EBM OVERVIEWEBM OVERVIEW

Dr. Faisal Al HaddadDr. Faisal Al Haddad

Consultant of Family Medicine Consultant of Family Medicine & Occupational Health& Occupational Health

PSMMCPSMMC

Outline of TalkOutline of Talk

Definition of EBM Definition of EBM

History of EBMHistory of EBM

Obstacles of EBMObstacles of EBM

How to practice EBM ( How to practice EBM ( The Five A’s )The Five A’s )

What is EBM?What is EBM?

Evidence-based medicine is the conscientious, explicit Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making and judicious use of current best evidence in making decisions about the care of individual patients while decisions about the care of individual patients while considering patient values. considering patient values.

The practice of evidence-based medicine means The practice of evidence-based medicine means integrating individual clinical expertise with the best integrating individual clinical expertise with the best available external clinical evidence from systematic available external clinical evidence from systematic research.research.

How did it start?How did it start? Late 1970’s clinical epidemiologists at McMaster Late 1970’s clinical epidemiologists at McMaster

University wrote a series of articles on how to read University wrote a series of articles on how to read clinical journals called clinical journals called critical appraisalcritical appraisal that were that were published in 1981 in Canadian Medical Association published in 1981 in Canadian Medical Association Journal.Journal.

This team started teaching the practice at the University This team started teaching the practice at the University and the term changed to EBM in a document for and the term changed to EBM in a document for resident applicants in 1990.resident applicants in 1990.

In 1991 the term EBM appeared in ACP JC.In 1991 the term EBM appeared in ACP JC.

Why EBM?Why EBM?

Daily need for valid information.Daily need for valid information.

Inadequacy of traditional textbooks – out of date, Inadequacy of traditional textbooks – out of date, ineffective, overwhelming.ineffective, overwhelming.

Disparity between our diagnostic skills and clinical Disparity between our diagnostic skills and clinical judgment – and up to date knowledge and clinical judgment – and up to date knowledge and clinical performance.performance.

The EBM process aims to make it easier to apply current The EBM process aims to make it easier to apply current quality evidence from research in clinical and healthcare quality evidence from research in clinical and healthcare decisions. decisions.

Obstacles to EBMObstacles to EBM

Shortage of coherent consistent scientific evidence.Shortage of coherent consistent scientific evidence.

Difficulty applying to my patient population.Difficulty applying to my patient population.

Developing skills for searching and appraising.Developing skills for searching and appraising.

TimeTime

Limited number of studies that show “EBM” works.Limited number of studies that show “EBM” works.

EBM - How to practice:EBM - How to practice:

The 5 A’sThe 5 A’s

AAsk – formulated clinical questionsk – formulated clinical question

AAcquire – best evidence to answer a questioncquire – best evidence to answer a question

AAppraise – evidence for validity, impact and applicabilityppraise – evidence for validity, impact and applicability

AApply – to our patientpply – to our patient

AAssess – effectivenessssess – effectiveness

AAsksk

Formulate the Question :Formulate the Question :

A clinical question related to the diagnosis, treatment, A clinical question related to the diagnosis, treatment, prognosis, or etiology of a patient’s illness. prognosis, or etiology of a patient’s illness.

Include the patient’s problem or diagnosis; the Include the patient’s problem or diagnosis; the intervention of interest, as well as any comparison intervention of interest, as well as any comparison intervention; and the outcome of interest.intervention; and the outcome of interest.

Needs to be focused and searchable.Needs to be focused and searchable.

PICOPICO QUESTIONQUESTION

PPatient population and problem of interestatient population and problem of interest

IIntervention of interest or exposurentervention of interest or exposure

CComparison of interestomparison of interest

OOutcome of interestutcome of interest

EXAMPLEEXAMPLE

A 55-year old Type II diabetic woman came to yourA 55-year old Type II diabetic woman came to your

clinic for regular follow up and result inquiring. You clinic for regular follow up and result inquiring. You notice that she has microalbuminuria. notice that she has microalbuminuria.

You decide to start her on ACEI to prevent progression You decide to start her on ACEI to prevent progression to nephropathy. Sit-in intern asks you if ACEI is more to nephropathy. Sit-in intern asks you if ACEI is more effective than ARB in term of prevention of effective than ARB in term of prevention of nephropathy?nephropathy?

PICO QUESTIONPICO QUESTION

Patients:Patients: Type II diabetic patients with Type II diabetic patients with microalbuminuria. microalbuminuria.

Intervention:Intervention: ACEI ACEI

Comparison: Comparison: ARBARB

Outcomes:Outcomes: Diabetic nephropathy Diabetic nephropathy

Aisha, a former nurse, brings her 18 months-old boy in Aisha, a former nurse, brings her 18 months-old boy in for a minor problem which is easily sorted out. for a minor problem which is easily sorted out. However, you noted that her child didn't have the However, you noted that her child didn't have the MMR vaccine till now. MMR vaccine till now.

When you ask Aisha 'why not' she says that she does not When you ask Aisha 'why not' she says that she does not

want to give her son the MMR because it is probably want to give her son the MMR because it is probably not safe and many boys have developed autism after not safe and many boys have developed autism after being immunized with the MMR. How would you being immunized with the MMR. How would you formulate clinical question? formulate clinical question?

AAcquirecquire

Search for AnswersSearch for Answers

Having formulated the question, the next step is to Having formulated the question, the next step is to try to find an answer.try to find an answer.

This step involves both an assessment of the type of This step involves both an assessment of the type of evidence that would be most appropriate to answer evidence that would be most appropriate to answer the question, as well as the actual search for the the question, as well as the actual search for the evidence.evidence.

Best study designBest study design

DiagnosisDiagnosis Controlled Trial,Controlled Trial,

Cross-sectional analytical studyCross-sectional analytical study

HarmHarm Cohort, population based-case controlCohort, population based-case control

PrognosisPrognosisCohort Studies,Cohort Studies,Case Control,Case Control,Case SeriesCase Series

TreatmentTreatment Double blind RCT or systematic review Double blind RCT or systematic review of RCTsof RCTs

Best EvidenceBest Evidence

Cochrane LibraryCochrane Library

Internet Database of Evidence-Based Abstracts and Articles Internet Database of Evidence-Based Abstracts and Articles (IDEA) (IDEA)

MEDLINEMEDLINE via via PubMed PubMed

Clinical EvidenceClinical Evidence

Up To DateUp To Date

BandolierBandolier

AAppraiseppraise

Appraise the EvidenceAppraise the Evidence

Once an article is located, it is necessary to appraise Once an article is located, it is necessary to appraise its validity and importance before applying the its validity and importance before applying the results. results.

The specific analysis of the paper, regarding validity The specific analysis of the paper, regarding validity and importance etc, depend on the type of study and importance etc, depend on the type of study design and the nature of the question.design and the nature of the question.

AApplypply

Apply the Results to Your PatientApply the Results to Your Patient

Is the evidence valid, important, applicable to your patient, Is the evidence valid, important, applicable to your patient, and and feasiblefeasible in your setting? in your setting?

Would your patient fit inclusion and not exclusion criteria?Would your patient fit inclusion and not exclusion criteria?

Were all clinically important outcomes considered?Were all clinically important outcomes considered?

Are costs and risks acceptable?Are costs and risks acceptable?

Are patients values/expectations considered?Are patients values/expectations considered?

AAssessssess

Assess the OutcomeAssess the Outcome

The final step includes an evaluation of your The final step includes an evaluation of your performance in searching the literature, as well as an performance in searching the literature, as well as an assessment of the patient’s response.assessment of the patient’s response.

Perform self evaluations to improve your skills in Perform self evaluations to improve your skills in using EBM.using EBM.

Self EvaluationSelf Evaluation

Are my questions well formulated?Are my questions well formulated?

Am I effectively/efficiently searching?Am I effectively/efficiently searching?

How am I doing with critical appraisal?How am I doing with critical appraisal?

Am I integrating what I have learned into clinical Am I integrating what I have learned into clinical practice?practice?

Are patients benefiting?Are patients benefiting?

EBM conclusionEBM conclusion

The use of current best available evidence in The use of current best available evidence in making decisions about patient care while making decisions about patient care while considering patient values.considering patient values.

Requires skills for critical appraisal as well as Requires skills for critical appraisal as well as skills for applying evidence appropriately to skills for applying evidence appropriately to individual patients.individual patients.

Lifelong process of learning enhanced by self-Lifelong process of learning enhanced by self-evaluation.evaluation.

Any Question?Any Question?

Thank youThank you