EVIDENCE-BASED MEDICINE

THE INTEGRATION OF BEST RESEARCH EVIDENCE

WITH CLINICAL EXPERTISE AND PATIENT VALUES
GOAL: OPTIMIZES CLINICAL OUTCOMES AND
QUALITY OF LIFE

BEST RESEARCH EVIDENCE

Clinically relevant research
Patient centered clinical research
Diagnostic test with excellent accuracy
and precision
Powerful prognostic markers
Efficacious and safe therapeutic,
rehabilitative and preventive regimens
The new ones

Clinical expertise
Ability to use clinical skills and past
experience to rapidly identify each
patients unique health state and
diagnosis
To identify their individual risks and
benefits of potential interventions
To identify their personal values and
expectations

PATIENT VALUES
PATIENTS UNIQUE PREFERENCES,
CONCERNS AND EXPECTATIONS

MUST BE INTEGRATED INTO CLINICAL

DECISIONS

How do we practice ebm

Converting the need for
information into an answerable
question
Tracking down the best evidence
Critically appraising that
evidence for its validity and
applicability

How do we practice ebm

Integrating the critical appraisal
with our clinical expertise and
with our patients unique biology
values and circumstances
Evaluating our effectiveness and
efficiency in executing steps 1-4
and seeking ways to improve
them both for next time

WELL-BUILT CLINICAL QUESTIONS

BACKGROUND QUESTIONS
* Ask for general knowledge about a
disorder
**Have two essential components:
1. a question root with a verb
(who,what,where,when,how,why)
2. a disorder or an aspect of a disorder

When do complications of acute pancreatitis usually

occur?

WELL-BUILT CLINICAL QUESTIONS

FOREGROUND QUESTIONS
*

ASK FOR SPESIFIC KNOWLEDGE ABOUT MANAGING

PATIENTS WITH A DISORDER

**Have four (or three) components

1. patient and / or problem
2. intervention
3. comparison intervention (if relevant)
4. clinical outcomes
In older patients with heart failure, does adding digoxin to
standard diuretic and ACE inhibitor treatment yield enough
reduction in morbidity and/or mortality to be worth its side
effect ?

Central issues in clinical work where

clinical questions often arise

Clinical findings
Etiology
Clinical manifestations of disease
Differential diagnosis
Diagnostic tests
Prognosis
Therapy
Prevention
Experience and meaning
Self improvement

CLINICAL SCENARIO
A five week old baby boy has been
admitted with projectile vomiting.You
are unable to palpate a pyloric
tumour.You decide to admit the child
and observe him at least for the next
24 hours .However the parents are
keen to take their child home now.
Ultrasound of the pylorus: result neg.

CLINICAL QUESTION
IN INFANTS WITH PROJECTILE
VOMITING IN WHOM THERE IS NO
PALPABLE TUMOUR, DOES
ULTRASOUND AID IN DIAGNOSIS
(RULE IN OR OUT) OF PYLORIC
STENOSIS ?

READ AN ARTICLE AND DECIDE

ARE THE RESULTS OF THIS
DIANOSTIC ARTICLE VALID ?
ARE THE VALID RESULTS OF THIS
STUDY IMPORTANT ?
CAN YOU APPLY THIS VALID
IMORTANT EVIDENCE ABOUT A
DIAGNOSTIC TEST IN CARING FOR
YOUR PATIENTS ?

EVIDENCE BASED MEDICINE

A 27 WEEK GESTATION INFANT,BW 900 GRAMS
CRANIAL ULTRASOUND: BLOOD IN BOTH VENTRICLES ()
1 MONTH LATER: HEMORHAGE NEG. BUT THE LEFT LATERAL
VENTRICEL IS DILATED BEYOND THE 97TH CENTILE FOR
POSTCONCEPTUAL AGE
*THE INFANT REMAINS WELL/NO ABNORMAL NEUROLOGICAL
SYMPTOMS AND SIGNS
*PARENTS ASK: WHETHER THEIR CHILD WILL HAVE ANY
LONG TERM DISABILITY

EVIDENCE BASED
MEDICINE
FORMULATE THE QUESTION:

In a premature infant with very low birth weight

who is expected to survive, and who has posthemorrhagic Ventriculography, what is the risk
of future neurological disability?

EVIDENCE BASED
MEDICINE
PUBMED SEARCH :
Choose the right word
** INFANT, NEWBORN (MeSH)
** VENTRICULOGRAPHY (TEXT WORD)
** DISABILITY

EVIDENCE BASED
MEDICINE
PERFECT MATCH: RECENT, POPULATION-BASED
Aziz K, Vickar DB, Sauve RS, et al.
PROVINCE-BASED STUDY OF NEUROLOGIC
DISABILITY CHILDREN WEIGHING 500
THROUGH 1249 GRAM AT BIRTH IN RELATION TO
NEONATAL CEREBRAL ULTRASOUND FINDINGS.
PEDIATRICS 1995;95:837-844
MAKE A CRITICAL APPRAISAL OF PROGNOSIS

EVIDENCE BASED
MEDICINE
SUMMARY :
THE STUDY PATIENTS: PROVINCIAL COHORT OF
646 PRETERM INFANTS WITH BIRTH WEIGHTS
500 GM TO 1249 GM WHO SURVIVED BEYOND
THE FIRST YEAR OF AGE.
PROGNOSTIC FACTOR: CRANIAL ULTRASOUNDS
TO DETECT INTRAVENTRICULAR HEMORRHAGE
(IVH) OR CEREBRAL VENTRICULOMEGALY (CV)

EVIDENCE BASED
MEDICINE
SUMMARY :
FOLLOW UP ASSESSMENTS WERE PERFORMED
AT 2-3 YEARS OF AGE, INCLUDED PHYSICAL,
SENSORY AND PSYCHOLOGICAL ASSESSMENT.
THE OUTCOME:DISABILITY (WHICH INCLUDED
CP, VISUAL LOSS, MENTAL RETARDATION,EPI
LEPSY, AND NEUROSENSORY HEARING LOSS.

EVIDENCE BASED
MEDICINE
SUMMARY :
**
**
**
**
**

WELL DEFINED SAMPLE

AT UNIFORM STAGE OF ILLNESS
FOLLOW UP SUFFICIENTLY LONG AND COMPLETE
OBJECTIVE OUTCOME CRITERIA (BLINDED ??)
NO ADJUSTMENT FOR OTHER PROGNOSTIC
FACTORS
** NO VALIDATION IN AN INDEPENDENT TEST
SET OF PATIENTS

PLEASE READ OTHER SOURCES FOR YOUR SELF !