Evidence-based medicine (EBM) involves integrating the best available research evidence with clinical expertise and patient values and preferences. The key steps of EBM include formulating a clinical question using a PICO framework, searching for relevant evidence, critically appraising the evidence, and applying it to clinical decision making. EBM aims to provide the best care for patients by using the most current and valid research available.
Evidence-based medicine (EBM) involves integrating the best available research evidence with clinical expertise and patient values and preferences. The key steps of EBM include formulating a clinical question using a PICO framework, searching for relevant evidence, critically appraising the evidence, and applying it to clinical decision making. EBM aims to provide the best care for patients by using the most current and valid research available.
Evidence-based medicine (EBM) involves integrating the best available research evidence with clinical expertise and patient values and preferences. The key steps of EBM include formulating a clinical question using a PICO framework, searching for relevant evidence, critically appraising the evidence, and applying it to clinical decision making. EBM aims to provide the best care for patients by using the most current and valid research available.
Evidence-based medicine (EBM) involves integrating the best available research evidence with clinical expertise and patient values and preferences. The key steps of EBM include formulating a clinical question using a PICO framework, searching for relevant evidence, critically appraising the evidence, and applying it to clinical decision making. EBM aims to provide the best care for patients by using the most current and valid research available.
Medicine (EBM) Tim FOME Fakultas Kedokteran Universitas Andalas 1/9
Introductory Lecture: Objectives
1. What What is evidence-based medicine? What does it look like in practice?
2. How
1. 2. 3.
Formulate Clinical Questions
Search for Evidence Appraisal of research Apply to clinical problem
What is evidence-based medicine?
Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values - Dave Sackett Patient Concerns EBM Best research Clinical Expertise evidence
What is EBM NOT?
What we have always done
Cookbook medicine Only a cost-cutting trick Only randomized trials
Evidence based medicine
IS Tracking down the best external evidence with which to answer our clinical questions
Life long learning
The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a medical course, but a life course, for which the work of a few years under teachers is but a preparation.
Sir William Osler (1849-1919), from: The Student of
Medicine
How do I decide what to do?
How do I make decisions?
Dogma: Natural is best
Tradition: Weve always done it that way Convention: Everyone does it this way Evidence-Based: Evidence supports this way
How do I decide what to do?
The answer from EBM use of current best evidence
Evidence: systematic observation
Meta-Analysis Randomized Controlled Trial Uncontrolled Trial Case Series Anecdote
Meta-Analysis Randomized Controlled Trial Uncontrolled Trial Case Series Anecdote More systematic observation better evidence
Integrating evidence & practice
EBM Cycle Evaluate Application
Patient problems
Apply Evidence
Clinical Question
Critical Appraisal
Literature Search
The EBM Cycle
1. Assess the patient: A clinical question arises from caring for a
patient. 2. Ask the question: Construct a well-built foreground question derived from the case. 3. Acquire the evidence: Find the answer from the evidence presented in the medical literature and identify the best resource from among the many. 4. Appraise the evidence: Appraisal includes validity (closeness to truth) and applicability (usefulness in clinical practice). 5. Apply: Communicate the evidence to your patient and integrate the evidence with clinical expertise, patient preference and apply. 6. Self-evaluation: Evaluate the process and outcome.
Clinical Questions Ask the question: Construct a well-built foreground question derived from the case.
Two Types of Questions are
Generated in the EBM Cycle Background Questions ask about general knowledge relating to a condition, diagnostic test or treatment. They typically start with who, what, where, when, how, or why.
Foreground Questions ask for specific knowledge to
inform clinical decisions for patient care.
Clinical Questions Background - What is it? General information on a condition or disease Foreground What do I do for this patient? Patient Intervention/Investigation Comparison Intervention/Investigation Outcome (Patient-Oriented)
PICO P = Patient, population or target problem at hand How would you describe a group of patients similar to your own? What is the condition or disease you are interested in?
I = Intervention What do you want to do to this patient? Treat, diagnose or observe?
C= Comparison What is the main alternative (gold standard) to compare with the intervention? Your clinical question does not always need a direct comparison.
O= Outcome What can you hope to improve, accomplish, measure or affect? What are the relevant outcomes? (morbidity, death, complications) Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well-built clinical question: a key to evidence-based decisions. ACP J Club. 1995 NovDec;123(3):A12-3.
Formulating the Foreground Question
The following formula will help construct the question:
In patients [include significant demographics]
with [specify Target Problem ] does [specify
Intervention] or [specify Comparison, if any]
affect [specify Outcome]?
Clinical Questions - PICO
Example: In a 5 year old child with conjunctivitis (patient) will topical antibiotics (intervention) compared to no treatment (comparison) lead to quicker symptom relief (outcome)?
In a 5 year old child with conjunctivitis (patient) will
topical antibiotics (intervention) compared to no treatment (comparison) lead to improved cure rates (outcome)?
Question Domains Foreground questions fall into general question domains. Each domain is best answered by particular study types. Study types are powerful limits to finding best evidence. Question Domain
Suggested Best Study Types
Diagnosis
RCTs > prospective studies (which make a blind
comparison to the gold standard)
Therapy
RCTs > cohort studies > case-control studies
Etiology/Harm
RCTs > cohort studies > case-control studies
Prognosis
cohort studies > case-control studies
Economic Analysis
costs and cost analysis
Literature Search Acquire the evidence: Find the answer from the evidence presented in the medical literature and identify the best resource from among the many.
Should I ask a colleague?
Searching: finding good answers?
Searching made easy
Finding Evidence-based Answers
Trip Database (http://www.tripdatabase.com/) Database of Abstracts of Reviews of Effectiveness (http://www.crd.york.ac.uk/crdweb/) DynaMed (http://www.dynamicmedical.com/) *Subscription required. Essential Evidence Plus (http://www.essentialevidenceplus.com/) *Subscription required. Cochrane Library (http://www.cochrane.org/) *Subscription for full access, abstracts free. FPIN (http://www.fpin.org/) *Subscription required. Clinical Evidence (www.clinicalevidence.com/) *Subscription required.
Critical Appraisal Appraise the evidence: Appraisal includes validity (closeness to truth) and applicability (usefulness in clinical practice).
Rapid Critical Appraisal
Its peer-reviewed, therefore it must be OK ????
Which resources do I use to
answer my question? Part of the process in answering foreground questions is understanding how to select resources that yield the best evidence. Understanding the pros and cons of those resources will lead to information mastery. The Evidence Pyramid can help determine where to go.
Evidence Pyramid Synthesized & Evaluated Literature
Best Evidence
Primary Literature
May or May not be
Evidence-Based
Provided by HealthLinks, University of Washington, http://healthlinks.washington.edu/ebp/ebptools.html
Evidence Pyramid How do I use the pyramid? That depends on the kind of question you are asking. What kind of information are you after? A systematic review may not be necessary for every situation. Start at the bottom and work your way up. There are more Clinical Reference Texts than Systematic Reviews.
Start Here: Base Resources
Give background information Help to define the PICO elements Form the basis of foreground questions Make up the largest percentage of resources Where do I find them? Library catalog, discovery tool for clinical texts http://guidelines.gov review article limit in MEDLINE
Top of the Pyramid Resources
Have the most evidence to support their conclusions Best for answering foreground questions Less abundant in the literature But more clinically relevant for decision making
How do I find them?
Consult a point-of-care resource such as DynaMed Search MEDLINE for systematic reviews, meta-analyses or individual study types e.g. RCTs
The best evidence depends
on the type of question Level
Treatment
Prognosis
Diagnosis
Systematic Review of
Systematic Review of
Systematic Review of
II
Randomised trial
Inception Cohort
Cross sectional
III
Apply Evidence
Apply: Communicate the evidence to your
patient and integrate the evidence with clinical expertise, patient preference and apply.
Applying to the individual
What do the results mean on average? What do they mean for this individual?
Evaluate Application Self-evaluation: Evaluate the process and outcome.
In short EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
Is keeping up to date Mission Impossible?
Bluegreenblog 2006
Review the World Literature Fortnightly*
*"Kill as Few Patients as Possible" - Oscar London
MedicalPer Articles Year per Year Medical Articles
2500000
5,000? per day
2000000 1500000
1,500 per day
1000000
95 per day
500000 0
Biomedical
MEDLINE
Trials
Diagnostic?
Coping with the overload:
three possible things you might try A. Read an evidence-based abstraction journal (and cancel other journals) B. Keep a logbook of your own clinical questions C. Run a case-discussion journal club with your practice
What are your clinical questions?
A 35 year old man says his brother recently died of a
ruptured cerebral aneurysm. He is worried about whether he might have one and what the chances are that it would rupture. A 60 year old women worried about her rheumatoid arthritis. She asked whether the rheumatoid arthritis could kill her. Do patients with rheumatoid arthritis have higher mortality? You use methotrexate for rheumatoid arthritis patients. But you are confused is the methotrexate benefit patients? Do patients with rheumatoid arthritis benefit from methotrexate?
