EBM Introduction and Basics

EVIDENCE-
BASED
MEDICINE
LECTURE
DR. ROPHEKA L. FLORO
THIRD YEAR RESIDENT
DEPARTMENT OF FAMILY AND COMMUNITY
MEDICINE
Developing Clinical Questions
Introductory Case:
• A 45-year-old male with hypertension presents to your clinic for follow
up. At a prior visit he was screened for diabetes.
• His hemoglobin A1C has been 7.0% on two occasions, which is a new
diagnosis of diabetes.
• His blood pressure is well controlled at 125/80.
• He has no evidence of microalbuminuria or kidney disease.
• You recall from medical school that ACEi are good for preventing
diabetic kidney disease, but you’re not sure if this fact applies to this
patient.
• You want to find this answer.

• This module will walk you through the process of developing a clinical question!
By the end of this session,
you will be able to:
• Explain the difference between
• Background and foreground questions
• Differentiate between
• Patient-oriented evidence and disease-oriented
evidence
• Identify foreground questions and then apply
the PICO format to create searchable clinical
queries
• Population, Intervention/Comparison, Outcome
So, how do I develop a clinical
question?
• Two types of questions:
• 1- Background Questions
• 2- Foreground Questions
Background
• Background questions ask “who, what, Questions
where, when, why, or how” about a single
disease , drug, intervention, or concept.
• Think of these as basic questions you EBM

Basic Clinical
Background
might find from a textbook or a general
EBM resource
• Eg, prevalence, ddx, pathophys,
sensitivity/specificity of a test, med
dosing/adverse reactions
Intro case:
Background Question Brainstorming
• What are some background • Some possibilities/suggestions:
questions that you can • For diabetic kidney disease:
• What is the mechanism?
think of related to our
• What is the pathology?
gentleman with diabetes
• How does an ACEi work
and HTN, related to the use • to lower BP?
of an ACE inhibitor? • to reduce diabetic nephropathy?
• Who • What dose of an ACEi do I prescribe?
• What Background • What labs should I check for
Questions
someone on an ACEi?
• Where • Potassium? Creatinine?
• When EBM
• How often?
• Why
Basic Clinical
Background • What are the side effects of using an
ACEi in patients with high blood
• How pressure?
question?
• Two types of questions:
• 1- Background Questions
• 2- Foreground questions:
Foreground
Questions
• Foreground questions ask for specific
knowledge to inform a clinical issue on a
specific patient, intervention,or therapy.
• If based on expert opinion or best practices, General
Resources Research
they are guidelines. Studies
• If based on EBM, they typically eg, Guidelines
compare two things (or against placebo) in a
research study:
• Diagnostic tests
• Drugs
• Treatments
Information Mastery Resources, by Type:
Background Foreground
Questions Questions
General
EBM Resources Research
Basic Clinical
Background Studies
eg, Guidelines
To develop a searchable
“Medical Student “Resident Questions” clinical query,
Questions” eg, appropriate steps in you need to formulate
eg, etiology, pathophys, workup and management a foreground question
pharmacology in the PICO format
(Based on BU and Dartmouth models)

Information Mastery Resources
Background Foreground
Questions Questions
• PubMed Clinical
Queries
• TRIP Database
General Research • Google Scholar
Clinical
Resources Studies
• Google “site:.gov”
EBM Case-control Randomized Critically-

Basic Case-series Systematic
Backgroun Guidelines Controlled Appraised
Clinical Cohort Reviews
d studies Trials Topics
• Medscape Evidence-
Structured
• eMedicine Based
Abstracts
• Summaries
Epocrates
• Lexicomp
• ACP Journal • DynaMed • Cochrane

• JAMA Rational Clinical • Guideline.gov
Examination • USPSTF/AHRQ Club • Essential Evidence Plus Library
• Symptom to Diagnosis • Institute for Clinical • BMJ EBM • Bandolier
• EE+ Calculators Systems Improvement Online • BMJ Clinical Evidence
• NICE-UK • Journal Watch
(Based on BU and Dartmouth models)
The PICO Question Components
• Problem and Population
• What is the disease or condition?
P • What are the important characteristics of my
patient?
• Intervention
• What is the intervention I am looking for?
• Is it realistic (availability, cost, convenience, etc)?
I C • Is this different from how I currently practice?
• Comparison
• What is the alternative to the intervention?
• Outcome
O • Is it something patients care about?
• Or is it something only physiologists/pharmacists
care about?
(Jackson, 2006; Flaherty, 2004)
question?
Focusing the PICO question
• Population
• Starting with your patient, ask "How would I describe a group of
patients similar to mine?"
• Be precise but brief.
• Intervention/Comparison
• Ask “What is the main intervention I am considering?”
• and “What is the main comparison/control?”
• Be specific, but consider feasible alternatives.
• Outcomes
• Ask "What can I hope to accomplish?" or "What could this exposure
really affect?“
• Select patient-oriented outcomes instead of “the numbers.”
(University of Oxford EBM Tools, 2013)
Intro Case:
Foreground PICO Question Brainstorming
• Problem/Population
• “In adult patients with diabetes mellitus II and
P hypertension”
• Intervention
• “Does an ACEi”
• Comparison
I C • “Compared to placebo” or “BB/CCB/diuretic/etc.”
• Outcome
• “Prevent development of microalbumuria?”
OR
• “Prevent worsening of eGFR?”
O
Are these outcomes
our patient cares about?
APPRAISING AN
ARTICLE ON
THERAPEUTICS
EXERCISE
• 47 year-old female
• Post-menopausal
• Chest pain on exertion,
on and off for 7 months
• Elevated total cholesterol
FORMULATE A FOCUSED
QUESTION
P – patients with elevated cholesterol
I – antihyperlipidemics
O – coronary event/death prevention
M – randomized controlled trial

THE QUESTION CAN BE REVISED
AS FOLLOWS
Among patients with elevated cholesterol,

what is the efficacy of antihyperlipidemics in
preventing coronary event or death in a
randomized controlled trial?
IDENTIFY KEY CONCEPTS IN THE
QUESTION PHRASED
Among patients with elevated cholesterol,
what is the efficacy of antihyperlipidemics
in preventing coronary event or death
in a randomized controlled trial?

JOURNAL REPORT
• Case Scenario
• Research Question
• Search
• Title
• Source
• Authors
• Appraisal
THERAPEUTICS
RELEVANCE
IS THE OBJECTIVE OF THE ARTICLE
COMPARING THERAPEUTIC
INTERVENTIONS SIMILAR TO YOUR
CLINICAL DILEMMA?
Ascertain the objective of the study before going any further
a. Population of the study - similar characteristics to your patient
b. Intervention and comparative interventions - includes

therapeutic intervention you want to test
c. Outcome of the study – one of the outcomes measured should

be the goal you and your patient wish for
THERAPEUTICS
IS IT VALID?
WAS THE ASSIGNMENT TO THE DIFFERENT

TREATMENT GROUPS RANDOMIZED?
- look at the methods section of the abstract or full text
- Randomization ensures that selection bias will be
avoided.
- Randomization controls both known and unknown
factors that affect treatment and hopefully equalizes
these factors across the interventions being compared.
THERAPEUTICS
IS IT VALID?
WAS FOLLOW-UP COMPLETE?
• Look at the number of patients enrolled at the outset
and compare this with the number of patients reported
in the results table
• A drop-out rate of 20% or more is usually declared

substantial
• Check whether an intention to treat analysis was done

or if an explanation was made why drop-outs occurred
THERAPEUTICS
IS IT VALID?
WERE PATIENTS ANALYZED IN THE
GROUPS TO WHICH THEY WERE
RANDOMIZED?
- Refer to the methods section again. In this case, the
investigator reported how outcomes were measured
- Description of outcome measurements is important if
the study is to be replicated and to determine if these
are the outcomes you and your patient are aiming for.
- Laboratory markers as surrogate markers, will they
translate into clinically important endpoints such as
morbidity and mortality?
THERAPEUTICS
IS IT VALID?
WAS THE STUDY BLINDED?
- Again to answer, look into the methods section

- Blinding eliminates the possibility of observer and reporter bias
because treatment assignments are not known to certain persons
- 2 types of blinding:
a. Single – treatment not known to patients
b. Double – treatment not known to patients and physicians
c. Triple – treatment not known to patients, physicians, and
statisticians / analysts
THERAPEUTICS
IS IT VALID?
OVER-ALL IS THE STUDY VALID?
Ideally to state that the study is valid, we want a YES

answer to all questions.
However, that is too strict especially if studies are limited,

so a YES answer to the FIRST TWO questions will
ascertain the validity of the study.
THERAPEUTICS
WHAT ARE THE RESULTS?
HOW LARGE WAS THE TREATMENT

EFFECT?
- Look at outcomes reported in means or percentages OR compute
for the:
a.Risk in Treatment (Rt)– number of patients who did not get well in
the treatment group
b.Risk in Control (Rc) – number of patients who did not get well in
the control group
c. Relative Risk (RR) = Rt / Rc
d.Relative Risk Reduction (RRR) = (1-RR) x 100%

RELATIVE RISK – measures impact of treatment
RR = 1, no difference between treatment and control
RR>1, treatment more harmful
RR<1, treatment is more effective
RELATIVE RISK REDUCTION – also measures impact

expressed as percent
- a positive value is the percent by which treatment will reduce the
risk of a negative outcome for the patient. The greater the RRR,
the effective the treatment.
THERAPEUTICS
WHAT ARE THE RESULTS?
HOW PRECISE WAS THE ESTIMATE OF
TREATMENT EFFECT?
Reliability is measured by the p-value or the 95%
confidence interval.
- A p-value of 0.05 means that only 5% of the results is
due to chance and the rest is actually due to the
interventions being tested.
- As for the 95% CI, the narrower it is, the more reliable
the study.
THERAPEUTICS
IS IT APPLICABLE?
ARE THE MEDICAL, SOCIAL, AND

ECONOMIC RESOURCES NEEDED TO
ADMINISTER THE TREATMENT
AVAILABLE IN YOUR SETTING?
- Compare the study population and your own patient

- Treatment should be available, affordable and
accessible in Philippine setting.
THERAPEUTICS
IS IT APPLICABLE?
IN YOUR PERCEPTION, WERE THE TREATMENT
AND ITS OUTCOMES AS MEASURED IN THE
ARTICLE PREFERRED BY THE PATIENT AND
FAMILY?
-Think beyond the scientific rigor of the article and consider

treatment and outcome measures in terms of the patient and his
family’s values and wishes.
-It is useless to insist on a treatment which is not in consonance with

the patient and family’s culturally acceptable beliefs.
THERAPEUTICS
IS IT APPLICABLE?
DO YOU THINK THAT THE PATIENT, FAMILY AND/OR COMMUNITY
WILL BE WILLING TO ACCEPT AND PAY FOR THE TREATMENT
IN QUESTION?
Financial capacity in the realm of patient’s capability is an important aspect in
prescribing treatment options
Number Needed to Treat (NNT) = 1 / ARR
Absolute Risk Reduction (ARR) = Rc – Rt
Cost Effectiveness = NNT x cost of the drug x duration of treatment

RESOLUTION OF THE THERAPEUTIC
DILEMMA
Apply the information to your patients and their families

once you have concluded that the article is relevant, valid
and very much applicable.
Monitor patient’s progress to check whether this would be

an effective intervention
APPRAISING AN
ARTICLE ON
DIAGNOSTICS
Department of Family and Community Medicine
Ropheka Floro RN MD
Third year Resident
EVIDENCE-BASED
MEDICINE
DIAGNOSTICS
DR. ROPHEKA L. FLORO
First year resident
May 9, 2018 Department of Family and Community Medicine

Objectives
To appraise and determine the relevance

and validity of an article on diagnostics.
Date Your Footer Here 34

CLINICAL SCENARIO

Date
RESEARCH QUESTION
P Asian patients with right lower quadrant pain
I RIPASA score
C Histopathology
O Diagnosis of Appendicitis
M Cross-sectional Study

RESEARCH QUESTION
Among Asian patients with right lower quadrant

pain, what is the relevance of the RIPASA score
in diagnosing Appendicitis in a cross-sectional
study?

The search process

The search process

The search process

The search process

The search process

The search process

The search process

The search process
• sci-hub.hk

The search process

CRITICAL
APPRAISAL
Date Your Footer Here

DIAGNOSTICS
IS IT RELEVANT?
WAS THE OBJECTIVE OF THE PAPER
RELEVANT TO YOUR CLINICAL
QUESTION?
- We can only ensure that the results of the article are
applied to practice if the objectives of the article are
relevant to the clinical problems we often see in family
practice
RELEVANCE
• IS THE OBJECTIVE OF THE STUDY

RELEVANT TO YOUR CLINICAL QUESTION?
YES.

RESEARCH QUESTION
P Adult Asian patients with

right lower quadrant pain
Adult Asian Population
(>=18yrs)
Abdominal Pain
I RIPASA score
RIPASA score
Alvarado score
Multi-slice CT Scan
C Histopathology Histopathology
O Diagnosis of Appendicitis Diagnosis of Appendicitis
M Cross-sectional Study
Your Footer Here
Retrospective Cohort Study
Date 53
DIAGNOSTICS
IS IT VALID?
WAS A REPRESENTATIVE SAMPLE OF

SUBJECTS TO WHOM THE DIAGNOSTIC TEST
IS SUPPOSED TO BE ADMINISTERED
GATHERED?
- Full spectrum of patients: healthy, very sick, and in between
- the accuracy of the diagnostic test among patients with low risk for the
disease is different from patients with high risk of the disease.
- Look at: inclusion and exclusion criteria of the study, the demographic
and clinical characteristics of the patients usually seen in the first
section of the results.
VALIDITY
• DID THE PATIENT SAMPLE INCLUDE AN

APPROPRIATE SPECTRUM OF PATIENTS TO
WHOM THE TEST WILL BE USED?

DIAGNOSTICS
IS IT VALID?
WAS THE DIAGNOSTIC TEST AND REFERENCE

STANDARD DESCRIBED IN DETAIL TO PERMIT
RELIABLE REPLICATION?
The author should describe in detail issues that are important in:
a. Patient preparation – diet, drugs to be avoided, precautions after the test
b. Performance of the test – technique, possibility of pain
c. Analysis and Interpretation of Results
These are necessary in order to permit duplication of the test in the reader’s own
setting and get the same result
VALIDITY
• WAS THE REFERENCE STANDARD AN ACCEPTABLE

ONE?
YES.
Computed Tomography scan is the most acceptable modality
in the diagnosis of Acute appendicitis pre-operatively.
Histopathology findings are the gold-standard in the

diagnosis post-operatively.

VALIDITY
• WERE THE METHODS FOR PERFORMING THE

TEST DESCRIBED IN SUFFICIENT DETAIL TO
PERMIT REPLICATION?
YES.

DIAGNOSTICS
IS IT VALID?
WAS THERE AN INDEPENDENT COMPARISON

WITH THE REFERENCE STANDARD?
- A Reference Standard for a diagnostic test is the test

that gives the information nearest to the truth.
- If the diagnostic test approximates the standard then it
also measures the “truth”
- Comparison with the reference standard eliminated the
possibility of a Verification or Work-up Bias
DIAGNOSTICS
IS IT VALID?
WAS THE READING OR INTERPRETATION OF THE

DIAGNOSTIC TEST AND REFERENCE STANDARD DONE
INDEPENDENTLY?
- Test results and reference standard results should be assessed
independently of each other by interpreters who were not aware of
the results of the other investigation
VALIDITY
• WAS THERE AN INDEPENDENT AND BLIND

COMPARISON WITH A REFERENCE
STANDARD?
DIAGNOSTICS
WHAT ARE THE RESULTS
WHAT ARE THE LIKELIHOOD RATIOS FOR THE

DIFFERENT TEST RESULTS?
- Know the likelihood ratios to determine the probabilities of the
disease being present or absent in the patient
DISEASE NO DISEASE
POSITIVE True Positive (a) False Positive (b)
NEGATIVE False Negative (c) True Negative (d)

Sensitivity (Sn) = a / a + c
- percentage of patients with disease who have a positive test for the disease in
question
Specificity (Sp) = d / b + d
- percentage of patients without the disease who have a negative test for the
disease in question
Likelihood Ratios (LR) – indicate how much a diagnostic test will raise or lower
the pre-test probability of the target disorder in question
Positive LR = Sn / 1-Sp
Negative LR = 1-Sn / S
LR = 1, means that the post-test probability is of the
target disease in question is the same as the pre-test
probability
LR>1, indicates an increased likelihood of a disease
LR <1, indicates a decreased likelihood of a disease
RESULTS
• WHAT WERE THE LIKELIHOOD RATIOS FOR

THE DIFFERENT POSSIBLE TEST RESULTS?
LIKELIHOOD RATIO
LR (+) = SN/1-SP
LR (-) = 1-SN/SP
Sensitivity: 95.2%
Specificity: 73.6%

PATHOLOGY PATHOLOGY Sensitivity (Sn) = a / a + c
(+) (-) 178 = 0.952 = 95.2 %
178 + 9
RIPASA (+) 178 29
RIPASA ( - ) 9 81 Specificity (Sp) = d / b + d

81 = 0.736 = 73.6%
29 + 81
TOTAL 187 110
Your Date Here Your Footer Here 68

DIAGNOSTICS
WHAT ARE THE RESULTS
WILL THE APPLICATION OF THE

LIKELIHOOD RATIOS BE HELPFUL TO MY
CLINICAL DECISIONS?
- This can be answered by a Nomogram
- The Nomogram does all the conversions and allows
us to go simply from pre-test to post-test
probabilities
POSITIVE POSITIVE POSITIVE
PRE-TEST PRE-TEST
LIKELIHOOD POST-TEST POST-TEST
PROBABILITY ODDS
RATIO (LR) ODDS PROBABILITY
PRE-TEST PRE-TEST
PROBABILITY ODDS (p)
(P)
NEGATIVE NEGATIVE NEGATIVE

LIKELIHOOD POST –TEST POST –TEST
O = p x LR (+) Ø = (O / O + 1)

Positive LR = Sn / 1-Sp
PRE-TEST PRE-TEST
PROBABILITY ODDS (p)
(P)
Negative LR = 1-Sn / Sp
p = (P/1-P)
NEGATIVE NEGATIVE NEGATIVE
LIKELIHOOD POST –TEST POST –TEST
O = p x LR (-) Ø = (O / O + 1)
CLINICAL DECISION TREE
GRAY ZONE
25% 70%
Lower Testing 50% Upper Testing
Threshold PATIENT Threshold
RESULTS
• WHAT WERE THE LIKELIHOOD RATIOS FOR

THE DIFFERENT POSSIBLE TEST RESULTS?
LIKELIHOOD RATIO:
LR (+) = 0.952 / 1 - 0.736 = 3.606
LR (-) = 1 - 0.952 / 0.736 = 0.065

APPLICABILITY
WILL THE REPRODUCIBILITY OF THE

TEST RESULT AND ITS INTERPRETATION
BE SATISFACTORY IN MY SETTING?
• YES
ARE THE RESULTS APPLICABLE TO MY

PATIENT?
• YES

APPLICABILITY
• CONVERTING PRE-TEST PROBABILITY TO PRE-TEST

ODDS
• (P/1-P) = 0.5 / (1 – 0.5) = 1
• MULTIPLY THE PRE-TEST ODDS BY THE LIKELIHOOD

RATIO TO GET THE POST-TEST ODDS (O)
If the RIPASA score is (+): 1 x LR (+)
= 1 x 3.606 = 3.60
If the RIPASA score is (-): 1 x LR (-)
= 1 x 0.065 = 0.06

APPLICABILITY
• If the RIPASA score is (+)
• (O / O + 1)
• 3.6 / 3.6 + 1 = 0.78 ~ 78%
• If the RIPASA score is (-)

• 0.06 / 0.06 +1 = 0.056 ~ 5.6%

CLINICAL DECISION TREE
If test is (-), 5.6 % chance If test is (+), 78 % chance

of having AP of having AP
25% 70%
50%
Lower Testing Upper Testing
Threshold
PATIENT Threshold
DIAGNOSTICS
ARE THE RESULTS APPLICABLE?
ARE THE MEDICAL, SOCIAL AND ECONOMIC RESOURCES

NEEDED TO PERFORM THE DIAGNOSTIC TEST
AVAILABLE IN YOUR SETTING?
-Reproducibility of the interpretation is necessary for the test to be applied in your
setting.
- Physician’s personal and professional experiences influence how scientific

evidence is being implemented in clinical practice
DIAGNOSTICS
WAS THE DIAGNOSTIC TEST AND ACCURACY IN

THE EVIDENCE PREFERRED BY THE PATIENT
AND FAMILY?
- Even if the evidence was very good, it must still be viewed in the context of the
patient
- Patient’s characteristics and the patient’s prior experience with the diagnostic test
or intervention should always be considered for a more acceptable plan of action.
DIAGNOSTICS
IF THE PHYSICIAN GIVES THE DIAGNOSTIC TEST TO A

SIMILAR PATIENT IN THE COMMUNITY, WILL HE GET
THE SAME RESULTS?
- Good clinical decision making considers the balance between individual rights
and fair distribution of service across populations.
- Reproducibility and issues in compliance should be assured before

implementation to ensure similar accuracy
DIAGNOSTICS
ARE THE PATIENT, FAMILY AND COMMUNITY

WILLING TO ACCEPT AND PAY FOR THE
DIAGNOSTIC TEST?
- Financial capacity within the realm of patient’s capability
- Every individual wants the best for their money, therefore clinical
interventions must be acceptable for the patient, family and
community.
CONCLUSION
• Thus, if the test is positive, the probability that the

patient has Acute Appendicitis is 78%, which exceeds
my threshold level but only by 8%, patient may start
treatment.
• And also if the test is negative, the probability that the
patient has Acute Appendicitis is 5.6%, so there is no
need to do further test to rule out the disease.

Shared Decision Making
Medical Literature
Appraise
Read
Apply
Question
Decide
Patient
Clinical Jazz = Traditional EBM + Shared Decision Making
(Structure) + (Improvisation)
(Shaughnessy, 1998)
Resources
• AAFP. EBM Toolkit

• http://www.aafp.org/journals/afp/authors/ebm-t
oolkit/resources.html
• University of Oxford. EBM toolkit

• http://www.cebm.net/index.aspx?o=1023
• PUNs and DENs worksheet
• http://www.networks.nhs.uk/nhs-networks/mk-i
mpacte/documents/Puns%20and%20Dens%2
0booklet%20v2.4.pdf
References
• Boston University School of Medicine. Curricular innovations: finding information
framework. 2013. Available from: http://medlib.bu.edu/busm/fif/ and
http://www.bumc.bu.edu/oaa/files/2013/10/BUSM-FIF.pdf Accessed November 11, 2013].
• Dartmouth College Biomedical Libraries. Evidence-based medicine resources: finding
evidence-based answers to clinical questions quickly and effectively. 2012. Available from
http://www.dartmouth.edu/~biomed/resources.htmld/guides/ebm_resources.shtml and
http://www.dartmouth.edu/~biomed/resources.htmld/guides/FindingGoodAnswers.pdf
Accessed November 11, 2013.
• Tufts University School of Medicine, Department of Family Medicine, Center for
Information Mastery. Concepts of information mastery. 2013. Available from
http://medicine.tufts.edu/Education/Academic-Departments/Clinical-Departments/Family-M
edicine/Center-for-Information-Mastery/Concepts-of-Information-Mastery
Accessed November 11, 2013.
• University of Oxford. Centre for Evidence Based Medicine: EBM tools. 2013. Available
from http://www.cebm.net/index.aspx?o=1023 Accessed November 11, 2013.
• Jackson R, et al. The GATE frame: critical appraisal with pictures. ACP Journal Club 2006
Mar/Apr: 144
References
• Atroshi I, Flondell M, Hofer M, Ranstam J. Methylprednisolone injections for the carpal tunnel syndrome: a randomized,
placebo-controlled trial. Ann Intern Med 2013;159(5):309-17.
• Chan LS, Takata GS, Shekelle P, et al. Evidence assessment of management of acute otitis media: II. Research gaps and
priorities for future research. Pediatrics 2001;108:248-54.
• Flaherty RJ. A simple method for evaluating the clinical literature. Fam Pract Manag 2004 May;11(5):47-52.
• James PA, Oparil S, Carter BL, et al. Evidence-based guideline for the management of high blood pressure in adults:
report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014.
doi:10.1001/jama.2013.284427.
• Lv J, Perkovic V, Foote CV, Craig ME, Craig JC, Strippoli GF. (). Antihypertensive agents for preventing diabetic kidney
disease. Cochrane Database Syst Rev 2012 Dec 12;23:CD004136.
• Marshall SC, Tardif G, Ashworth NL. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst
Rev 2007;2: CD001554.
• Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet 2013;13: 62388-
0.
• Slawson D, Shaughnessy A, Bennett J. Becoming a medical information master: feeling good about not knowing
everything. J Fam Pract 1994;38(5):505-13.
• Slawson D, Shaughnessy A, Bennett J. Becoming an information master: a guidebook to the medical information jungle. J
Fam Pract 2004;39(5):489-99.
• Shaughnessy AF, Slawson DC, Becker L. Clinical jazz: harmonizing clinical experience and evidence-based medicine . J
Fam Pract 1998;47:425-8.
• Thompson PL, Gilbert RE, Long PF, Saxena S, Sharland M, Wong IC. Effects of antibiotics for otitis media on mastoiditis
in children: a retrospective cohort study using the United Kingdom General Practice Research Database. Pediatrics 2009;
123(2):424-30.

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EBM Introduction and Basics

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EVIDENCE-

• You want to find this answer.

• Think of these as basic questions you EBM

(Based on BU and Dartmouth models)

EBM Case-control Randomized Critically-

• ACP Journal • DynaMed • Cochrane

O – coronary event/death prevention

M – randomized controlled trial

Among patients with elevated cholesterol,

what is the efficacy of antihyperlipidemics

in preventing coronary event or death

in a randomized controlled trial?

a. Population of the study - similar characteristics to your patient

b. Intervention and comparative interventions - includes

c. Outcome of the study – one of the outcomes measured should

WAS THE ASSIGNMENT TO THE DIFFERENT

• A drop-out rate of 20% or more is usually declared

• Check whether an intention to treat analysis was done

- Again to answer, look into the methods section

Ideally to state that the study is valid, we want a YES

However, that is too strict especially if studies are limited,

HOW LARGE WAS THE TREATMENT

c. Relative Risk (RR) = Rt / Rc

d.Relative Risk Reduction (RRR) = (1-RR) x 100%

RELATIVE RISK REDUCTION – also measures impact

ARE THE MEDICAL, SOCIAL, AND

- Compare the study population and your own patient

-Think beyond the scientific rigor of the article and consider

-It is useless to insist on a treatment which is not in consonance with

Number Needed to Treat (NNT) = 1 / ARR

Absolute Risk Reduction (ARR) = Rc – Rt

Cost Effectiveness = NNT x cost of the drug x duration of treatment

Apply the information to your patients and their families

Monitor patient’s progress to check whether this would be

May 9, 2018 Department of Family and Community Medicine

To appraise and determine the relevance

Date Your Footer Here 34

Date Your Footer Here 35

P Asian patients with right lower quadrant pain

Date Your Footer Here 39

Among Asian patients with right lower quadrant

Date Your Footer Here 40

Date Your Footer Here 41

Date Your Footer Here 42

Date Your Footer Here 43

Date Your Footer Here 44

Date Your Footer Here 45

Date Your Footer Here 46

Date Your Footer Here 47

Date Your Footer Here 48

Date Your Footer Here 49

Date Your Footer Here

• IS THE OBJECTIVE OF THE STUDY

Date Your Footer Here 52

P Adult Asian patients with

O Diagnosis of Appendicitis Diagnosis of Appendicitis

WAS A REPRESENTATIVE SAMPLE OF

• DID THE PATIENT SAMPLE INCLUDE AN

Date Your Footer Here 55

WAS THE DIAGNOSTIC TEST AND REFERENCE

• WAS THE REFERENCE STANDARD AN ACCEPTABLE

Histopathology findings are the gold-standard in the

Date Your Footer Here 57

• WERE THE METHODS FOR PERFORMING THE