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
Formulate Clinical Questions
1. Search for Evidence
2. Appraisal of research
3. 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
evidence Expertise
 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
 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 Nov-
Dec;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

I Systematic Systematic Systematic

Review of Review of Review of

II Randomised Inception Cross

trial Cohort 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

5,000?
per day
Medical Articles Per Year

1,500
per day
95 per
day
 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