EBM - background

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EBM - background

• A vast and growing volume of evidence to guide
  clinical decisions
• A rapidly increasing understanding of how to
  produce valid clinical research by modern
  computers
• Users become more sophisticated in their ability
  to distinguish credible from trivial research
  results
• More general awareness that many physicians, do
  not practice medicine according to the best
  current research evidence

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Changes Over Time in Doctors Knowledge
At 15 years (1973), failure rate 64 (compared to
34 at 5 years).
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Changes Over Time in Doctors Knowledge
General Internal Medicine
Other Subspecialities
Cardiology, Gastroenterology
At 15 years (1973), failure rate for
cardiologists and gastroenterologists approx.
85 (compared to 25 at 5 years).
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Changes in Knowledge over Time

• A significant inverse correlation (r -0.3)
  between scores and years elapsed
• Knowledge declined sharply within 15 years of
  certification
• Procedure-oriented subspecialists had lower scores

Reference
Ramsey PG et al. Changes over time in the
knowledge base of practicing internists JAMA
1991 266(8) 1103-7.
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Information Needs in Office Practice

• 47 internal medicine physicians during a half day
  of typical office practice
• Actual information needs estimated by a brief
  interview after each patient visit
• From 409 patient visits 269 questions were raised
• About two questions for each 3 patients

Reference
Covell DG et al. Information needs in office
practice are they being met? Ann Int Med 1985
103 596-9.
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Information Needs in Office Practice

• For each physician an average of four questions
  per session were not answered immediately
• Of these the physician expected to find answers
  to a half i.e. two-thirds of the time when
  information regarding patient management is
  required by a physician it is not forthcoming
• Questions were not worded in terms that would
  make finding the answers easy
• The physician is by default then practicing the
  art of medicine, rather than the science

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?????? ?

• Conscientious(??), explicit(??), and
  judicious(?????) use of current best evidence in
  making decisions about individual patients
• Archie Cochrane 1972
• Integration of clinical expertise, evidence and
  patients value.

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Oxford Center for Evidence-based Medicine Levels
of Evidence (May 2001)
Level Therapy
1a ????? Systematic review (????????????, ??????)
1b ????, ?????????????
1c All or none
2a ????? (????????, ??????)
2b ???? Cohort study?????????????
2c Outcomes Research Ecological studies
3a ????? (??????-????, ??????)
3b ?? - ???? Case-control study
4 ????????? ????????? ??? - ????
5 ???????????, ????, ????, ????, ???????
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????????

• ??????????? (Original article)
• ?????????????????? Level 5
• ??? Bob Phillips, Oxford Center for EBM ? June
  2005 E-mail ??

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???????

• ???? (Question formulation)
• ???? (Evidence search)
• ???? (Critical appraisal)
• ???? (Evidence application)
• ???? (Outcome evaluation)

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?????

• P Participant
• I Intervention (E Exposure)
• C Comparison
• O Outcome
• T Time

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Well-formulated Diagnosis Question

• Is diagnostic ultrasound imaging as accurate as
  MRI in detecting partial thickness rotator cuff
  tear in middle age?

Participants
Comparison
Outcome
Intervention
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Well-formulated Diagnosis Question

• Is diagnostic ultrasound imaging as accurate as
  MRI in detecting partial thickness rotator cuff
  tear in middle age?

P
I
C
O
Participants
Comparison
Outcome
Intervention
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???EBM???
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????

• ?????????
• PubMed????
• Cochrane Library????

17
??????

• ???????,???????????(???)???????(?????),???????????
  ?????????,???????,??????????????????

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???????
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?????????

• ????????
• MEDLINE
• Cochrane Library
• SkolarMD
• PubMed
• UpToDate
• MD Consult
• ProQuest

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?????????

• ?????? ?????????
• ????
• ???????????????????,??????????????????????????
  ????????????????????????????,?????????
• ???????????,???????????
• AIDS
• Acquired Immune Deficiency Syndrome
• Acquired-Immuno Deficiency Syndrome
• Immunodeficiency Syndrome, Acquired

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• (2)??????
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  ???????????????,?????????????,?????????????????
  ???????????????????,?????????????,????????????????
  ?????????????????,???????????
• ?????????????(????)??????(????)??
• MEDLINE MESH
• Virus Diseases  
       Retroviridae Infections       
     Lentivirus Infections     
      HIV Infections           
      ?Acquired Immuno Deficiency
  Syndrome                  
  (Acquired Immune Deficiency Syndrome)            
          (Acquired-Immuno
  Deficiency Syndrome)             
  (AIDS)                
    (Immunodeficiency Syndrome, Acquired)
• ???????Medical Subject Heading(MeSH)?Library of
  Congress Subject Headings( LCSH).

???????????????????
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?????????

• ??????
• ??????(Boolean Logic) AND, OR, NOT
• ????(Adjacency)
• A adjn B (A?B????N??,??????)
• ?cerebral adj2 surgery??? cerebral
  surgery,surgery cerebral,cerebral aneurysm
  surgery, cerebral comlications of surgery???.
• ??(??)?? (Truncation)
• ??????????????????? ????
• ?Flavor???flavored, flavorful, flavoring etc.
• ??????(Set No.)
• 1 and 2, s1 and s2
• ????(Limit)?? ???????????
• ??????(Search fields)

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?????????

• ???????????
• ???????????,????,??????????
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• ????????????,?????????????????,???????????????,???
  ??????
• ??????
• ?????,?????????E-mail?????????????????

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Evidence Resources VGHKS LIB Holding

• Database
• Cochrane Library (26 December 2004, Wiley
  InterScience)
• UpToDate
• MD Consult
• OVID Medline (?????)
• Skolar MD (?????)
• InfoPOEM (Trial, ???5/31)
• PubMed(Free)
• E-Journal-15 Titles
• E-Book-34 Titles
• Books-30 Titles

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???????

• http//ebm.bmjjournals.com/ ?????????? ????????
• http//www.cebm.net ????????
• http//www.jr2.ox.ac.uk/bandolier/
• http//www.uptodate.com ?? ???????????????
• http//www.york.ac.uk/inst/crd/ centre for
  reviews and dissemination
• http//www.clinicalevidence.com/ceweb/conditions/i
  ndex.jsp BMJ ???????
• http//www.pubmed.org ????????????? ?? Medline
• http//www.cochrane.org ???? ??????? ????
• http//www.bestreatments.org
• http//www.nice.org.uk/
• http//www.guideline.gov
• http//www.acpjc.org ACP journal club (American
  College Of Physicians)

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Critical Appraisal Skills Programme
27
??????

• ????????
• ?????????????Review?????
• ?????????????RCT?????
• Fellow?????????????????
• ??????????
• ????OSCE?????
• ???????????????

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Warning of EBM

• Not all that evidence-based is golden
• Many authors and advertisers use the term
  evidence-based to sell their boojournals and
  services
• Evidence-based information is perishable the
  date of publication should be recent

Prof. RB Hyanes, APC, Dec 2005