Evidence Based Medicine Part I.
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Transcript of Evidence Based Medicine Part I.
![Page 1: Evidence Based Medicine Part I.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649ec75503460f94bd4044/html5/thumbnails/1.jpg)
Evidence Based Medicine
www.bradfordvts.co.
uk
Part I
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Centre for Evidence-Based Medicine
What I’ve done / do/don’t do
Done: I’ve gotten out of date and retrained in Internal Medicine twice
Do: I run an in-patient General Medicine service (all comers) at a UK DGH:» 208 admissions last month» strive to use evidence at the bedside
Don’t: I’ve cancelled my journal subscriptions (and give away the JCI and BMJ)
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Centre for Evidence-Based Medicine
The Problems:
We need evidence (about the accuracy of diagnostic tests, the power of prognostic markers, the comparative efficacy and safety of interventions, etc.) about 5 times for every in-patient (and twice for every 3 out-patients).
We get less than a third of it
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Centre for Evidence-Based Medicine
The Problems:
To keep up to date in Internal Medicine, I need to read 17 articles a day, 365 days a year
Need to read Don’t Nor does anyone else
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Centre for Evidence-Based Medicine
Median minutes/week spent reading about my
patients:
Self-reports at 17 Grand Rounds: Medical Students: 90 minutes House Officers (PGY1): 0 (up to 70%=none) SHOs (PGY2-4): 20 (up to 15%=none) Registrars: 45 (up to 40%=none) Sr. Registrars 30 (up to 15%=none) Consultants:
» Grad. Post 1975: 45 (up to 30%=none)» Grad. Pre 1975: 30 (up to 40%=none)
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Centre for Evidence-Based Medicine
Performance deteriorates, too
Determinants of the clinical decision to treat some, but not other, hypertensives:
1 Level of blood pressure.2 Patient’s age.3 The physician’s year of graduation from
medical school.4 The amount of target-organ damage.
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Centre for Evidence-Based Medicine
No wonder, then, that CME is growing
Big, and getting huge. Usually instructionally (fact) oriented. Several randomised trials have shown
that it does not improve clinical performance.
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Centre for Evidence-Based Medicine
Three solutions
Clinical performance can keep up to date:1 by learning how to practice evidence-
based medicine ourselves.2 by seeking and applying evidence-based
medical summaries generated by others.3 by applying evidence-based strategies
for changing our clinical behaviour.
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Centre for Evidence-Based Medicine
When did EBM begin ?
Certainly in post-revolutionary Paris.
Arguably in B.C China.
Some late-comers named it in 1992.
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Centre for Evidence-Based Medicine
What evidence-based medicine is:
The practice of EBM is the integration of individual clinical expertise
with the best available external clinical evidence
from systematic research.and
patient’s values and expectations
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Centre for Evidence-Based Medicine
I.Individual Clinical Expertise:
Clinical skills and clinical judgement Vital for determining whether the
evidence (or guideline) applies to the individual patient at all and, if so, how
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Centre for Evidence-Based Medicine
II. Best External Evidence:
From real clinical research amongintact patients.
Has a short doubling-time (10 years). Replaces currently accepted diagnostic
tests and treatments with new ones that are more powerful, more accurate, more efficacious, and safer.
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Centre for Evidence-Based Medicine
III. Patients’ Values & Expectations
Have always played a central role in determining whether and which interventions take place
We’re getting better at quantifying and integrating them
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Centre for Evidence-Based Medicine
What EBM is not:
EBM is not cook-book medicine» evidence needs extrapolation to my
patient’s unique biology and values EBM is not cost-cutting medicine
» when efficacy for my patient is paramount, costs may rise, not fall
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Centre for Evidence-Based Medicine
Evidence-Based Medicine:The Practice
When caring for patients creates the need for information:
1 Translation to an answerable question (patient/manoeuvre/outcome).
2 Efficient track-down of the best evidence » secondary (pre-appraised) sources
e.g., Cochrane; E-B Journals» primary literature
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Centre for Evidence-Based Medicine
Evidence-Based Medicine:The Practice
3 Critical appraisal of the evidence for its validity and clinical applicability generation of a 1-page summary.
4 Integration of that critical appraisal with clinical expertise and the patient’s unique biology and beliefs action.
5 Evaluation of one’s performance.
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Centre for Evidence-Based Medicine
We needn’t always carry out all 5 steps to provide
E-B Care
Asking an answerable question. SearchingSearching for the best evidence. Critically-appraisingappraising the evidence. Integrating the evidence with our
expertise and our patient’s unique biology and values
evaluating our performance
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Centre for Evidence-Based Medicine
We’ve identified 3 different modes of practice
“Searching & appraising”» provides E-B care, but is expensive in time and
resources “Searching only”
» much, quicker, and if carried out among E-B resources, can provide E-B care
“Replicating” the practice of experts» quickest, but may not distinguish evidence-
based from ego-based recommendations
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Centre for Evidence-Based Medicine
Even fully EB-trained clinicians work in all 3
modes
“Searching & appraising” mode for the problems I encounter daily.
“Searching only” mode among E-B resources for problems I encounter once a month.
“Replicating” the practice of experts mode for problems I encounter once a decade(and crossing my fingers!).
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Centre for Evidence-Based Medicine
Patients can benefit
Even if <10% of clinicians are capable of practicing in the “searching & appraising” mode (5% of GPs)
As long as most of them practice in a “searching” mode within high-quality evidence sources (70-80% of GPs):» Cochrane Library, E-B Journals, E-B
Guidelines, etc
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Centre for Evidence-Based Medicine
Three solutions
Clinical performance can keep up to date:1 by learning how to practice evidence-
based medicine ourselves.2 by seeking and applying evidence-based
medical summaries generated by others.3 by applying evidence-based strategies
for changing our clinical behaviour.
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Centre for Evidence-Based Medicine
Information required within seconds
Systematic reviews, periodically updated, of randomised trials of the effects of health care (from all sources, and in all languages):
The Cochrane Collaboration.
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Cochrane Systematic Reviews (522; another 500 in preparation)
Database of Abstracts of Reviews of Effectiveness (1895)
Registry of Randomised Controlled Trials (218,355)
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Centre for Evidence-Based Medicine
Information required within seconds
CD-Evidence-based journals of 2º publication:
screen 50-70 clinical journals per week for clinical articles that pass critical appraisal quality filters conclusions likely to be true.
select the subset that are clinically relevant.
summarise as “more-informative” abstracts.
add commentaries from clinical experts.
introduce with declarative titles.
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Centre for Evidence-Based Medicine
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Centre for Evidence-Based Medicine
2. Seeking and Applying EBM generated by others
Evidence-Based Medicine is published in: English French German Italian Portuguese Spanish
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Centre for Evidence-Based Medicine
2. Seeking and Applying EBM generated by others
New Evidence-based journals of 2º publication: E-B Cardiovascular Medicine E-B Health Policy & Management E-B Nursing E-B Mental Health
And as new departments in 1º journals.
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Centre for Evidence-Based Medicine
2. Seeking and Applying EBM generated by others
E-B Textbooks: E-B Pain Relief E-B Cardiology
includes icons for levels of evidence “E-B On-Call”
includes > 1300 CATs
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Centre for Evidence-Based Medicine
Can you really practice EBM?
Is there any “E” for EBM ?
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Centre for Evidence-Based Medicine
Conventional Wisdom
“only about 15% of medical interventions are supported by solid scientific evidence” (BMJ Editorial)
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Centre for Evidence-Based Medicine
Even on the U.S. Talk-Shows: (“Health Outrage of
the Week”)
“..... this would put 80 to 90 per cent of accepted medical procedures in this country under the heading of quackery!”
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Centre for Evidence-Based Medicine
Problems with Conventional Wisdom
uses clinical manoeuvres, rather than patients, as the denominator.
tends to focus on high-technology, “big ticket” items.
relies on simple literature searches that miss over half of the most rigorous types of evaluations.
conducted from armchairs.
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Centre for Evidence-Based Medicine
Performed an empirical study on a busy in-patient
service
on the general medicine in-patient service of the Nuffield Department of Medicine at the Oxford-Radcliffe NHS Hospital Trust (“The John Radcliffe”)
all our admissions arise from urgent referral from local GPs or via the Emergency Room