EBM Introduction 7-8 Feb 07

8/14/2019 EBM Introduction 7-8 Feb 07

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Introduction to Evidence-

Based Medicine

Dr.Dr. MazenMazen FerwanaFerwana, MD,ABFM, JBFM, PhD, MD,ABFM, JBFM, PhDConsultant Family MedicineConsultant Family Medicine

Ass. Prof. KingAss. Prof. King SaudSaud Bin AbdulBin Abdul AzizAziz Medical UniversityMedical University

Chairman, Research Committee Residency TrainingChairman, Research Committee Residency Training-- FMFM

Director, Cochrane Review Initiative ProjectDirector, Cochrane Review Initiative Project

NGCEBM, Task Teams SupervisorNGCEBM, Task Teams Supervisor


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EBM is the integration of theEBM is the integration of the

current best evidencecurrent best evidence fromfrom

research with ourresearch with our clinical expertiseclinical expertiseandand patientpatients valuess values, preferences, preferences

and circumstances.and circumstances.

What is EBM?hat is EBM?hat is EBM?


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You are R2 working paediatric outYou are R2 working paediatric out-- patientpatientclinic. A mother comes to see you about herclinic. A mother comes to see you about her

33--yearyear--old child who she says is alwaysold child who she says is alwaysunwell with coughs and colds. Her childunwell with coughs and colds. Her childattends a day nursery as she is working fullattends a day nursery as she is working full

time. She is having trouble with her boss attime. She is having trouble with her boss atwork as she is always taking time off work towork as she is always taking time off work tolook after her sick child. In desperation shelook after her sick child. In desperation she

has been searching the internet and foundhas been searching the internet and foundseveral sites that encourage the use ofseveral sites that encourage the use ofimmune system boosters in children. Inimmune system boosters in children. Inparticular she asks you aboutparticular she asks you about probioticsprobiotics andandhands you an article.hands you an article.

Clinical ScenarioClinical Scenario


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Your answer?Your answer?

(A) Yes: Good evidence(A) Yes: Good evidence

(B) NO: NO evidence(B) NO: NO evidence

(C) I Don(C) I Dont knowt know


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If you donIf you dont knowt know

How youHow you

willwillansweranswer

youryourpatient?patient?


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1. Read textbooks1. Read textbooks

2. Ask your senior colleague2. Ask your senior colleague

3. Search the EBM literature3. Search the EBM literature


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Clinicians need informationClinicians need information

We need it up to 60 times a week (twiceWe need it up to 60 times a week (twiceper three patients)per three patients)

It could affect up 8 decisions a dayIt could affect up 8 decisions a dayWe only get 30% of itWe only get 30% of it


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Do We Read?Do We Read?

50% had not read a medical50% had not read a medicaljournal article in the last yearjournal article in the last year


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Information jungleInformation jungle

WWWWWW 800 million web sites800 million web sites

MEDLINEMEDLINE has about 400,000 newhas about 400,000 newentries added each yearentries added each year

To keep ahead by reading everything ofTo keep ahead by reading everything ofpossible importance,possible importance, need to readneed to read

6,0006,000articles each day!articles each day!


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Why we get it wrongWhy we get it wrong

OurOur informationinformation isis out of date !!out of date !!

OurOur textbookstextbooks areare out of date !!out of date !!

Nobody can read enough journals to keepNobody can read enough journals to keep

up.up.

Th b l ti Th f A t MI


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21

5

101

1 2

8

7

8

12

4

3

1

1

2

8

7

2

1

1

1

2

81

5

156

NotMentioned

Routine

Experimental

Rare/Never

Specific

M

M

M

M

MM

Textbook/ReviewRecommendations

Odds Ratio (Log Scale)

0.5 1.0 2.0

Favours Treatment Favours Control

RCTs Pts

1 23

2 65

3 149

4 316

7 1793

10 254411 265115 331117 392922 5452

P


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Lag time from time ofLag time from time of knowingknowing to timeto time

of implementationof implementation

13 yrs for13 yrs for thrombolyticthrombolytic therapytherapy


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Another exampleAnother example

10 yrs for corticosteroids to speed10 yrs for corticosteroids to speed

fetal lung maturityfetal lung maturity


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Are We Failing?Are We Failing?

Negative correlationNegative correlationbetween our upbetween our up--toto--datedate

knowledge and the yearsknowledge and the yearssince graduationsince graduation


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The Slippery SlopeThe Slippery SlopeThe Slippery Slope

years since

graduation

r = - 0.54

P < 0.001

...

...

. ... . .... .

....

.........

...knowledgeof current

best care


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How you get the information?How you get the information?

Just In CaseJust In Case SurveillanceSurveillance

Just In TimeJust In Time FocusedFocused


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The Usefulness EquationThe Usefulness EquationThe Usefulness Equation

UsefulnessUsefulness == ValidityValidityxx RelevanceRelevance

of any sourceof any source WorkWork


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WorkWorkWork

The least effort and time toThe least effort and time toget the proper informationget the proper information


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ValidityValidityValidity

TheThe TruthTruth

What we do does moreWhat we do does more

good than harm.good than harm.


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RelevanceRelevanceRelevance

POEMPOEM: Patient: Patient--oriented evidence thatoriented evidence that

mattermattermortality, morbidity, quality of lifemortality, morbidity, quality of life

DOEDOE: Disease: Disease--oriented evidenceoriented evidence

pathophysiologypathophysiology, pharmacology, etiology, pharmacology, etiology


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Comparing DOE and POEMComparing DOE and POEM

DOEDOE POEMPOEM

AntihypertensiveAntihypertensive

therapytherapy

Lowers BloodLowers Blood

PressurePressure

DecreasesDecreases

MortalityMortality


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Keeping UpKeeping UpKeeping Up

Concentrate onConcentrate on high yieldhigh yieldjournals withjournals with

favorable POEM:DOE ratiofavorable POEM:DOE ratio

Consider three questions to determineConsider three questions to determine

relevancerelevance

PatientPatient--orientedoriented

Common to practiceCommon to practice

Require change of practiceRequire change of practice


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EBM: 1EBM: 1--22--33--44--55

One goal: improve the quality of careOne goal: improve the quality of care

Two fundamental principlesTwo fundamental principlesThreeThree --EsEsto define EBMto define EBM

FourFour --RVARRVAR-- to appraise a paperto appraise a paperFiveFive --AsAs-- to practice EBMto practice EBM

OneOne GoalGoal


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Quality of CareClinical decisions:Diagnostic test

Therapeutic intervention

Prognosis

Clinical Practice Guidelines

Research

Evidence

Clinical

Experience

Patient

Expectation

Preference

OneOne-- GoalGoal


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TwoTwo-- Fundamental principlesFundamental principles

1.1. Evidence has a hierarchy ofEvidence has a hierarchy of

strengthstrength

2. Evidence alone is never the sole2. Evidence alone is never the sole

basis for decisionsbasis for decisions

1 Hierarchy of Evidence1 Hierarchy of Evidence


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1. Hierarchy of Evidence1. Hierarchy of Evidence

MetaMeta--analysis of RCTsanalysis of RCTsMultiMulti--centric large RCTscentric large RCTs

Single Centre RCTSingle Centre RCT

Observational studiesObservational studiespatientpatient--important outcomesimportant outcomes

Clinical experienceClinical experience

Basic researchBasic researchtest tube, animal, human physiologytest tube, animal, human physiology

E id l i h2 E id l i h


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2. Evidence alone is not enough2. Evidence alone is not enough

PatientsPatients valuesvalues

Would you give a DNR consent for aWould you give a DNR consent for a

terminally ill child in case of arrest, if he isterminally ill child in case of arrest, if he is

your relative?your relative?


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Three (Three (EsEs))-- EBM ComponentsEBM Components

Evidence Experience

Expectations


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FourFour--RVRARVRA to Appraise The Evidenceto Appraise The Evidence

1.1. Relevance:Relevance: It focuses on medical problemsIt focuses on medical problemscommon to our practice. patientcommon to our practice. patient--orientedorientedevidenceevidence

2.2.

Validity:Validity:Correctness (Correctness (likely to be true)true)

3.3. Results:Results: Clinically important

4.4. Applicability:Applicability: Applicable in and useful for my

patients

5 A i EBM


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Acqu i re theEvidence(s) Appraisethe evidence(s)

Apply Thebest evidence

to patient

Ask clinicalquestions

55 AAs to practice EBMs to practice EBM

AssessYourself


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Patient carePatient care


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Patient carePatient care

EBM will hopefully modify individual patientEBM will hopefully modify individual patient

carecare

Use of proven therapies and diagnostic testsUse of proven therapies and diagnostic testsonlyonly


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I tit tiI tit ti


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InstitutionsInstitutions

Improve resource utilizationImprove resource utilization

More effective and efficient careMore effective and efficient care

Reduced cost per patient.Reduced cost per patient.

The use of EBM clinical practiceThe use of EBM clinical practiceguidelines and clinical pathwaysguidelines and clinical pathways


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Health Care PolicyHealth Care Policy

Health care policy must be reliant on usingHealth care policy must be reliant on using

the best available evidence to aid fundingthe best available evidence to aid fundingdecisions.decisions.

Screening (cancer, genetics)Screening (cancer, genetics)

Preventative healthcare (cholesterol lowering)Preventative healthcare (cholesterol lowering)In determining resource distribution withinIn determining resource distribution withincommunities (inpatient vs. communitycommunities (inpatient vs. community--basedbased

care)care)In new health technology assessment.In new health technology assessment.

M di l Ed tiMedical Education


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Medical EducationMedical Education

Worldwide trend toward curriculaWorldwide trend toward curriculaSelfSelf--directeddirected

ProblemProblem--basedbased

UpUp--toto--date physiciansdate physicians


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EBM Introduction 7-8 Feb 07

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