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Evidence Based Medicine. Dr. Bonagua 1.18.

2011
Intro:
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Clinicians deal with unavoidable uncertainty, arising from a


number of sources, every time they make decisions about
diagnosis, therapy or prognosis
Lab medicine plays a central role in managing theis day to
day uncertainty
Lab tests and imaging studies help the clinician determine
the cause and severity of illness, predict its clinical course
and eval the patients response to therapy
Like all other aspects of medicine, lab tests also retain
intrinsic elements of uncertainty
Lab tests are prone to systematic and random error, both
in the conduct of the test and analysis of the results
Evindece based med is a way to quantify and manage med
uncertainty
EBM both demands ...
Requires to question the reliance of noncontrolled
observations and experience and even experts opinions,
and rejects practice standards based on dogma or
unquestioned intuition
Requires practitioners to be aware of how susceptible any
source of info is to random and systematic error
EBM calls for practitioner to thoroughly search the peer
reviewed literature that reports scientific studies, critically
eval these reports for validity and importance, and convert
the data they report into probabilitie that can help
clinicians and patients reduce the uncertainty that
surrounds decisions about diagnosis
Purpose: alert clinicians to important advances in internal
med, gen and family practice, surgery, psych, pedia, and
OB by selecting from biomedical literature those original
and review articles whose results are most likely to be
both true and useful
Thse articles are summarized in value added abstracts and
commented on by linical experts, the author of the original
article is...

Procedures:
-

Detecting, using prestated criteria, the best original and


review articles on the cause, course, dx, prevention, tx,
quality of care, or economics of dso in the foregoing fields
Introducing these articles with declarative titles and
summarizing the accurately in structured abstracts that
describe their objectives, methods, results, and
conclusions
Adding brief highly expert commentaries...
Disseminated to general public

Increasing med knowledge


-

27kg of guidelines
3000 new papers per day
Medline 1000
RCTs 46

How much do we read in clinical practice


-

hour or less a week: 3%


1 hour: 46%
1 hours: 23%
2 hours: 20%
3 hours or more: 8%

Where do we get knowledge

Print source
General specialty
books
Pharmaceutical
textbooks
Journals
Drug company info
Self made compendia
Human sources

Reported
62
25

Observed
27
3

14

18
1
4
33

7
1
7
53

Educational strategy
-

Talks by experts not GPs


Subjects are chose n by others
Usually relate to secondary care
Often about topics we feel comfortable with
Usually large lectures
Very little follow up

How many do we see


-

100-200 consultaions a week


5k 10k a yaer
It is difficult to be sure that one is doing the right thing for
all these cases
One relies on experience
Use 2 m pieces of info stored in your memory

Arent we doing okay anyway?


-

In 1994, 17% of family practitioners thorught that aspirin


had no effect on the survivial of patients having MI
Variation in prescribing, diagnostic tests, supervision of
chronic conditions

Why EBM?
-

Too many patients


Too many problems
Too many journals
Information overload
No time to read
Read waht i am familiar with
Avoid difficult issues

Ocntents
-

Why EBM?

EBM: looked upon as a new paradigm, replacing the traditional


medical paradigm...
US preventive task force:
-

De-emphasizes intuition, unsystematic clinical experience


and pathophysiologivc rationale as sufficient grounds for
decision makin...
Requires new skills fo the pjhysician, including efficient
literature searching, and the application of formal rules of
evidence in evaluating the clinical literature
Dependent of the use of randomized controlled trials, as
well as systematic reviews of a series of trials and emta
analysis although it is not restricted to these
Emphasis on dissemination of info, as well as its collection,
so that the evidence can reach clinical practice
An approach to practicing in which the clinicialn is aware
of the evidence in support of clinical practice and the
strength of that evidence- the conscientious, explicitand
judicious use of current...

EBM is not cost-cutting:


-

When directed towards the benefits of individual patients,


EBM identifies and...
Process involves
o Converting info needs into focused questions
o Critically appraising the evidence for validity adn
clinical usefulness
o Applying the results in clinical practicw
o Evaluating the performance of the evidence in
clinical application
EBM is not cook-book medicine
- requires that the best external evidence be integrated
External evidence can inform, but can never replace
indivicual cinical expertise

A: good scientific evidence benefits outweigh potential risks


B: at elast fair scientific evidence
D: at elast fair scientific evidence suggest s that the risk of th clinical
service outweigh potential benefits. Clinicians should not routinely
offer the serivde to asymptoati patients
Keeping skills up to date:
-

Practice:
- when caring
-

Invitro test tube research -> animal research -> idesas, editorial, ->
case erports, -> case series -> randomized clinical trials

Grades of recommendation

A: consistent level 1 studies


o Consistent randomised controlled clinical trial,
sohort study all or none, clinical decision rule
validated in diff pop
B: consistent level 2 or 3 studies
o Consistent retrospective cohort, exploratory
cohort, ecological study, outcome research ,dase
control study, or extrapolations from elvel A
studies
C: case series or extrapolations from levelB

Grade working group


-

Takes in account more tahn one dimensions


Despite the diff between systems, the purposes are the
same: to guide users of clinical reaserch...

Translation to an answerable question


Efficient track dwon of...
Critical appraisal of the evidence for its validity and clinical
applicability
Application of the results of the critical appraisal in clinical
practice
Evaluation of ones performance

Misapprehensions about EBM:


-

In the years after you graduate:


o Your memory of what you learned will lose its
freshmness
o New treatment methods will be found that the
never taught you in schoolbecause they didnt
exist
If you are to remain a good doc, you need to stay on top of
new developments a sthey occur
EBM provides you with the tools you need to find
important inew medical research quickly and easily and to
work out its implications for your practice

Ebm ignores clinical experience and training


How to practice evidence based medicine, dr. Must do the
ff steps:
Frame a clinical ques that can be informed by evidence
Throroughly effectively and efficiently search the peer
reviewed lit to find studies that pertain

Asking focused ques


-

Asking well built clinical questions


Must be precise and relevant

**notes not complete ang bilis magflash ng slides ni doc ling.


Methods of evidenced based medicine
Evidenced based decision making
Purpose of evidence based decision making

Decision making is a term applied


****putang ina ang bilis mag flash!!!!!
Searching literature

These topics are very important in using EBM


-

Broadly defined as methods in medical decision makin or


analysis
Applications of probabilistic and stat principles...

Need for users guide serie;


-

Individual patient and research: principal surces


Info about individual patient is elicited though careful hx,
PE and other investigations
Ways in which clinicians...: scientific research

Attribute
Validity

Quality
Can i trust this info

Lcinicla importance

If true, will the use...

Format
Is there a high
density of valid info

Fpr reasons of both logic and efficiency, we have sought uniformity


in presentation:
1.

Are the results ...

Tracking down articles:


-

Ask someone
Check ref list in tect book
Bibliography

Primary studies:
-

Therapy
o Was the assignment of patients wto tx
randomized
Dx:
o Was there an independent blind comparison
with a ref standard?
o Did the patient sample include an appropriate
spectrum of the sort
Harm
o Were there clearly identified comparison groups
Prognosis
o Representative patient sample and follow up

Integrativce:
-

Overvies:
o Did the review address a clearly focused queston
Decision analysis
Practice guidelines: flowchart

Framing the clinical question


-

Define patient populations


Address clinically salient issue

Use probability regarding usefulness

Appraising the quality of...


Validity: has sensibily defined a normal result. Determine dthe
reproducibility