Title: EVIDENCEBASED MEDICINE
1EVIDENCE-BASED MEDICINE
- Dr. Monica Hughes
- Clinical Research Registrar
- Department General Practice
2EBM- WHY NOW?
- Consolidate your expertise
- Prepare you for your job as an autonomous
practitioner responsible for making decisions - Significant component Final MB
3LEARNING OUTCOMES
- Define the term EBM
- Understand the components involved in EBM
- Discuss the merits of available evidence
resources
4BUYING A MOBILE PHONE
- How do you choose your mobile phone????
- From where do you get reliable information????
5BUYING A MOBILE PHONE
- Would you trust the information you get from this
salesperson????
6BUYING A MOBILE PHONE
- What about the Carphone Warehouse website?
7BUYING A MOBILE PHONE
- Would you trust what your friends say?
8BUYING A MOBILE PHONE
- What about the OFCOM website?
9STRAW POLL
- Salesperson
- Carphone Warehouse Website
- Friends
- Ofcom Website
10HOW DO WE MAKE CLINICAL DECISIONS?
- Toss a coin?
- Guess?
- Ask a friend?
- Do what your consultant tells you!
- Do no harm?
- Text books or Journals?
11HOW DO WE MAKE CLINICAL DECISIONS?
Schools Of Thought..
Dogma ?
This is the best way to do it
Policy ?
This is the way we do it around here
Experiential ?
This way worked the last few times
Whimsical ?
This way might work
Nihilism ?
It doesnt really matter what we do
Patient deferential ?
How would you like us to proceed?
Expert deferential ?
What would you do?
12WHAT IS EBM?
- Evidence-based medicine is the process of
systematically finding, appraising and using
contemporaneous research findings as the basis
for clinical decision making. - Rosenberg 1995
13SHIFT IN PRACTICE
- Traditional Approach
- Quantity of clinical experience indicates Dr
quality - Experience of basic science is needed for
decisions - Didactic medical training is sufficient
- See loads of patients, know your science and do
what the consultants says
14SHIFT IN PRACTICE
- EBM Approach
- Inform all our decision making from best current
evidence - Optimises our decisions
- Allows every practitioner to formulate identical
conclusions - Accept knowledge is continually evolving never
have all the information to answer every question - Know how to find and formulate the information in
context - Apply knowledge consistently and objectively
15SHIFT IN PRACTICE ..WHY BOTHER?
- Medicine is NOT static
- HRT NSAIDs
- Government policy
- Clinical governance Patient safety
- GMC
- Duties Of A Doctor Revalidation
- Increasingly informed Jo Public
- www. etc,
16SHIFT IN PRACTICE ..WHY BOTHER?
- But ultimately
- EBM improves health care
17How many minutes did you spend last week reading
around your patients?
- Medical students
- PRHOs
- SHOs
- SpRs
- Consultants
18How many minutes did you spend last week reading
around your patients?
- Medical students 120mins
- PRHOs
- SHOs
- SpRs
- Consultants
19How many minutes did you spend last week reading
around your patients?
- Medical students 120mins
- PRHOs 10mins
- SHOs
- SpRs
- Consultants
20How many minutes did you spend last week reading
around your patients?
- Medical students 120mins
- PRHOs 10mins
- SHOs 30mins
- SpRs
- Consultants
21How many minutes did you spend last week reading
around your patients?
- Medical students 120mins
- PRHOs 10mins
- SHOs 30mins
- SpRs 45mins
- Consultants
22How many minutes did you spend last week reading
around your patients?
- Medical students 120mins
- PRHOs 10mins
- SHOs 30mins
- SpRs 45mins
- Consultants 60mins
23ELEMENTS OF EBM
- EBM begins and ends with patients
- EBM The search algorithm
- 1) Convert patient health needs into answerable
questions - 2) Track down best evidence
- 3) Critically appraise evidence
- 4) Apply results to clinical practice
- 5) Evaluate your performance
24ELEMENTS OF EBM
- EBM begins and ends with patients
- EBM The search algorithm
- 1) Convert patient health needs into answerable
questions
25Formualting Answerable questions that you can
answer.
- Answerable questions are the backbone of
practising EBM - In practice, good questions usually include-
PICO - Patients clinical needs
- Intervention or exposure
- Comparison intervention (if appropriate)
- Clinical Outcomes (diagnosis/prognosis/therapy/eve
nt)
26Applying the results to clinical practice.e.g. AF
- John, a retired 78yr old gentleman is your last
patient of the day. He has a long history of AF
and is on aspirin. He says to you my friend has
atrial fibrillation and he is on warfarin -
should I be on warfarin?
27Applying the results to clinical practice.e.g. AF
- Patient In patients with AF and who are gt65.
- Intervention .would prescribing
- warfarin.
- Comparison .compared to
- aspirin .
- Outcome .lead to lower
- mortality or morbidity?
- .. Cause any increased risk?
-
28Applying the results to clinical practice. e.g.
AF
29Applying the results to clinical practice.e.g.
AF
Stroke Risk with AF on Warfarin
Stroke Risk with AF on Aspirin
30Can you apply this evidence into clinical
practice?
- Can the results be extrapolated to your patient?
- Availability of tests/treatment
- Affordability of tests/treatment (NB NICE etc)
- Are there adverse risks?
- Are there alternatives?
- What are the patient preferences?
31Applying the results to clinical practice. e.g.
AF
- Major bleeding risk
- Population prevalence 10/1000
- Aspirin Not significantly different to placebo
- Warfarin 15/1000
- Are you going to give him warfarin?
- John is very unsteady on his feet and is prone to
falls - Are you still going to give him warfarin???
32ELEMENTS OF EBM
- EBM begins and ends with patients
- EBM The search algorithm
- 1) Convert patient health needs into answerable
questions - 2) Track down the best evidence
33Tracking down best evidence..
- General search strategy
- Select evidence resource
- Library/databases/guidelines/colleagues
- Design search strategy
34Tracking down best evidence..
- Hierarchy of evidence
- Systematic review
- Meta-analysis
- RCT
- Cohort study Prospective e.g. Doll
- Case controlled study -Retrospective
- Cross sectional study -Snapshot
- Case series Rare
35ELEMENTS OF EBM
- EBM begins and ends with patients
- EBM The search algorithm
- 1) Convert patient health needs into answerable
questions - 2) Track down the best evidence
- 3) Critically appraise evidence
36Critically appraising the evidence.
37ELEMENTS OF EBM
- EBM begins and ends with patients
- EBM The search algorithm
- 1) Convert patient health needs into answerable
questions - 2) Track down the best evidence
- 3) Critically appraise evidence
- 4) Apply the results into clinical practice
38Applying results to clinical practice.
39Applying results to clinical practice.e.g. MI
- John, a retired 78yr old gentleman is your last
patient of the day. He had an MI 2months ago and
was told his cholesterol is normal. He says to
you my friend had a heart attack and is on a
drug called a statin- should I be on this?
40Applying results to clinical practicee.g. MI
- Patient In patients gt70 who had an MI but
cholesterol is normal. - Intervention .would adding
- a statin.
- Comparison .in addition to
- usual care...
- Outcome .lead to lower
- mortality or morbidity
-
41Applying results to clinical practice. e.g. MI
- Heart Protection Study (Lancet 2002)
- Statin therapy offers a 33 reduction in further
CHD events in high risk patients EVEN when
cholesterol normal or low - John should get the statin prescription
42ELEMENTS OF EBM
- EBM begins and ends with patients
- EBM The search algorithm
- 1) Convert patient health needs into answerable
questions - 2) Track down the best evidence
- 3) Critically appraise evidence
- 4) Apply the results into clinical practice
- 5) Evaluate your performance
43Evaluate Performance
- Audit
- Clinical efficacy
- Cost analysis
- Patient surveys
- Prescribing rates
- Referral rates
- Mortality/morbidity rates
44ELEMENTS OF EBM.. In Summary
- EBM begins and ends with patients
- EBM The search algorithm
- 1) Convert patient health needs into answerable
questions - 2) Track down the best evidence
- 3) Critically appraise evidence
- 4) Apply the results into clinical practice
- 5) Evaluate your performance
45EVIDENCE RESOURCES HIERARCHY
- Most reliable -----
- 1 Systematic review databases
- 2 Review Journals
- 3 EBM guidelines and textbooks
- 4 Medline/Electronic databases
- 5 Opinions, texts ---least
reliable
46EVIDENCE RESOURCES
- 1. Systematic review databases
- The Cochrane Library
- Best source for structured systematic reviews
(SR) - Explicit search quality criteria
- Numerical data presented in standardized graphics
enabling quick decisions - Database of Abstracts of Reviews of Effectiveness
(DARE) - SR structured abstracts
- Free
47EVIDENCE RESOURCES .contd
- 2. Review Journals
- Summarises systematic reviews
- Offers balanced commentary on selected papers
from major journals - Example
- Evidence-Based Medicine
http//ebm.bmjjournals.com -
48EVIDENCE RESOURCES .contd
- 3. EBM guidelines and textbooks
- Clinical practice guidelines
- The best sources rate the strength of evidence
- SIGN -- http//www.sign.ac.uk/
- NICE -- http//www.nice.org.uk/
- Always consider external validity to your patient
- Evidence-based textbooks
- Least detail, but most efficient source for
simple queries - Clinical Evidence is the best (explicit
protocols)
49EVIDENCE RESOURCES.contd
- 4. Medline/Electronic databases
- Medline
- The largest biomedical literature database, but
- Misses some journal articles, misclassifies
others, lacks comprehensiveness in psychology
sociology - Can be overwhelming if not searching selectively
- PubMed
- is a free Medline service
50EVIDENCE RESOURCES .contd
- 5. The least reliable
- Colleagues or expert opinion, throw-away
journals - Convenient and fast
- Often invalid , incomplete, and biased
information - Textbooks
- Generally not systematically researched
- Usually based on expert opinion
- Most are out of date - check for recent citations
51Some final thoughts..
- EBM
- Goal
- Provide BEST patient care using current BEST
evidence - Issues
- TIME required to stay current
- Research accumulating exponentially
- Challenge
- Make BEST use of our limited time through
- DEVELOP information retrieval management skills
52ON-LINE STUDENT RESOURCES
- Available on
- www.qub.ac.uk/cm/gp
- Or
- www.qub.ac.uk/qol
- Past papers
- www.qub.ac.uk/fmhs/5EBMpaper.htm
- Also see School Medicine website for further
practice sample questions
53Thanks for your attention..