EvidenceBased Medicine For the Practicing Clinician

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Evidence-Based Medicine For the Practicing
Clinician

• SGIM Task Force on EBM
• September 21, 2000

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Todays Roadmap

• 8am Intro Assessment
• 9am Asking Questions Searching
• 10am BREAK
• 1020 Asking Questions Searching
• 11am Interpreting Evidence Diagnosis
• 1230 LUNCH
• 2pm Interpreting Evidence Therapy
• 345 BREAK
• 4pm Wrap-up

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Cast of Characters

• Emory
• Mark Williams
• Jennifer Kleinbart
• Wake Forest
• Mark Wilson
• Raquel Watkins
• Columbia Presbyterian
• Peter Wyer

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We Have Lots to Cover and I Hope to Avoid . . .

• The Dopeler Effect
• The Tendency of Stupid Ideas to Seem Smarter
  When They Come at You Rapidly

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We Wont Go Here ...
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And We Wont Hand out Masks
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We Will Highlight Successful Strategies
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Evidence-Based Is EVERYWHERE

• Evidence-Based Patient Information
• Evidence-Based Patient Choice

• Evidence-Based Sports Medicine

• Evidence-Based Orthodontics
• Evidence-Based Midwifery
• Evidence-Based Chiropractic Care
• Evidence-Based Alternative Medicine
• Evidence-Based Veterinarian Practice

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Back at the Home Office

• What Do Your Colleagues Think EBM Is???

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Common Beliefs about EBM

• Old Hat
• Ivory Tower Exercise
• Limiting Paralyzing
• Fixed Cookbook Approach
• A Tool for Cost Cutters
• Just about RCTs Statistics

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Others Find EBM Liberating

• It helps deal with information overload
• Its an approach to keeping up-to-date
• It stimulates life-long, self-directed learning
• Caring for patients necessitates that we track
  down clinically important information

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Evolution of Evidence-Based Medicine
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Its a Paradigm Shift

• When defects in an existing paradigm accumulate
  to the extent that the paradigm is no longer
  tenable, the paradigm is challenged and replaced
  by a new way of looking at the world
• A new paradigm for medical practice is emerging
• Evidence-based medicine requires new skills of
  the physician
• JAMA 1992 2682420-5

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Evidence Based Medicine

• Clinical intuition, unsystematic experience,
  pathophysiologic rationale

Evidence from clinical research
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Users Guides Series in JAMA(Evidence-Based
Medicine Working Group)

• Are the Results Valid?
• Are the Results Important?
• Will the Results Help Me Care for My Patients?

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Other Emerging EBM Descriptors

• Evangelism
• By
• Messiah

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EBM A Hierarchy of Evidence

• N-of-1 Trials
• Meta-Analysis of Homogeneous RCTs
• Single RCT
• Cohort Study
• Case-Control Study
• Case Series
• Individual Clinical Experience

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A Wise Clinician Once Told Me

• Whenever You Get Confused,
• Start Back with the Patient

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Patients with New Proximal DVTs

• What Are Your Current Practice Patterns?

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Ahh The Best Evidence

• RCT at 15 Centers in Canada
• 500 patients with acute proximal DVT
• Enoxaparin 1mg/kg SQ bid versus Standard
  continuous heparin infusion
• Equal rates of recurrent VTE (5-6) and major
  bleeding rare (1-2)
• 50 of LMWH group never hospitalized
• Levine, et al. NEJM 1996 334677-81

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How Would You Treat These Patients With Newly
Diagnosed DVT?

• 43 y/o truck driver whose husband is a nurse
• 68 y/o man 3 weeks s/p TKR who was participating
  in rehab program 3X/week
• 75 y/o woman with metastatic ovarian cancer who
  is non-communicative after CVA 2 yrs ago and has
  no advance directives

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Sounds Like Weve Got Some Uncertainty Here . .
.

• Well revisit this some more this afternoon
• For now, suffice it to say that
• we all are attracted to trying to use systematic
  research in our patient care
• we all need to further improve our skills to
  access this evidence, interpret it, and apply it
  to our individual patients

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The Basics of EBM

• ASK a Clinically Relevant Question
• ACCESS the Best Available Evidence
• APPRAISE its Quality Importance
• APPLY the Evidence in Patient Care

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Lets Look at the ACCESS Step

• 51 y/o female on HRT cigs has CP and mild
  hypoxemia. PE is entertained a helical CT scan
  is obtained and is negative
• I want to find evidence about how good the CT is
  to rule out a PE
• My Medline search combining pulmonary embolism,
  computed tomography, and senspec gave me 102
  hits
• OUCH!!!

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Ways to Solve This Problem

• Critique the literature yourself.
• Get the full text(s)
• Apply the Users Guides
• Interpret results and applicability for this
  patients
• Seek pre-digested EBM resources
• Interpret the results
• Apply to this patient
• Accept evidence-based practice protocols
• Apply to this patient

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Evidence-Based Resources

• Best Evidence
• ACP Journal Club
• Diagnostic Strategies for Common Medical Problems
• UpToDate
• Cochrane Library
• Websites (Journals CAT banks)
• Clinical Evidence (only print version)

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• Synopses
• Best Evidence
• Filters Importance (articles that could change
  what we do), Quality (absenes of major threats to
  validity)
• Appraisal Pre-appraised, standardized summaries

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• Summaries
• UpToDate
• Filters New evidence from the clinical
  literature
• Appraisal Expert review, with links to
  supporting evidence

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• Syntheses
• Cochrane Library
• Filters Randomized controlled trials about
  health interventions
• Appraisal Systematic review, standardized
  reports and summaries

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Acquiring InformationStudiesSynopses SummariesS
yntheses Systems
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• Studies
• PubMed
• Filter None, All of MEDLINE(searches improved
  by best single terms and expert strategies)
• Appraisal None, must do own appraisal

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