EVIDENCE BASED

MEDICINE
Categories of EBP Questions
Q
Definition
EBM is "the conscientious, explicit and judicious use
of current best evidence in making decisions about
the care of the individual patient. It means
integrating individual clinical expertise with the
best available external clinical evidence from
systematic research." (Sackett D, 1996)
Historical Evolution
• Has roots going back to 19th century.
• Recently broadened interest due to information
explosion that increased dramatically in the last decade.
• Has become more formalized that have enabled
practitioners to approach medical problems and
evaluate medical literature with greater consistency
and to deal with massive amounts of medical
information via a qualitative approach.
• Practitioners have a responsibility to ensure their
practice is based on sound clinical evidence and that the
care delivered is of a high quality.
Medicine and the information age
• Medicine has become an information intense discipline
• The volume of new medical information is staggering
• Example: MEDLINE (NLM, NIH)
• Started in 1966
• Contains ~4,800 biomedical journals
• Contains 13 million articles
• 400,000 new articles are added each year (that’s > 1,000 a day!)
• Access to medical information has increased dramatically
• Everyone is exposed to the media
• Almost everyone has access to the internet
• Interest in medical information has increased exponentially
• The media focus on “today’s medical research breakthrough”
• Increasing awareness and demands of patients and payers'
• Increasing demand for physician accountability
Evidence-based care
ØEvidence-based care refers to healthcare practices and interventions
that are supported by the best available evidence from well-designed
and conducted research studies.
ØThis approach emphasizes using scientific research, clinical expertise,
and patient preferences to inform decision-making in healthcare
delivery.
ØThe goal of evidence-based care is to provide patients with the most
effective treatments and interventions while minimizing harm and
unnecessary healthcare costs.
FACTS

vAbout 1/2 of ‘valid’evidence today is out of date in 5

years

vAbout 1/2 of valid evidence is notimplemented

Relationship between Clinical Medicine, Public
Health, EBM and Epidemiology…….

Medicine/Nursing
Public Health

EBM/EBP/C EPI

Health professionals with

MDs trained in EBM PhD, MS, or MPH
9
 Increased medical costs are…
• Driven primarily using new medical therapies and
technologies
• many of which are not proven to be better or more cost-
effective than existing treatments.

• Use of medical services is encouraged by the

• fee-for-service model (rewards providers for delivering
more care e.g., procedures and tests), and
• lack of incentives for consumers to lessen their demand
for services.

• Evidence that higher spending promotes better health

outcomes and/or higher quality care is slim to none.

10
 The importance of EBP in health system reform
• The development of a rational and sustainable health care system
will need to be based on the principles of EBP – including:

• Comparative effectiveness

• Costs and cost effectiveness

Ph ysi c i a n s n
eed t o
• Quantifying risks, and benefits u n derst a n d t
h ese
p ri n c i p l es
• Patient utilities and preferences

• Shared-decision making

• Performance measures

• Continuous quality improvement (CQI)

11
Misapprehensions & Misinterpretations about EBP

X1) Evidence-Based Practice ignores clinical

experience and clinical intuition.
X2) Understanding of basic investigation and
pathophysiology plays no part in evidence-based
Practice.
X3) Evidence-Based Practice ignores standard
aspects of clinical training such as the physical
examination.
EBM Principles/Steps
1. Construct a well-built/focused clinical question and classify it
into one category (therapy, diagnosis, etiology or prognosis)

2. Find/track the evidence in health care literature

3. Critically appraise or formally evaluate for validity, precision

and usefulness

4. Integrate the evidence with patient factors to carry out the

decision

5. Evaluate the whole process

Types of Questions
 (1) Background Questions
• Asked for general knowledge about a disorder/Condition

• Has two essentials' components:

• A question root ( who, what, where, how, why) + verb

eg. what causes...?

• A disorder/Condition;''HIV?”
Background...
• Textbooks answer background questions, they contain
collected & synthesized wisdom for topics that do not
change often.

• Not all topics are covered, easy to use, relatively

inexpensive and can be opinion-based rather than
evidence-based, written by experts in their fields.
 (2) Foreground Questions
u Asked for specific knowledge about managing
patients with a disorder
u It has 4 components (PICO (D) analysis):
P - Patient/Population
I - Intervention
C - Comparison
O - Outcome
• Basis of Evidence-based care involves the integration
of the best research evidence with clinical expertise
and patient values.
Best Clinical Evidence

Clinical Experience Patient’s Needs/

Preferences
 Foreground
Information
Background
Information
Novice Expert
Searcher Searcher
u At all stages you ask both kinds of questions,
but as experience increases the foreground
questions increase.
u It is essential that you understand the
background question before attempting to
answer the foreground ones.
PICO ANALYSIS
• Before attempting to search for
the evidence in the literature,
construct a well-built or clearly
structured question that could be
broken into the following four
parts
(1) Patient /Population

vWhat is the primary problem, disease or co-existing conditions?

vOn what groups do you want information?
vHow would you describe a group of patients similar to the one in
question?
vSometimes age or sex of a patient may be relevant and should
be included.
vExample: post-menopausal women with hypertension
 (2) Intervention
u What medical event do you want to study the effect of?

u Which main intervention are you considering, prescribing a

drug, ordering a test, ordering surgery?. . .

– Example: ERT
 (3) Comparison
u Compared to what?

u Better or worse than no intervention at all or than

another intervention?

u What is the main alternative to compare with the

intervention, are you trying to decide between two drugs,
a drug and a placebo, or two diagnostic tests?

u Sometimes there is no comparison.

- Example: no ERT
 (4) Outcome
u What is the effect of the intervention?

u What do you hope to accomplish, measure, improve, or

affect with this intervention?

u What are you trying to do for the patient, relieve or

eliminate the symptoms, reduce side effects, reduce cost? .. .

– Example: improve quality of life

What makes a clinical question well built?

• Question should be directly relevant to the problem

at hand.

• Question should be phrased to facilitate searching

for a precise answer.

• Asking a well-built question, like many clinical skills,

needs practice.
Categories of EBP Questions

• After constructing the PICO analysis, determine

the category of the question.

• There are the four categories of EBP questions

 1) Therapy

• Solves questions about which treatment to administer,

and what might be the outcome of different treatment
options.
• For most therapy questions one may want to look for
the best evidence namely a randomized controlled
study, and if the study can be a double blind, so much
the better.
- Example: find the evidence for the use of
anticoagulants in patients with atrial fibrillation
Therapy
When evaluating the literature to answer a therapy
question ask yourself:

• Was the study randomized and double blind to prevent

bias?
• Was follow-up > 80%?
• Were the groups similar at the start of the trial?
• Were all enrolled patients included in the conclusion of
the study?
• Was the study valid? did the authors answer the
question?
 2) Diagnosis
• Solves questions about degree to which a test is reliable and
clinically useful, to decide whether the patient would benefit
from it

• Most articles compare result of a certain diagnostic test with

that of a standard test regarded as being a "gold standard".

- Example: search for the best diagnostic test for COVID

 3) Etiology
• Solves problems about the relationship between a disease and
a possible cause

- Example: find out if a diet rich in saturated fats

increases the risk of heart disease, and if so by

how much
 4) Prognosis

• Answers questions about a patient's future health, life span and

quality of life in the event one chooses a particular treatment
option

- Example: find how would the quality-of-life change for a

patient who undergoes surgery for prostate cancer

The next step would be to determine the best study design needed
to answer the clinical question.
Types of Research Studies

• Certain study designs are superior to others when

answering questions.
• RCT are considered the best for addressing questions about
therapy.

• Etiology questions may be addressed by case-control &

cohort studies.

• Other aspects relevant to study design include placebo

comparison group and follow-up.
1) Randomized Controlled Trial (RCT)

• Answers therapy, prevention questions

• Randomization avoids selection bias
 2) Cohort study
• Answers prognosis, etiology, prevention questions
• Cohorts are defined populations that, as a whole, are followed in an
attempt to determine distinguishing subgroup characteristics.
• Researchers identify and compare two groups over a period of time.
 2) Cohort study

u At the start of the study, one of the

groups has a particular condition
or receives a particular treatment,
and the other does not.
u At the end of a certain amount of
time, researchers compare the two
groups to see how they did.
3) Case Control study
• Answers prognosis, etiology, prevention questions
• Identifies patients who already have the outcome of interest and
control patients without that outcome, and look back to see if they
had the exposure of interest or not.
4) Case series & Case Reports
• Answers prognosis, etiology, prevention questions

• Consist either of collections of reports on the

treatment of individual patients, or of reports on a
single patient.
Level Type of evidence

I Evidence obtained from at least one randomized

controlled trial or from meta-analysis of randomized
controlled trials

II Evidence obtained from at least one well-designed

controlled study without randomization

III Evidence obtained from well-designed non-

experimental descriptive studies, such as comparative
studies, correlation studies and case control studies

IV Evidence obtained from expert committee reports or

opinions and/or clinical experience of respected
authorities
Levels of Evidence
Depends on the Type of Research Methods Used
• Strong evidence from at least 1 systematic review of
multiple well-designed RCT.
• Strong evidence from at least 1 properly-designed
RCT of appropriate size.
• Evidence from well-designed trials without
randomization, or case-control studies.
• Evidence from well-designed non-experimental
studies from more than 1 center or research group.
• Opinions of respected authorities, based on clinical
evidence, descriptive studies or reports of expert
committees.
 The “best” evidence for therapy question

• This is found in double-blind randomized controlled trials

The “best” evidence for etiology question
u This is found in cohort studies.
 RCT

Cohort Studies

Case Control Studies

Case Series/Case Reports

Expert Opinion

Animal Research/ In Vitro Studies

Evidence Pyramid
–The base has the largest number of literature studies and
provides the least strength of evidence.
–If you do not find an upper level of evidence, go to the next
one.
–Remember that there may be no good evidence to support
clinical judgment.
The “best” evidence for diagnosis question

u This is found in controlled trials of prospective studies

that compare tests with a “gold standard” test

condition
present

patients Diagnostic
suspected of Test & Gold
disease Standard

condition
absent
The “best” evidence for prognosis question
u This is found in cohort or case control studies

Suffer
target
outcome

patients Prognostic time

Factors

Does not
Suffer
target
outcome
1 Research
Evidence

2
Clinical
Expertise

Patient
3 Preferences and
Value
Continuous
4 Quality
Improvement

5
Clinical
Guidelines

critical
6 appraisal
skills
ØThis involves using high-quality research studies, such
as randomized controlled trials (RCTs), systematic
reviews, and meta-analyses, to inform clinical decisions.

ØThese studies provide the strongest evidence for

evaluating the effectiveness of healthcare interventions.
ØHealthcare providers bring their clinical expertise and
experience to the decision-making process.

ØThey integrate research evidence with their knowledge

of the patient's unique circumstances, including medical
history, preferences, and values.
ØRecognizing that patients may have different priorities
and values, evidence-based care involves incorporating
patient preferences into treatment decisions.

ØThis ensures that care is patient-centered and aligns

with the individual's goals and values.
ØEvidence-based care emphasizes the importance of
ongoing evaluation and improvement of clinical
practices.
ØThis involves monitoring outcomes, analyzing data, and
adjusting interventions based on new evidence and
feedback from patients and healthcare providers.
ØClinical practice guidelines, developed by expert panels
based on the best available evidence, provide
recommendations for specific healthcare interventions.

ØThese guidelines help standardize care and promote

consistency in clinical practice.
ØHealthcare providers need critical appraisal skills to
assess the quality and relevance of research evidence.

ØThis involves critically evaluating study designs,

methodologies, and findings to determine the
trustworthiness and applicability of the evidence to
clinical practice.
ØOverall, evidence-based care aims to improve the
quality, safety, and effectiveness of healthcare by
integrating scientific evidence with clinical expertise
and patient preferences.

ØIt helps healthcare providers make informed decisions

and optimize outcomes for patients.
 Clinical problem

Develop answerable Expertise,

Decision making
questions Experience &
about diagnosis &
Pathophysiology
treatment

Search and obtain Critical appraisal of

relevant articles evidence
References

1. Guyatt, Gordon and Rennie, Drummond. Users’ Guide

to the Medical Literature: Essentials of Evidence Based
Clinical Practice American Medical Association 2002

2. Jekel, Katz, Elmore. Epidemiology, Biostatistics and

Preventive Medicine,

3. Second Edition, W. B.Saunders, 2001

 Evidence based Practice

Thank you