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Evidence Based

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?

-> PICO Table