Evidence

Based Medicine:
The Know What, How and Where!
Prof. Mayyada Wazaify

Evidence-based clinical practice is the process of turning clinical problems into questions, followed by a systematic literature

References:
1. Dr Kerry Hempenstall, RMIT University
Our Text Book
Watch the video
 Hot topic!
• Evidence-based speech pathology
• Evidence-based occupational therapy
• Evidence-based psychology
• Evidence-based design
• Evidence Based Library and Information Practice
• Evidence-based management
• Evidence-based medicine
• Evidence-based nursing
• Evidence-based pharmacy
• Evidence-based education

Applies scientific research to patient care

(“bench to bedside”)
 “A 21st century clinician who
cannot critically read a study is
as unprepared as one who
cannot take a blood pressure
or examine the cardiovascular
system.”
BMJ 2008:337:704-705
 Folk beliefs, anecdotes, intuition

Snake oil is an expression that originally referred to fraudulent health products or unproven medicine but has come to refer to any product with questionable or unverifiable quality or benefit. By extension, a
Galileo's main pieces of evidence were the phases of Venus, the eclipses of Jupiter's moons, the existence of tides (which Ga
 Ignorance of science

Until recent times, research findings have had little impact on medical practice.
For example, in mid 19thC, Lister showed how bacterial infection occurred. No impact on surgical cleanliness for more than 50 years.
Up until 1950’s many surgeons routinely wiped their implements on any handy cloth
 Expert opinion

-9:
Ed.1955, 1956, 1958

is Beth
Baby and Child Care” has actually sold more that 50 million copies, only
outmatched in sales by the Bible

The sudden shift in favour of front sleeping is best illustrated by ‘Baby and Child Care’ by Dr Benjamin Spock who recommended the back position in his 1955 edition, and the front position in 1956.
 Front vs. back

Over four fold increase risk

of sudden infant death
syndrome

front vs. non-front

Ruth Gilbert et al. Int. J. Epidemiol. 2005;34:874-887

Doctor Spock‘s 1950’s advice to have infants sleep face down was associated with 60,000 deaths from SIDS between 1974 and 199

8395.64
Is,-;"99s
·-
 What is Evidence Based Medicine?
25's J,s
• “The conscientious, explicit and judicious use
of current best evidence in making decisions
about the care of individual patients.”
• The practice of evidence-based medicine
means integrating:
- individual clinical experience with
- the best available external clinical evidence
from systematic research
(Sackett et al, 1996)

The term "evidence based medicine" (no hyphen) was coined at mcmaster medical school in canada in the 1980's to label this clinical learning strategy, which people at the school had been developing for over

f individual clinical expertise with the best available clinical evidence from systematic research."
, 2000.

t useful findings in clinical practice.

1126
 Why Evidence Based Medicine?
• Fresh graduates: a lot of info- No Experience
• Experienced clinicians: Not always updated
• No time to keep pace? New developments?
• Huge number of medicines available
• Polypharmacy+ comorbidity
• Malpractice?

ً‫أوﻻ‬

ً ‫ﺛﺎﻧﯾﺎ‬

ً ‫ﺛﺎﻟﺛﺎ‬

ً ‫راﺑﻌﺎ‬

ً ‫ﺧﺎﻣﺳﺎ‬

ً ‫ﺳﺎدﺳﺎ‬

ً ‫ﺳﺎﺑﻌﺎ‬
 The Evidence-based Medicine Triad
Source: Florida State University, College of Medicine. Retrieved 08.06.2015.
 3

What is best external evidence?

Accessible information from research

Internal evidence is composed of knowledge acquired through formal education and training, general experience accumulated from daily practice, and specific experience gained from an individual clinicia

External evidence is accessible information from research.

 balhen from 10

- 20

control ofBinc
experimental 10
Design
->

Randomization.

Source: http://library.downstate.edu/EBM2/2100.htm

pregnancy category Difference Between

D
Or
1,B

->
ne

Anicdotal Report is observations t *

-
-
 case control to cohort. Studies:

- Difference is time frame

case
outcomely Riskfador (I & II asci e6 &
confro

cohort
5 s is 10-15Y, 99% s, 91s5 7
strig
lung cancer -,0919

so in cohortwe startw ith Risk factor and

jusually they are
longtudinal studies,
a
is cross
sectional)
 cohort video
cross sectional/case control - S

↳in case control we startwith outcome

-& J o-, then - ";02s Is
·
,887

-> could cohort & si Retrospective?!!

we start with Risk fador -
18 ess.
2001-2020 is10 11956)
·

0%, in ess
Difference Between Colors case control and
cross-sectional 8

Do IStartwith it or outcome
2) Time frame? Is
 Systematic Review Review:
0

&vosystem, 20. 11;, -, S

-

key words thatI wantto use, or where do Iwantto

search. (Pubmed or cocraines.

Systematic
* review
only Describing and symphesizing S

Concluding Butmetanalysis isstatistics.

Watch the video
 The 5 Step EBP Process
1. ASK: Formulate an
answerable clinical question

2. ACCESS: Track down the best

Ask
I
Evidence
-> online.
3. APPRAISE: Appraise the
evidence for its validity and
usefulness
Assess Access

Aquire
↳Sisstepwise
4. APPLY: Integrate the results
with your clinical expertise
and your patient values/local
conditions
Apply Appraise

365,8
5. ASSESS: Evaluate the
effectiveness of the process
 Step 1: ASK
Ask
a focused (answerable) clinical question

• Background questions (What do I know about this?)

• Foreground (Clinical) Questions

P = Patient, population or problem (Who are the patients or

populations? What is the disease?)
I = Intervention (What do you want to do with this patient
(e.g. treat, diagnose, observe)?
C = Comparison intervention (What is the alternative to the
intervention (e.g. placebo, different drug, nothing?)
O = Outcome (What are the relevant outcomes (e.g.
morbidity, mortality, death, complications)?

Good questions are the backbone of EBM practicing. It is important to use all parts of the question if possible when you are
Patient specific, real patient related outcomes

Background questions
About the disorder, test, treatment, etc.

Foreground questions
About patient care decisions and actions

2 components:
a. Root* + Verb: “What causes …”
b. Condition: “… Ebola?”

* Who, What, Where, When, Why, How

 Why should I use PICO?
• To help define problem and clarify it in your own mind
• To prepare for searching
• To ask patient centered questions. Treatment of
Pneumococcal Pneumonia SHOULD be different for
– Terminal Cancer Patient
– Elderly, Severely Demented Patient
– Young mother of 2 children
• Developing the question requires:
– Some background knowledge of the condition
– Understanding of the patient and what are the outcomes
and beliefs that matter to this patient
• Death? Disability? Quality of life? Cost? Improvement
of symptoms?
5i
8
 Patient presenting with MI
Foreground’ Questions

About actual patient care decisions and actions

For treatment
4 (or 3) components:

In Patients with a MI
Does (I) cholesterol lowering therapy
Compared to placebo
reduce mortality (O)
u

you 3 1 8;/-
i)
 Example 1

Jean is a 55 year old woman who quite often crosses the Atlantic to visit
her elderly mother. She tends to get swollen legs on these flights and is
worried about her risk of developing deep vein thrombosis (DVT),
because she has read quite a bit about this in the newspapers lately. She
asks you if she would wear elastic stockings on her next trip to reduce
her risk of this.

ES
In 5S Y old I
does wearing
Reduce Risk ofDVT
compared with not
wearing 3
 Example 2

VACCINATION AND NEEDLE LENGTH

You are the practice nurse and one of your colleagues tells you it is
better to use a short needle than a long needle when immunising
babies for their first ever vaccinations, as it reduces the swelling and
decreases the parents anxiety about further vaccinations. You
wonder if your colleague is correct?

In Babies ----
 One more Example

Susan is expecting her first baby in two months. She has

been reading about the potential benefits and harms of
giving newborn babies vitamin K injections. She is
alarmed by reports that vitamin K injections in newborn
babies may cause childhood leukaemia. She asks you if
this is true and, if so, what the risk for her baby will be.
 Step 1: PICO Approach to questions

Patient
Intervention
Comparison intervention
Outcomes
26

Well Designed Questions

P: Describe the patient. What are the most important characteristics of the patient?
I : Intervention. Which intervention, prognostic factor, or exposure are you considering?
C: Comparison. What is the main alternative to compare with the intervention?
O: Outcomes. What can you hope to accomplish, measure, improve or affect?
 PICO
Describe the patient. What are
P the most important In an elderly female with isolated
characteristics of the patient?
systolic hypertension …

Intervention. Which
I intervention, prognostic factor, Is the treatment with verapamil …
or exposure are you
considering?

Comparison. What is the main

C alternative to compare with
the intervention?
more beneficial than nifidepine
treatment…
Outcomes. What can you hope
O to accomplish, measure,
improve or affect?
at reducing morbidity or mortality?
27
 Step 2: Try to answer the
question “internal evidence”

Step 3: Search for external

evidence

28

Internal evidence is composed of knowledge acquired through formal education and training, general experience accumulated from daily practice, and specific experience gained from an individual clinician

External evidence is accessible information from research.

Where to search for evidence?

55s
 ~uptodate, Dynamed
->
Topics I
(guidlines)
-> for Journal articles About
specific topic B.,s inpubmed,

E
enbese?, Canal?, Ledarin?

201119s. 10 studies
↳ Conclusive

I
= -
for synthesis
 EBP Step 2: ACCESS
Access
Track Down the Best Evidence
1. Start “hunting” from the best resource: Match your question
to the best medical information resource for this question.

• Well designed Systematic Reviews¹ can be a great place

to start they contain commentary about validity

¹A systematic review involves the application of scientific

strategies, in ways that limit bias, to the assembly, critical
appraisal, and synthesis of all relevant studies that
address a specific clinical question.
Review Article &5-

·55. Why not get info only from textbooks

and review articles?
• Texts and review articles?
– Dated – perhaps by several years (Not updated
– Often biased
• Author chooses article that he/she agrees with (or has
written)
• Author chooses articles of his/her friends
• Author does not identify all the relevant literature
• Review’s methods are not explained
• These resources help with background knowledge (learn
about disease, treatment or test) not foreground (answer
the specific clinical question for this patient)
 Why not get info only from
guidelines?
• They can assure standards of care but:
– Can be biased
– May not always be developed by experienced
experts
– Are not always evidence-based
– Can work for most patients but not for all
– Can work in some circumstances but not in all
– Can be dated
– There may not be guidelines for everything
The term "evidence based medicine" (no hyphen) was coined at mcmaster medical school in canada in the 1980's to label this clinical learning strategy, which people at the school had been developing for over
 uptodate

~
-
- www.bestpractice.bmj.com

• Clinical Evidence is a monthly, updated directory of

evidence on the effects of common clinical interventions,
published by the British Medical Journal Publishing
Group.

• It provides a concise account of the current state of

knowledge, ignorance, and uncertainty about the
prevention and treatment of a wide range of clinical
conditions based on thorough searches of the literature.
• It summarizes the best available evidence, and where
there is no good evidence, it says so.

38
Important Summary of
all we said today!
 Filtered and Critically Appraised
Evidence-Based Resources
• The Cochrane Library by The Cochrane Collaboration -> summary of
all systematic
n
via Wiley like pubmed reviews and
– Independent non-for-profit international collaboration
metaanally sis
– Reviews are among the studies of highest scientific evidence
– Minimum Bias: Evidence is included/excluded on the basis of
explicit quality criteria
– Reviews involve exhaustive searches for all RCT, both
published and unpublished, on a particular topic
– Abstracts searchable for free on the Internet; complete
database is available via HINARI for most countries
– 1995

The Cochrane Library; and

 Original papers (for RCT)

The gold standard peer-reviewed journals are:

• BMJ
• The Lancet
• Annals of Internal Medicine
• Journal of the American Medical Association
• New England Journal of Medicine

45
 EBP Step 3: Appraise: Appraise
Determine if the results are valid and useful
• Appraisal principles (primary and secondary research)
– What is the PICO of the study? Does it match my
question?
– How well was the study done? Is it biased?
– What do the results mean? Are they real and
relevant?

• More: University of Oxford’s Center of EBM:

http://www.cebm.net/index.aspx?o=1157
• Tools for evaluating studies can be found in the Evaluating the
Evidence section in the EBM tutorial at:
http://www.hsl.unc.edu/Services/Tutorials/ebm/welcome.htm
 EBP Step 4: APPLY:
Apply
Integrate the results with your clinical
expertise and your patient values
• Question to ask:
– Is the intervention feasible in my settings?
– What alternatives are available?
– Is my patient so different then those in the study that the
results cannot apply ?
– Will the potential benefits outweigh the potential harms of
treatment ?
– What does my patient think? What are his cultural beliefs?
– Individual decision making/group decision making/choice
 EBP Step 5: ASSESS Assess
Evaluate the effectiveness of the process.
How am I doing?
• Am I asking questions?
• Am I writing down my information needs?
• What is my success rate in the EBM steps?
• How is my searching going? Am I becoming more
efficient?
• Am I periodically syncing (checking) my skills and
knowledge with new developments?
• Teach others EBP skills
• Keep a record of your questions
Brain Massage
 In case of conflicting internal and
external evidence, clinicians
have several options:
(1) They may change their mind and align it
with the external evidence.
(2) They may determine that the external
evidence is not sufficiently convincing and
remain with the original decision. Or,
(3) they may choose to discuss with the
patient the conflict between the internal and
external evidence in a manner that enables the
patient to take part in the decision making
process.

This last approach is recommended because patient preference is considered an essential part of the evidence-based decision making process and decisions often
need to be made in the absence of clear research findings.
 Take Home Message
• Learn basic skills of
EBM

• Always ASK and form

answerable questions!

• Remember the
evidence pyramid and
5 S’s
 References
1. Centre for Evidence Based Medicine, Oxford, UK. www.cebm.net

2. Cochrane AL. Effectiveness and Efficiency : Random Reflections on Health

Services. London: Nuffield Provincial Hospitals Trust, 1972. Reprinted in 1989
in association with the BMJ. Reprinted in 1999 for Nuffield Trust by the Royal
Society of Medicine Press, London, ISBN 1-85315-394-X.

3. Gray JAM. 1997. Evidence-based healthcare: how to make health policy and
management decisions. London: Churchill Livingstone.

4. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS.
1996. Evidence based medicine: what it is and what it isn't. BMJ 312: 71–2 [3]
[Full text]

5. Inari Research and Health. Evidence-based Practice Resources for

HINARI Users. (Module 7.2)
 Homework-1:
Safety of Cardioselective Beta-
Blockers in Patients with Reactive
Airway Disease

59
 Assess the Patient

Mr. Jones is a 55-year-old male with

hypertension, dyslipidemia, and asthma.
He has had a myocardial infarction in the
past with resultant mild congestive heart
failure. He notes unchanged use of his
beta-agonist inhaler once or twice per
month, and is not on any inhaled or oral
steroids. He is currently symptom free.

60

We begin by assessing our patient, in this case, Mr. Jones…

 Ask Clinical Questions

Patient/ Intervention/
Comparison Outcome
Population Exposure

Increase
In patients Does
morbidity
with asthma use of a Compared to
from reactive
& an indication cardioselective placebo
airway
for beta-blocker beta-blocker
disease?

61

al questions: Patient, Intervention or exposure, Comparison, and Outcome.

 Application

• Back to our patient…

Based on evidence from a recent meta-analysis
accessed through multiple different
methods:
• Mr. Jones meets inclusion criteria (mild asthma)
• It is safe to start Mr. Jones on a cardioselective
beta-blocker without fear of worsening his
asthma or response to inhaled beta-agonists.

62
 Summary of EBM Method
Assess Our patient with coronary disease would benefit from
patient a beta-blocker, however he also has asthma.

In patients with asthma & an indication for a beta-blocker,

Ask clinical does use of a cardioselective beta-blocker increase
questions morbidity from reactive airway disease?

Acquire the Medline, Cochrane Library, ACP Journal Club, and UpToDate
best evidence provided access to information from the same meta-analysis.

Appraise High quality data was found: meta-analysis of RCTs.

An appraisal of the meta-analysis
the evidence was available via ACP Journal Club and UpToDate.

Apply This data can be applied to our patient:

evidence to based on this evidence, it is safe to start our patient
patient care on a cardioselective beta-blocker
63
 Homework
• Ghost writer
• Self-Plagiarism
• Redundant publication
• Whistle blower
• Impact Factor
• Scopus Journal
• Q1-Q4
• Conflict of Interest
• Write about “A Famous Story of Plagiarism” in
Academia (1 page only, use references)