07 Feb. 2008 07 Feb. 2008 Contribution to IBPOWER Presentation WP 4.
EBM Introduction 7-8 Feb 07
Transcript of EBM Introduction 7-8 Feb 07
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Introduction to Evidence-
Based Medicine
Dr.Dr. MazenMazen FerwanaFerwana, MD,ABFM, JBFM, PhD, MD,ABFM, JBFM, PhDConsultant Family MedicineConsultant Family Medicine
Ass. Prof. KingAss. Prof. King SaudSaud Bin AbdulBin Abdul AzizAziz Medical UniversityMedical University
Chairman, Research Committee Residency TrainingChairman, Research Committee Residency Training-- FMFM
Director, Cochrane Review Initiative ProjectDirector, Cochrane Review Initiative Project
NGCEBM, Task Teams SupervisorNGCEBM, Task Teams Supervisor
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EBM is the integration of theEBM is the integration of the
current best evidencecurrent best evidence fromfrom
research with ourresearch with our clinical expertiseclinical expertiseandand patientpatients valuess values, preferences, preferences
and circumstances.and circumstances.
What is EBM?hat is EBM?hat is EBM?
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You are R2 working paediatric outYou are R2 working paediatric out-- patientpatientclinic. A mother comes to see you about herclinic. A mother comes to see you about her
33--yearyear--old child who she says is alwaysold child who she says is alwaysunwell with coughs and colds. Her childunwell with coughs and colds. Her childattends a day nursery as she is working fullattends a day nursery as she is working full
time. She is having trouble with her boss attime. She is having trouble with her boss atwork as she is always taking time off work towork as she is always taking time off work tolook after her sick child. In desperation shelook after her sick child. In desperation she
has been searching the internet and foundhas been searching the internet and foundseveral sites that encourage the use ofseveral sites that encourage the use ofimmune system boosters in children. Inimmune system boosters in children. Inparticular she asks you aboutparticular she asks you about probioticsprobiotics andandhands you an article.hands you an article.
Clinical ScenarioClinical Scenario
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Your answer?Your answer?
(A) Yes: Good evidence(A) Yes: Good evidence
(B) NO: NO evidence(B) NO: NO evidence
(C) I Don(C) I Dont knowt know
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If you donIf you dont knowt know
How youHow you
willwillansweranswer
youryourpatient?patient?
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1. Read textbooks1. Read textbooks
2. Ask your senior colleague2. Ask your senior colleague
3. Search the EBM literature3. Search the EBM literature
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Clinicians need informationClinicians need information
We need it up to 60 times a week (twiceWe need it up to 60 times a week (twiceper three patients)per three patients)
It could affect up 8 decisions a dayIt could affect up 8 decisions a dayWe only get 30% of itWe only get 30% of it
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Do We Read?Do We Read?
50% had not read a medical50% had not read a medicaljournal article in the last yearjournal article in the last year
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Information jungleInformation jungle
WWWWWW 800 million web sites800 million web sites
MEDLINEMEDLINE has about 400,000 newhas about 400,000 newentries added each yearentries added each year
To keep ahead by reading everything ofTo keep ahead by reading everything ofpossible importance,possible importance, need to readneed to read
6,0006,000articles each day!articles each day!
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Why we get it wrongWhy we get it wrong
OurOur informationinformation isis out of date !!out of date !!
OurOur textbookstextbooks areare out of date !!out of date !!
Nobody can read enough journals to keepNobody can read enough journals to keep
up.up.
Th b l ti Th f A t MI
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1 2
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81
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NotMentioned
Routine
Experimental
Rare/Never
Specific
M
M
M
M
MM
Textbook/ReviewRecommendations
Odds Ratio (Log Scale)
0.5 1.0 2.0
Favours Treatment Favours Control
RCTs Pts
1 23
2 65
3 149
4 316
7 1793
10 254411 265115 331117 392922 5452
P
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Lag time from time ofLag time from time of knowingknowing to timeto time
of implementationof implementation
13 yrs for13 yrs for thrombolyticthrombolytic therapytherapy
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Another exampleAnother example
10 yrs for corticosteroids to speed10 yrs for corticosteroids to speed
fetal lung maturityfetal lung maturity
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Are We Failing?Are We Failing?
Negative correlationNegative correlationbetween our upbetween our up--toto--datedate
knowledge and the yearsknowledge and the yearssince graduationsince graduation
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The Slippery SlopeThe Slippery SlopeThe Slippery Slope
years since
graduation
r = - 0.54
P < 0.001
...
...
. ... . .... .
....
.........
...knowledgeof current
best care
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How you get the information?How you get the information?
Just In CaseJust In Case SurveillanceSurveillance
Just In TimeJust In Time FocusedFocused
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The Usefulness EquationThe Usefulness EquationThe Usefulness Equation
UsefulnessUsefulness == ValidityValidityxx RelevanceRelevance
of any sourceof any source WorkWork
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WorkWorkWork
The least effort and time toThe least effort and time toget the proper informationget the proper information
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ValidityValidityValidity
TheThe TruthTruth
What we do does moreWhat we do does more
good than harm.good than harm.
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RelevanceRelevanceRelevance
POEMPOEM: Patient: Patient--oriented evidence thatoriented evidence that
mattermattermortality, morbidity, quality of lifemortality, morbidity, quality of life
DOEDOE: Disease: Disease--oriented evidenceoriented evidence
pathophysiologypathophysiology, pharmacology, etiology, pharmacology, etiology
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Comparing DOE and POEMComparing DOE and POEM
DOEDOE POEMPOEM
AntihypertensiveAntihypertensive
therapytherapy
Lowers BloodLowers Blood
PressurePressure
DecreasesDecreases
MortalityMortality
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Keeping UpKeeping UpKeeping Up
Concentrate onConcentrate on high yieldhigh yieldjournals withjournals with
favorable POEM:DOE ratiofavorable POEM:DOE ratio
Consider three questions to determineConsider three questions to determine
relevancerelevance
PatientPatient--orientedoriented
Common to practiceCommon to practice
Require change of practiceRequire change of practice
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EBM: 1EBM: 1--22--33--44--55
One goal: improve the quality of careOne goal: improve the quality of care
Two fundamental principlesTwo fundamental principlesThreeThree --EsEsto define EBMto define EBM
FourFour --RVARRVAR-- to appraise a paperto appraise a paperFiveFive --AsAs-- to practice EBMto practice EBM
OneOne GoalGoal
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Quality of CareClinical decisions:Diagnostic test
Therapeutic intervention
Prognosis
Clinical Practice Guidelines
Research
Evidence
Clinical
Experience
Patient
Expectation
Preference
OneOne-- GoalGoal
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TwoTwo-- Fundamental principlesFundamental principles
1.1. Evidence has a hierarchy ofEvidence has a hierarchy of
strengthstrength
2. Evidence alone is never the sole2. Evidence alone is never the sole
basis for decisionsbasis for decisions
1 Hierarchy of Evidence1 Hierarchy of Evidence
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1. Hierarchy of Evidence1. Hierarchy of Evidence
MetaMeta--analysis of RCTsanalysis of RCTsMultiMulti--centric large RCTscentric large RCTs
Single Centre RCTSingle Centre RCT
Observational studiesObservational studiespatientpatient--important outcomesimportant outcomes
Clinical experienceClinical experience
Basic researchBasic researchtest tube, animal, human physiologytest tube, animal, human physiology
E id l i h2 E id l i h
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2. Evidence alone is not enough2. Evidence alone is not enough
PatientsPatients valuesvalues
Would you give a DNR consent for aWould you give a DNR consent for a
terminally ill child in case of arrest, if he isterminally ill child in case of arrest, if he is
your relative?your relative?
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Three (Three (EsEs))-- EBM ComponentsEBM Components
Evidence Experience
Expectations
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FourFour--RVRARVRA to Appraise The Evidenceto Appraise The Evidence
1.1. Relevance:Relevance: It focuses on medical problemsIt focuses on medical problemscommon to our practice. patientcommon to our practice. patient--orientedorientedevidenceevidence
2.2.
Validity:Validity:Correctness (Correctness (likely to be true)true)
3.3. Results:Results: Clinically important
4.4. Applicability:Applicability: Applicable in and useful for my
patients
5 A i EBM
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Acqu i re theEvidence(s) Appraisethe evidence(s)
Apply Thebest evidence
to patient
Ask clinicalquestions
55 AAs to practice EBMs to practice EBM
AssessYourself
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Patient carePatient care
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Patient carePatient care
EBM will hopefully modify individual patientEBM will hopefully modify individual patient
carecare
Use of proven therapies and diagnostic testsUse of proven therapies and diagnostic testsonlyonly
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I tit tiI tit ti
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InstitutionsInstitutions
Improve resource utilizationImprove resource utilization
More effective and efficient careMore effective and efficient care
Reduced cost per patient.Reduced cost per patient.
The use of EBM clinical practiceThe use of EBM clinical practiceguidelines and clinical pathwaysguidelines and clinical pathways
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Health Care PolicyHealth Care Policy
Health care policy must be reliant on usingHealth care policy must be reliant on using
the best available evidence to aid fundingthe best available evidence to aid fundingdecisions.decisions.
Screening (cancer, genetics)Screening (cancer, genetics)
Preventative healthcare (cholesterol lowering)Preventative healthcare (cholesterol lowering)In determining resource distribution withinIn determining resource distribution withincommunities (inpatient vs. communitycommunities (inpatient vs. community--basedbased
care)care)In new health technology assessment.In new health technology assessment.
M di l Ed tiMedical Education
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Medical EducationMedical Education
Worldwide trend toward curriculaWorldwide trend toward curriculaSelfSelf--directeddirected
ProblemProblem--basedbased
UpUp--toto--date physiciansdate physicians
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