Evidence Based Medicine… The Road ahead: Bridging the gap from theory to Practice

Evidence Based Medicine…Evidence Based Medicine…The Road ahead: Bridging the gap The Road ahead: Bridging the gap

from theory to Practicefrom theory to Practice

Amr Nadim, MD.Professor of Obstetrics & Gynecology Ain Shams Faculty of MedicineThe QAInc. Advisory Board

What happened …?

• Over the past decade, the term

"evidence-based medicine" (or EBM) has

gained considerable currency.

• EBM has been described as a "paradigm

shift" that will "change medical practice in

the years ahead."

The medical practice so far…

• Based experience gained from clinical practice

• Information essentially driven from– The basic science research– Observational studies that are NOT necessarily

controlled– Expert opinion– Advocacy

So, when faced with a problem, Doctors may…

• Reflect on their own clinical experience,

• Reflect on the underlying biology,

• Go to a textbook,

• Ask a local / international expert.

• Believe in what they are told by pharmaceutical

companies

What is the problem any way…?

• Bias, bias and bias…

The Founding Father

Prof. Archibald Leman Cochrane a British medical epidemiologist whose book Effectiveness and Efficiency:

Random Reflections on Health Services (1972) and subsequent

advocacy caused increasing acceptance of the concept of

Evidence Based Medicine

(January 12, 1909 - June 18, 1988)

The People at McMaster Universityas early as 1992

…introduced Evidence Based Medicine

as a Shift of Paradigm

What is EBM…?

• “The conscientious, explicit and judicious use

of current best evidence in making decisions

about the care of individual patients"

• It is about the WISE use of the EVIDENCE to

achieve a QUALITY OF PATIENT CARE

Evidence-based medicine is:

the SYSTEMATICSYSTEMATIC, SCIENTIFICSCIENTIFIC and EXPLICITEXPLICIT

use of current best evidence in making decisions

about the care of individual patients.

EBM: The Theory

Patient Values…?

• The unique preferences, concerns, The unique preferences, concerns,

and expectations each patient brings and expectations each patient brings

to a clinical encounter.to a clinical encounter.

• They may differ from phase to phase.. They may differ from phase to phase..

from one encounter to another.from one encounter to another.

• These must be integrated into clinical These must be integrated into clinical

decisions if they are to serve the decisions if they are to serve the

patient.patient.

Clinical Expertise…?

Ability to use The clinical skills & past experience Ability to use The clinical skills & past experience

to rapidly identify to rapidly identify Each patient’sEach patient’s::

– Unique health state.Unique health state.

– Individual risks/benefits of interventions Individual risks/benefits of interventions

(Diagnostic or therapeutic).(Diagnostic or therapeutic).

– Personal values and expectations.Personal values and expectations.

What is The Best Research Evidence ?What is The Best Research Evidence ?

Clinically relevant, Clinically relevant, Patient-centeredPatient-centered research research

about:about:

– Diagnostic tests: Diagnostic tests: To detect the diseaseTo detect the disease

– Prognostic markers: Prognostic markers: To follow up the diseaseTo follow up the disease

– Therapeutic / preventive regimens: Therapeutic / preventive regimens: To treatTo treat

– Harm: Harm: That treatments/diagnostic tools may cause.That treatments/diagnostic tools may cause.

EBM: The Theory

A Paradigm Shift…?

Paradigm..?

• “An entire constellation of beliefs, concepts, values, techniques, and so on shared by the members of a given community"

Paradigm Shift…?

EBM: The Theory

• A Paradigm shift:The medical community is shifting gears

Advocacy Inquiry

Opinion Evidence

Disease-oriented

Patient-oriented

Intermediate results

Final outcomes

And in doing so, one should…

• Define the problem in the form of an

answerable clinical question.

• Perform an elaborate search for the best

available evidence.

• Appraise this evidence for relevance

&validity.

• Incorporate it in his practice

• Become a life-long learner.

I have no particular talent…I am merely inquisitive

What we used to do…

Time spent reading around one’s patients is slim:

Self-reports from Oxford :

• House Officers: none

• S.H.O.’s: 10 minutes

• Registrars: 90 minutes

• Senior Registrars: 45 minutes

• Consultants:

– Post 1975: 60 minutes

– Pre 1975: 30 minutes

What EBM originally advocated…

Ask a Focused Clinical Question

Appraise itFor validity

Incorporate it in your practice

Go to the medline and search for the

Best available evidence

Become a life-long learner

While you are formulating your question…

•Alendronate improvesBMD

•Alendronate reduces fracture Risk

•HRT Lowers LDL and Increases HDL

• HRT reduces incidence of Cardiovascular events

DOE POEM

DOE (intermediate outcomes)– Disease-Oriented Evidence

A test result / A physiological number

POEM (final outcomes))– Patient-Oriented Evidence that Matters to

the Patient Will I die? Will I suffer? My quality of life?

POEMPPatient-Oriented

EEvidence

that MMatters…

To whom?

To you …and To your patient

And While Doing So You Should Respect The EVIDENCE Hierarchy

What we used to do…

And in many instances we find ourselves lost in a maze…

What EBM is now proposing…

Information Mastery

Everything is based on the usefulness equation:

Usefulness = Relevance x Validity

Work

Cochrane Library

Specialty-specificPOEMs

Best Evidence

Clinical Evidence

Textbooks, Up-to-Date, 5-Minute Clinical Consult

Usefu

lness

Journals/ Medline

Drilling for the evidence

Levels of Evidence and Grades of Recommendations

Grade of recommendation

Level of evidence

Interventions

1a Systematic review of randomized controlled trials A

1b Individual randomized controlled trial

2a Systematic review of cohort studies

2b Individual cohort study

3a Systematic review of case-control studies B

3b Individual case-control study

C 4 Case series

D 5 Expert opinion without explicit critical appraisal or based on physiology or bench research

EBP has changed the world

• Source of knowledge is expert opinion

• Clinical skills are seen as semi-mystical

• Research is marginal to practice

Source of knowledge is systematic review of evidence

Clinical skills can be audited and managed

Research and evidence go together

• Most of what doctors need to know is in their heads.

• Most medical care is assumed to be beneficial

Doctors must use information tools constantly/ they must constantly be updated and learn new skills.

Widespread recognition that the balance between doing good and harm is fine

EBP has changed the world

• Clinical performance is not systematically audited

• Doctor patient relationship is essentially master/pupil

Clinical performance is regularly reviewed and managed

Patient partnership is often thought.

EBP has changed the world

• Patients do not have easy access to the knowledge base of doctors

• The doctor is smartest

Patients have as much access to the evidence base of medicine as doctors

Often the patient is smarter

EBP has changed the world

The Pre-internet Patient..

The Clinician of the Future

– Learn how to say “I do NOT know” with ease and confidence

– Knows then how to find the best available evidence.

– Listen to the patient, appreciate his preferences, determine which tests and treatment will do more good than harm by tailoring the best available evidence to the individual’s condition.

– Discuss the options with the patient and help him make an informed choice depending on his values and preferences

Ahmad Nadim

In few words, EBM changed the medical practice….

A Doctor

• More resourceful

• Aware of the concept of Information Mastery

• Following Evidence Based Guidelines.

• Publishing and Appraising Evidence Based Researches and Literature

A Patient

• More Resourceful

• Aware of his writes

• Able and willing to take part

in the Decision Making

process concerning his life

• Not bluffed by DOEs but

essentially with POEMs

However…

Many Leaks From Research To Practice

Paul Glasziou, CEBM, Oxford UniversityThe 3rd Asia Pacific Congress on EBM, November 2004

Paul Glasziou, CEBM, Oxford University

Practicing Evidence Based Medicine

Linking evidence to practice

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What EBM Did Bring To Our Medical Practice Over The Past Decade?

• WHO Medical Eligibility Criteria• WHO Cire • WHO Reproductive Health library• RCOG green top guidelines• The Cochrane Library• Fostering the concept of life-long learning.• CAT Banks• Putting an emphasis on the importance of

controlled clinical trials.

And so, we are left with…

Peer reviewing: detecting errors

• 60% response rate

• Median number of errors detected 2

• Maximum number detected 5

• Percentage not detecting any 20%

600 word study with 8 errors …Sent to 400 reviewers

Problems with peer reviewing

• Slow

• Expensive

• A lottery

• Ineffective

• Biased

• Easily abused

• Can’t detect fraud

The power of peer review

• Reviewer A “I found this paper an

extremely muddled paper with a large

number of deficits.”

• Reviewer B “It is written in a clear

style and would be understood by any

reader.”

An EBM New Vision of peer review

• “Peer review is changed from being an arbitrary decision made in a closed box to an open scientific discourse.”

• The Critical Appraisal Process has generated Post-publication peer reviewers

A word on patients

• The impact of medical journals on patients and the

public is mainly via the mass media

• Most mass media coverage is reasonable, but

some can be way off beam, sometimes causing

major problems

• The public are often very confused by conflicting

reports from scientific journals

• That’s why Evidence Based Medicine will be a

way of avoiding such confusion.

A word on patients

• Patients increasingly have access to the same

information as doctors, including journals

• The BMJ has just appointed a patient editor

• Ten years from now journals might be for

doctors and patients

What will survive as the world changes completely

• Clear ethical values• Being clear about our mission• Putting patients first• Constantly trying to improve• Basing what we do on evidence• Leadership• Become Lifelong learners and Mastering the

information

• EBM paved the way for accreditation

processes

• It provided a rational

• In this respect Evidence Based Medicine has

been the Bible for setting principles and

guidelines for peer reviewers in their ultimate

search for completion of Accreditation

Process

??? In Practice

Performance

In Practice Competence

Guidelines

Information

The Doctor

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The Evidence

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“Knowing is not enough; we must apply

Willing is not enough; we must do…”

Goethe

Do you want to start Practicing EBM…?

Reflect on your practice on regular basis.

Inquire …DO NOT advocate

Feel good about NOT knowing everything

Learn to ask a focused clinical question

Let someone else DO the heavy lifting

Learn to use a computer

A New Role for EBM

• If all practitioners had the skill to:

– Do a rapid literature search on one or two search engines

– Rapidly critically assess the media’s study of the week

– Be able to judge the quality of critically appraised

information provided by a third party,

… then the gap between evidence and practice

would quickly narrow.

A New Role for EBM

• Presence of an internet connection in every practitioner’s office will signal a revolution in the practice of Medicine.

• Basic information about any problem or symptom, no matter how rare or unusual, can be obtained within a few minutes by the clinician.

• Best available evidence, recently updated is there for any patient within the time constraints of a visit to a busy practice.

A New Role for EBM

• CAPRE stands for “Critically Appraised Practice Reflection Program” – which includes identifying a patient with a specific

problem, – providing the patient with EBM information

answering their questions and then determining if they did or did not follow the advice.

A New Role for EBM

• The final step, all on line, is to feed back to the program a description as to whether the patient adopted the recommendations or not, and for the physician to self assess to determine if he or she might have presented the information more effectively.

• The new role of EBM is in assisting the physician in diagnosing and managing their patients and being educated on line

InfoRetriever 4.1Windows 95/98/NT/ME/2000/XP, PocketPC and Web

650 critical reviewsof recent research from the Journal of Family Practice POEMs section

Bayesian diagnostic test / H&P calculator

Basic drug info by class and cost for 1200 drugs

Key evidence-basedtreatment guidelines

Cochrane Databaseof Systematic Reviews:over 1200 abstracts

102 clinical predictionrules

www.MedicalInforetriever.com

1500 short research synopses (400 added per year)

5 Minute Clinical Consult

What EBM originally advocated…

Ask a Focused Clinical Question

Appraise itFor validity

Incorporate it in your practice

Go to the medline and search for the

Best available evidence

Become a life-long learner

What EBM Is now Able to Provide…

Ask a Focused Clinical Question

Appraise The Evidence

For validity

•Incorporate it in your practice

•Create a partenaria with your patient

Go to the Evidence Based sites

maintained by a third party

Become a life-long learner

Access them at point of care

…and after all, is EBM a “Paradigm Shift”…?

• This may involve lot of philosophy that is exceeding

the scope of this presentation.

• To shortly answer the question: The answer is

“NO”.

• Instead let us better consider EBM and traditionally

practiced medicine as a continuum that will help you

to better practice medicine by

– Providing a quality care to your clients and

– Remaining up to date.

“When a steamroller comes through, you should choose to become either part of the roller or part of the road.”

Thank you…