Evidence ­based medicine is the gold standard for clinical care. It implies the integration of best research evidence with clinical expertise and patient values. There is still a wide gap between availability of evidence and its incorporation into routine practice in our country. Barriers to implementation could be personal, social, institutional, financial and legal barriers. True practice of evidence ­based care can only occur where evidence­ based decisions coincide with patients’ beliefs and clinicians’ preferences. Continuing medical education programs should be set with integrating evidence ­based medicine teaching and learning within clinical training. The importance of presence of local national guidelines which need to take into account variation in expertise, resources and patient preferences across our geographical and cultural contexts . Customisation of a guideline to meet the local needs of a target patient population is critical to successful implementation.

1. Wafaa B. Basta
Specialist Gynaecology & Obstetrics Mataria Teaching Hospital,
MRCOG
ERC MEMBER
2nd ERC-RCOG International Conference, Sonesta Cairo 3rd March 2012
16th Annual International Conference ,Ain Shams University 30th May 2012
10th Annual Meeting of Al-Azhar University 15th June 2012

2. What is evidence-based
medicine?
“Evidence-based medicine is the integration of : best
research evidence with clinical expertise and patient
values”
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB,
Richardson WS: EBM : what it is and what it isn’t.
BMJ 1996;312:71-2.
Patient
Concerns
Clinical
Expertise
Best research
evidence
EBM

3. Classification of evidence
levels1++ High-quality meta-analyses, systematic reviews of randomised
controlled trials or randomised controlled trials with a very low risk of
bias
1+ Well-conducted meta-analyses, systematic reviews of randomised controlled
trials or randomised controlled trials with a low risk of bias
1- Meta-analyses, systematic reviews of randomised controlled trials or
randomised controlled trials with a high risk of bias
2++ High-quality systematic reviews of case–control or cohort studies or high-
quality case–control or cohort studies with a very low risk of confounding
,bias or chance and a high probability that the relationship is causal
2+ Well-conducted case–control or cohort studies with a low risk of
confounding, bias or chance and a moderate probability that the relationship
is causal
2- Case–control or cohort studies with a high risk of confounding ,bias or
chance and a significant risk that the relationship is not causal
3 Non-analytical studies, e.g. case reports, case series
4 Expert opinion

5. Why bother with Evidence-Based
Practice?
• Is the gold standard for clinical care.
• Long history of relying on anecdotal
experiences, has lead to practices that were
ineffective and in some cases, produced
harmful outcomes.

6. Which doctor do you
want?
William Osler, 1900 Smart young doctor

7. Which doctor do you
want?
Wise & experienced smart young doctor

8. Implementation of
Evidence
 Despite :
• growing awareness about the value of
evidence based medicine and
• increased access to research work,
 There is still:
• a wide gap between availability of evidence
and
• its incorporation into routine practice in our
country.

9. researchers
decision makers

10. Implementation of Evidence in
Egypt
Widely
applied
Ante-natal
steroids to reduce
neonatal M&M
The use of Anti-D
Immunoglobulin
for Rh
prophylaxis
Management of
breech
presentation
Partially
applied
Tocolytic Drugs for
Preterm Labour
Reducing the risk of
VTE during Pregnancy
and the Puerperium
Management of Early
Pregnancy Loss
Rejected
External Cephalic
Version (ECV)
Operative Vaginal
Delivery
Birth After Previous
Caesarean Birth
Limited
presentation
Malaria in pregnancy
diagnosis & treatment
Obstetric Cholestasis
HIV in Pregnancy,
Management

11. Effectively applied
Guidance

12. Effectively applied Guidance
 Implementation of use of corticosteroids to
reduce neonatal morbidity has occurred
almost simultaneously with the generation
of evidence supporting it, the reasons for
that:
o The perceived amplitude of the problem.
o The magnitude of anticipated benefit.
o No serious side effects.
o Good experience with its use.
o Strong public opinion.
o Low costs of the intervention.

13. Evidence
Effectively applied
Guidance
 Easily implementable evidence into
clinical practice is that evidence
supported by expert opinion & patients’
beliefs.

14. Effectively applied
Guidance
Evidence
Expert
Opinion
 Easily implementable evidence into
clinical practice is that evidence
supported by expert opinion and
patients’ beliefs.

15. Evidence
Patient's
believes
Expert
Opinion
Effectively applied
Guidance
 Easily implementable evidence into
clinical practice is that evidence
supported by expert opinion & patients’
beliefs.

16. Effect of Believes
 Elective single embryo transfer in ART in order
to minimise the risk of iatrogenic multiple
pregnancies.
 RCT showed comparable success rates after either
single or double embryo transfer.
 This was supported from opinion leaders.
 However, this policy is yet to be implemented widely.
 Why?
 financial considerations.
 couples’ and clinicians’ strongly held beliefs about
success rates.
 an active preference for twins.

17. Evidence
Clinician’s
&
patient’s
believes
Expert
Opinion

18. Possible Barriers for EBM
Implementation
True practice of evidence based care can only occur
where evidence based decisions coincide with
patients’ beliefs and clinicians’ preferences.
Patient
Concerns
Clinical
Expertise
Best research
evidence
EBM
Patient
Concerns
Clinical
Expertise
Best research
evidence
EBM

19. Possible Barriers for EBM
Implementation
 Those barriers could be linked to:
 The clinician.
 Patients & community.
 Institutional barriers.

20. Possible Barriers for EBM
Implementation
 Those barriers could be linked to:
 The clinician.
 Patients & community.
 Institutional barriers.

21. Clinician Preferences
 Clinicians can be
resistant to change
and reluctant to
discontinue
treatments they
have been offering
for years.
e.g. Use of Beta
agonist for preterm
labour.

22. Lack of Clinician Expertise
 Lack of certain
surgical expertise.
 e.g. Sacrospinous
fixation , sacral
colpopexy.
 Total / subtotal
hystrectomy.

23. Time Constrains
Despite practitioners’
willingness to follow well
designed guidelines, time
constraints could be
major limiting factors.
e.g. CS versus VD
e.g. Medical versus
surgical evacuation

24. Lack of up to date knowledge
In addition to the
pressures of clinical work,
the huge number of
guidelines on a wide
range of topics can
overwhelm practitioners.

25. Fear of Litigation
Fear of legal accusation
is a barrier for new
guidance application
especially in a
community with many
incorrect believes.
Practicing defensive
medicine.

26. Possible Barriers for EBM
Implementation
 Those barriers could be linked to:
 The clinician.
 Patients & community.
 Institutional barriers.

27. Wrong Patients’ Believes
It is difficult to accept
information which is
inconsistent with
prevailing attitudes,
cultural views or
patients’ believes.
‫أبن‬7
‫وأبن‬ ‫يعيش‬
8‫أل‬‫أسهل‬ ‫القيصرية‬
‫وأأمن‬
‫بارضع‬
‫نضيف‬
‫المية‬
‫نزلت‬
‫والولد‬
‫هايتخنق‬
‫أزاى‬ ‫يعنى‬
‫مع‬ ‫تمارين‬
‫بأنام‬ ‫،انا‬ ‫الحمل‬
‫ضهرى‬ ‫على‬9
‫شهور‬

28. Counselling problems
‫هو‬ ‫ليه‬ ، ‫أختار‬ ‫انا‬ ‫عايزانى‬
‫اية‬ ‫الصح‬ ‫عارفة‬ ‫مش‬ ‫أنت‬
•No acceptance for drug side
effects.
•No acceptance for possible
surgery complications.
•Improper perception for
treatment options.

29. Attacking Media
Aggressive media
Aggressive patients
Defensive medicine

30. Over-population
Traffic jams----
Delayed transportation.
Late presentation.
% of Illiteracy.
% of poverty.

31. Possible Barriers for EBM
Implementation
 Those barriers could be linked to:
 The clinician.
 Patients & community.
 Institutional barriers.

32. Limited Resources
Human and non.
e.g. Nursing staff,
machines ,instruments.
Defective funding of
local research work.

33. Defects in :
Continuous medical
education.
Timed training programs .
Performance review of
junior staff .
Teamwork & Leadership
Financial &legal support to
clinicians.

34. Lack of:
 Referral system + continuity of care.
 Concept of subspecialty.
 Tertiary specialized centres.
 Mass screening programs.
 Accurate recording & statistics with
transparency.
 Audit and feedback.

35. Health Institutions in
Egypt
 University Hospitals.
 General organization of Teaching Hospitals.
 Therapeutic institution.
 MOH including 1ry &2ndry health care
services.
 Private hospitals & clinics.

36. How to improve
implementation ?
 Health care workers :
Continuous
Medical
Education
Time –targeted Training
Simulators
Fire-drills
Woking under supervision
In-dependant
Improving
Working hours
Financial support
Legal support

37. How to improve
implementation ?
 Patients & community:
Patients
Educations
Media
Health care
workers
Changing
concepts &
believes

38.  Institutional level:
Sufficient financial
funding
Local research work
Local guidelines
Local unified
protocols
Build up health system
Involve all health
organizations
with clear referral
pathway
How to improve
implementation ?

39. 1. ASK a clinical question.
2. ACCESS - search for best evidence.
3. APPRAISE the evidence for its validity,
clinical relevance , applicability & precision.
4. AGGREGATE the evidence with your clinical
expertise and patient concerns & make an
evidence-based decision.
5. APPLY your decision.
6. AUDIT -evaluate your own performance .

40. 1. ASK a clinical question.
2. ACCESS - search for best & epidemiological
evidence.
3. APPRAISE the evidence for its validity, clinical
relevance , applicability & precision.
4. Develop Local national Guidelines.
5. Disseminate Guidelines.
6. APPLY on clinical practice.
7. AUDIT monitor the effect on outcome.
8. Customize guidance for local use according to
audit & patient acceptance.
9. Update guidelines to improve clinical out
come.

43. Audit
Knowledge Translation
1
2 3
4
5generation Develop
guidancedisseminate
application
decisions
Steps from evidence generation to clinical application
1. generation of evidence from research; 2. develop guidance; 3. disseminate the
guidance; 4. application of policy; 5. individual clinical decisions, including a) patient’s
circumstances, b) patient’s wishes, and c) evidence;6 . Audit & update guidance.
6

44. Appraisal of evidence
 GRADE system :The Grading of
Recommendations Assessment, Development and
Evaluation .
 Not based exclusively on study design
 Is able to discriminate between the quality of
evidence and the strength of individual
recommendations.
 Are graded to reflect the strength of the
underlying evidence based on the design and
quality of each study as well as the consistency,
clinical relevance and external validity of the whole
body of evidence.
 Used in NICE, SIGN, RCOG guidance.

45. Grades of
RecommendationsA At least one meta-analysis, systematic review or randomised
controlled trial rated as 1++ and directly applicable to the target
population; or A systematic review of randomised controlled
trials or a body of evidence consisting principally of studies rated
as 1+ directly applicable to the target population and
demonstrating overall consistency of results
B A body of evidence including studies rated as 2++ directly applicable to
the target population, and demonstrating overall consistency of results;
or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+ directly applicable to
the target population and demonstrating overall consistency of
results; or Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4;or Extrapolated evidence from studies rated as
2+
GPP Recommended best practice based on the clinical experience of the
guideline development group

46. Development of
guidelines
Steps in drafting a guideline/ recommendation:
 Establish the guideline panel and define the scope of the
guidelines.
 Prioritise the problems and ask precise clinical questions.
 Decide on the relative importance of outcomes.
 Identify the existing evidence for every clinical question.
 Develop separate evidence profiles (using GRADE) for each
outcome.
 Determine the overall quality of available evidence across
outcomes.
 Decide on the balance between desirable and undesirable
consequences.
 Formulate the recommendation reflecting its strength.

47. Dissemination of Guidelines
 Quicker in recent years.
 Free of charge copies distributed in the
workplaces.
 Published in a public domain.
 Dissemination by active educational
intervention by specialized team.
 Practice networks that share knowledge
among target groups .e.g. local cancer
networks in UK.
 Computerized decision support.

48. Clinical Audit
 During the development of the guideline,
the development group should have
identified key points for audit involving
clinical outcomes.
 This information allows the guideline
groups to modify the guidelines in
further reviews & to meet the needs of
the local population more effectively.

49. Modifications to local
guidance
 Customisation of a guideline to meet the local
needs of a target patient population is critical
to successful implementation.
 This approach is particularly important for the
adoption of international guidelines which
need to take into account variation in
expertise, resources and patient preferences
across different geographical and cultural
contexts.
 The RCOG has produced Clinical Governance
Advice 1d10 which details consensus methods
for adaptation of RCOG Guidelines.

51. Updating guidelines
 A guideline should be updated (or
withdrawn) in the presence of new
evidence.
 In order to keep practice guidelines up
to date, it is recommended that they
should be reviewed no later than 3 years
after completion.

52. Conclusion
 Evidence based medicine is the gold standard
for clinical care.
 It implies the integration of best research
evidence with clinical expertise and patient
values.
 There is still a wide gap between availability of
evidence and its incorporation into routine
practice in our country.
 Barriers to implementation could be personal,
social, institutional, financial and legal barriers.
 True practice of evidence based care can only
occur where evidence based decisions
coincide with patients’ beliefs and clinicians’
preferences.

53. Conclusion
 Continuing medical education programs
should be set with integrating evidence based
medicine teaching and learning within clinical
training.
 The importance of presence of local national
guidelines which need to take into account
variation in expertise, resources and patient
preferences across our geographical and
cultural contexts .
 Customisation of a guideline to meet the local
needs of a target patient population is critical
to successful implementation.

54. researchers
decision makers
“Great things
are not
accomplished
by those who
yield to trends
and fads and
popular
opinion.”
-Jack Kerouac