Evidence Based

Medicine Wrap-up
Dr Meirion Evans
Dr Bethan Stephens
Wrap-up session outline
• EBM overview
• Q&A session for the panel
• Single Best Answer questions
• EBM Week evaluation
EBM Week

Evidence based medicine is the conscientious,

explicit, and judicious use of current best
evidence in making decisions about the care of
individual patients.

• Highlighted why EBM is important

• Provided the platform to enable you to
effectively practice EBM
EBM - the five steps
Ask - frame your clinical question
Access - find the ‘best evidence’
• Where is the best place to look?
• Levels of evidence
• what type of study would give you the best evidence?
• Secondary sources
• any quality secondary sources?
• Systematic reviews
• is there a systematic review?
• Bibliographic databases
Appraise - critically appraise the evidence
• Examine research to judge its trustworthiness,
value, and relevance:

• correct study design for question

• randomisation process
• bias
• confounding
• statistical significance vs. clinical significance
• surrogate outcomes
Apply - integrate best evidence into practice
• How similar is my patient to study population?

• Is the treatment feasible in my clinical practice?

• What alternatives are available?
• What are the harms and benefits?
• What is my patient’s preference?
Assess - evaluate the outcome
• Was the evidence you found of suitable quality?

• How practical and useful was the investigation or

treatment?
• What clinical difference did it make?
• What did the patient feel about the treatment?
The EBM triad
Quantitative or Qualitative?
How
Why?
much?

• studies using detailed observation or interview

• fill the gaps in knowledge that numbers cannot answer
• shed light on beliefs, thoughts, and motivations

• why do parents worry so much about fever in children?

• why do men want a PSA test?
The Panel
The Panel Experts
• Bethan Stephens (chair)

• Ben Carter
• Naomi Stanton
• Meirion Evans
Panel Questions
Single Best Answer
Question 1
You are participating in a multi-centre randomised
controlled trial and are trying to persuade your
colleagues to help with patient recruitment. Some
of them are sceptical about the ethics of
randomisation.

What is the main aim of randomisation?

What is the main aim of randomisation?

a. Increase the external

validity of the results
b. Reduce bias
c. Reduce confounding
d. Reduce cost
e. Reduce the number 0% 0% 0% 0% 0%

of patients lost to

as

st
g
.

..
in
i..

co
bi

a.
nd
l
va

fp
ce
follow-up uc

ou

du
al

ro
d

nf
rn

Re

Re

be
co
te

um
ex

ce

en
du
he

Re
et

th
as

ce
re

du
c

Re
In
Answer 1
• Reduce Confounding

• A confounder is another variable, apart from the one we

are studying, which is related to both the outcome and
exposure.
• Randomisation ensures that any patient characteristics
that may affect the outcome are distributed evenly
between the groups.
• This means that any observed differences between the
groups are due to the intervention and not to any
confounding variables.
Question 2
• A 27 year-old woman who has migraine comes to see
you. Her father also has migraine but less frequently.
She asks if there is any difference in the frequency of
migraines between men and women.
• You find a cross-sectional study in which 200 people
were asked about migraine attacks over the previous
three months.
• Out of 100 women, 20 reported having a migraine
compared to 10 men out of 100.

• The relative risk of a woman having a migraine

headache compared to men is ...
The relative risk of a woman having a migraine
headache compared to men is ...
a. 0.44
b. 0.5
c. 2.0
d. 2.25
e. 20

0% 0% 0% 0% 0%
44

25

20
5

2
0.
0.

2.
Answer 2
• 2.0

• Risk in women = 20/100 = 20%

• Risk in men = 10/100 = 10%
• Relative risk = 20/10 = 2.0
Question 3
• During a baby clinic, one of the mothers asks you
whether boys are more liable than girls to suffer
from asthma.
• You decide to search the medical literature in
order to find out.

• Which type of epidemiological study is the best

for answering this question?
Which type of epidemiological study is the best
for answering this question?
a. Case-control study
b. Cohort study
c. Cross-sectional study
d. Ecological study
e. Randomised
controlled trial 0% 0% 0% 0% 0%

dy
dy

dy

al
ud

tri
tu
tu

tu
st

ls
ls

ls

d
rt

lle
na
tro

ic a
ho

ro
tio

og
n

Co

nt
co

ec

ol

co
e-

Ec
s-s
s

d
Ca

os

ise
Cr

om
nd
Ra
Answer 3
• Cross sectional study

• This is a question about the frequency

(prevalence) of a chronic disease.
• A cross-sectional study, e.g. a survey of
schoolchildren, is the most straightforward way
to answer the question.
Question 4
• A 56-year-old woman is seen in urology clinic
with recurrent urinary tract infections.
• Afterwards the consultant shows you a
retrospective cohort study of 8,020 people
showing that individuals with a history of
recurrent urinary tract infection had a
significantly elevated risk of bladder cancer,
relative risk (RR) = 2.0.

• What can you conclude from this?

What can you conclude from this?
a. individuals who have recurrent urinary tract infections
have a high probability of developing bladder cancer
b. it is unlikely that this is a chance finding as the relative
risk is much higher than 1
c. the incidence of bladder cancer is very high amongst
those with recurrent urinary tract infections
d. the large number of individuals involved guarantees
that the results will be statistically significant
e. those individuals with recurrent urinary tract infections
are twice as likely to develop bladder cancer as those
without recurrent urinary tract infections
Question 4
a. High probability
b. Unlikely chance as
RR>1
c. Incidence very high in
recurrent UTI
0% 0% 0% 0% 0%
d. Large no. guarantees
significance

>1

y
y

...

el
ilit

...

ign
RR

lik
re
b
ba

ss
as

2x
in
o

ee
e

TI
h
pr

nc

nt
g

tU
e. Recurrent UTI 2x likely
hi
h

a
g

ch

en
ar
ry
Hi

gu
ve
y

rr
el

cu
no
e
ik

nc

Re
l
Un

e
e

rg
id

La
c
In
Answer 4
• Those individuals with recurrent urinary tract
infections are twice as likely to develop bladder
cancer as those without recurrent urinary tract
infections

• The RR=2.0 shows that individuals who have had

recurrent urinary tract infection are twice as
likely as those who have not to develop bladder
cancer
Question 5
• A 64-year-old man has recently had a myocardial
infarction and is offered home cardiac
rehabilitation. He asks you if home cardiac
rehabilitation is better than centre-based
rehabilitation.
• A meta-analysis of home versus centred-based
cardiac rehabilitation shows significant
heterogeneity between studies included.

• To what does the term heterogeneity regarding

a synthesis of studies in a meta-analysis refer?
To what does the term heterogeneity regarding
a synthesis of studies in a meta-analysis refer?
a. a mixture of observational and interventional
studies
b. a mixture of statistically significant and
statistically non-significant results
c. statistical associations between the studies
d. study results which are more different from
each other than would be expected by chance
e. study results which are very similar to each
other
To what does the term heterogeneity regarding
a synthesis of studies in a meta-analysis refer?
A. Mix of observational
and interventional
B. Mix of significant and
non significant results
C. Statistical associations
D. Results more different
0% 0% 0% 0% 0%
than by chance
E. Study results very

r
s

il a
n
...

...

.
h.
tio

im
no
nd

t
c ia

nt

s
la

nd

ry
similar

re
so
na

ta

ve
ffe
as
tio

lt s
di
ca

l
ca
va

u
e
ifi

sti

es
or
er

ign

yr
ati

m
bs

fs
fo

ud
ts
St
o

ul
o

St
ix

s
ix

Re
M
M
Answer 5
• Study results which are more different from each
other than would be expected by chance

• When undertaking a meta-analysis the studies

should be as similar as possible. When this ideal
is not met it is called study heterogeneity
• Individual estimates of treatment effects will
vary. Where this is more than would be
expected by chance this is heterogeneity.
Evaluation
The EBM week met its learning
outcomes
a. Strongly agree
b. Agree
c. Neither agree nor
disagree
d. Disagree
e. Strongly disagree 0% 0% 0% 0% 0%

ee
e

er

ee
e

re
re

ith

gr

gr
Ag
ag

sa

sa
Ne

Di
ly

di
ng

ly
ro

ng
St

ro
St
The plenaries were useful

a. Strongly agree
b. Agree
c. Neither agree nor
disagree
d. Disagree
e. Strongly disagree 0% 0% 0% 0% 0%

ee
e

er

ee
e

re
re

ith

gr

gr
Ag
ag

sa

sa
Ne

Di
ly

di
ng

ly
ro

ng
St

ro
St
The tutorials were useful

a. Strongly agree
b. Agree
c. Neither agree nor
disagree
d. Disagree
e. Strongly disagree 0% 0% 0% 0% 0%

ee
e

er

ee
e

re
re

ith

gr

gr
Ag
ag

sa

sa
Ne

Di
ly

di
ng

ly
ro

ng
St

ro
St
Did you attempt any of the SDL
exercises?
a. Yes, individually
b. Yes, as a group
c. No, didn’t have
time
d. No, couldn’t be
bothered
0% 0% 0% 0% 0%
e. No, couldn’t
d

ss
p

d
access them
ivi

ou

tim

re

ce
d

he
gr

ac
in

No

ot
s,

No
s,

Ye

tb
Ye

No
I enjoyed the EBM week!

a. Strongly agree
b. Agree
c. Neither agree nor
disagree
d. Disagree
e. Strongly disagree 0% 0% 0% 0% 0%

ee
e

er

ee
e

re
re

ith

gr

gr
Ag
ag

sa

sa
Ne

Di
ly

di
ng

ly
ro

ng
St

ro
St