practise
▸Ranging from large super specialist to quacks
▸Using a Pubmed search for term "Evidence based medicine“
▸ Total of 29,650 articles were found but only 102 articles were from South
Asian countries.
▸They were from India (75), Pakistan (16), Bangladesh (7), Nepal (4).
▸None were from Sri Lanka, Afghanistan, Bhutan, or Maldives.
▸This reflects scarcity of awareness about EBM in this region
46
48. What EBM additionally provides is
Opportunity for change
Opportunity for better treatment
48
49. 49
Conclusion
▸The major challenge which is faced by health care professionals
is providing evidence based, cost effective quality care that will
improve the practise and patient outcomes.
▸Because so much research is published all the time, clinicians are
unaware of most of it or they do not have the tools to assess its
quality.
50. REFERENCES
1. Sackett DL, Straus SE, RichardsonWS, Rosenberg W, Haynes RB. Evidence- Based
Medicine – How to Practice and Teach EBM. Churchill. Livingstone, 2nd Edition
2000.
2. Sackett DL, Rosenberg WMC, Gray JA, Haynes RB Richardson WS. Evidence
based medicine: What it is and what it isn’t. Br. Med J 1996;312:71-72.
3. Guyatt GH, Evidence–based Medicine. Ann Intern Med. 1991;114(ACP J Club.
Suppl 2): A-16
50
51. “A 21st century clinician
who cannot critically read a
study is as unprepared as
one who cannot take a
blood pressure or examine
the cardiovascular system.”
BMJ 2008:337:704-705
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