EBM1 EVIDENCE-BASED MEDICINE Dr. Monica Hughes Clinical Research Registrar Department General Practice.

EBM 1

EVIDENCE-BASED MEDICINE

Dr. Monica Hughes

Clinical Research Registrar

Department General Practice

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EBM- WHY NOW?

1) Consolidate your expertise

2) Prepare you for your job as an autonomous practitioner responsible for making decisions

3) Significant component Final MB

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LEARNING OUTCOMES

Define the term EBM

Understand the components involved in EBM

Discuss the merits of available evidence resources

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BUYING A MOBILE PHONE

• How do you choose your mobile phone????

• From where do you get reliable information????

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• Would you trust the information you get from this salesperson????

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• What about the Carphone Warehouse website?

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• Would you trust what your friends say?

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• What about the OFCOM website?

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STRAW POLL

• Salesperson

• Carphone Warehouse Website

• Friends

• Ofcom Website

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HOW DO WE MAKE CLINICAL DECISIONS?

• Toss a coin?

• Guess?

• Ask a friend?

• Do what your consultant tells you!

• Do no harm?

• Text books or Journals?

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HOW DO WE MAKE CLINICAL DECISIONS?

Dogma

Policy

Experiential

Whimsical

Nihilism

This is the best way to do it

This is the way we do it around here

This way worked the last few times

This way might work

It doesn’t really matter what we do

Patient deferential

Expert deferential

How would you like us to proceed?

What would you do?

Schools Of Thought……..

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WHAT IS EBM?

‘Evidence-based medicine is the process of systematically finding, appraising and

using contemporaneous research findings as the basis for clinical decision

making.’

Rosenberg 1995

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SHIFT IN PRACTICE

• Traditional Approach

– Quantity of clinical experience indicates Dr quality

– Experience of basic science is needed for decisions

– Didactic medical training is sufficient

See loads of patients, know your science and do what the consultants says

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SHIFT IN PRACTICE

• EBM Approach

– Inform all our decision making from best current evidence

– Optimises our decisions

– Allows every practitioner to formulate identical conclusions

– Accept knowledge is continually evolving –never have all the

information to answer every question

– Know how to find and formulate the information in context

Apply knowledge consistently and objectively

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SHIFT IN PRACTICE ……..WHY BOTHER?

Medicine is NOT static

• HRT & NSAIDs

Government policy

• Clinical governance & Patient safety

GMC

• Duties Of A Doctor & Revalidation

Increasingly informed Jo Public

• www. etc,

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SHIFT IN PRACTICE ……..WHY BOTHER?

But ultimately

EBM improves health care

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How many minutes did you spend last week reading around your patients?

• Medical students

• PRHOs

• SHOs

• SpRs

• Consultants

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• Medical students 120mins

• PRHOs

• SHOs

• SpRs

• Consultants

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• PRHOs 10mins

• SHOs

• SpRs

• Consultants


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• PRHOs 10mins

• SHOs 30mins

• SpRs

• Consultants


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• PRHOs 10mins

• SHOs 30mins

• SpRs

45mins

• Consultants


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• PRHOs 10mins

• SHOs 30mins

• SpRs

45mins

• Consultants

60mins

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ELEMENTS OF EBM

‘EBM begins and ends with patients’

EBM – The search algorithm

1) Convert patient health needs into answerable questions

2) Track down best evidence

3) Critically appraise evidence

4) Apply results to clinical practice

5) Evaluate your performance

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ELEMENTS OF EBM




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Formualting Answerable questions that you can answer….

‘Answerable questions are the backbone of practising EBM’

In practice, good questions usually include:- ‘PICO’

• Patient’s clinical needs

• Intervention or exposure• Comparison intervention (if appropriate)

• Clinical Outcomes (diagnosis/prognosis/therapy/event)

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Applying the results to clinical practice….e.g. AF

• John, a retired 78yr old

gentleman is your last patient

of the day. He has a long

history of AF and is on aspirin.

He says to you ‘my friend has

atrial fibrillation and he is on

warfarin - should I be on

warfarin?’

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Patient In patients with AF and who are >65….

Intervention ….would prescribing

warfarin….

Comparison ….compared to

aspirin ….

Outcome ….lead to lower

mortality or morbidity?

….. Cause any increased risk?

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Applying the results to clinical practice…. e.g. AF

Stroke Risk with AF

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Stroke Risk with AF on WarfarinStroke Risk with AF on Aspirin

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Can you apply this evidence into clinical practice?

• Can the results be extrapolated to your patient?

• Availability of tests/treatment

• Affordability of tests/treatment (NB NICE etc)

• Are there adverse risks?

• Are there alternatives?

• What are the patient preferences?

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Applying the results to clinical practice…. e.g. AF

• Major bleeding risk

– Population prevalence: 10/1000

– Aspirin: Not significantly different to placebo

– Warfarin: 15/1000

• Are you going to give him warfarin?

• John is very unsteady on his feet and is prone to falls

• Are you still going to give him warfarin???

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ELEMENTS OF EBM




2) Track down the best evidence

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Tracking down best evidence…..

General search strategy

• Select evidence resource

• Library/databases/guidelines/colleagues

• Design search strategy

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Tracking down best evidence…..

Hierarchy of evidence

• Systematic review

• Meta-analysis

• RCT • Cohort study Prospective e.g. Doll

• Case controlled study -Retrospective

• Cross sectional study -Snapshot

• Case series –Rare

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ELEMENTS OF EBM






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Critically appraising the evidence….

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ELEMENTS OF EBM






4) Apply the results into clinical practice

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Applying results to clinical practice….

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Applying results to clinical practice….e.g. MI

• John, a retired 78yr old

gentleman is your last patient

of the day. He had an MI

2months ago and was told his

cholesterol is normal. He says

to you ‘my friend had a heart

attack and is on a drug called

a statin- should I be on this?’

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Applying results to clinical practice…e.g. MI

Patient In patients >70 who had an MI but cholesterol is normal….

Intervention ….would adding

a statin….

Comparison ….in addition to

usual care...

Outcome ….lead to lower

mortality or morbidity

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Applying results to clinical practice…. e.g. MI

• Heart Protection Study (Lancet 2002)

– Statin therapy offers a 33% reduction in further CHD events in high risk patients EVEN when cholesterol normal or low

John should get the statin prescription

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ELEMENTS OF EBM








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Evaluate Performance

Audit

Clinical efficacy

Cost analysis

Patient surveys

Prescribing rates

Referral rates

Mortality/morbidity rates

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ELEMENTS OF EBM…….. In Summary








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EVIDENCE RESOURCES HIERARCHY

Most reliable -----

1] Systematic review databases

2] Review Journals

3] EBM guidelines and textbooks

4] Medline/Electronic databases

5] Opinions, texts ---least reliable

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EVIDENCE RESOURCES

1. Systematic review databases:

• The Cochrane Library:

– Best source for structured systematic reviews (SR)

– Explicit search & quality criteria

– Numerical data presented in standardized graphics enabling

quick decisions

• Database of Abstracts of Reviews of Effectiveness (DARE)

– SR structured abstracts

– Free

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EVIDENCE RESOURCES …….contd

2. Review Journals:

• Summarises systematic reviews

• Offers balanced commentary on selected papers from major

journals

Example

Evidence-Based Medicine

http://ebm.bmjjournals.com

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3. EBM guidelines and textbooks:

• Clinical practice guidelines

– The best sources rate the strength of evidence

• SIGN -- http://www.sign.ac.uk/

• NICE -- http://www.nice.org.uk/

– Always consider external validity to your patient

• Evidence-based textbooks

– Least detail, but most efficient source for simple queries

• Clinical Evidence is the best (explicit protocols)

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EVIDENCE RESOURCES…….contd

4. Medline/Electronic databases:

• Medline

– The largest biomedical literature database, but:

• Misses some journal articles, misclassifies others, lacks

comprehensiveness in psychology & sociology

• Can be overwhelming if not searching selectively

• PubMed

– is a free Medline service

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5. The least reliable:

• Colleagues or expert opinion, & “throw-away” journals

– Convenient and fast

– Often invalid , incomplete, and biased information

• Textbooks

– Generally not systematically researched

– Usually based on “expert opinion”

– Most are out of date - check for recent citations

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Some final thoughts……..

EBM

• Goal– Provide BEST patient care using current BEST evidence

• Issues– TIME required to ‘stay current’ – Research accumulating exponentially

• Challenge– Make BEST use of our limited time through

• DEVELOP information retrieval & management skills

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ON-LINE STUDENT RESOURCES

Available on

www.qub.ac.uk/cm/gp

Or

www.qub.ac.uk/qol

• Past papers

• www.qub.ac.uk/fmhs/5EBMpaper.htm

• Also see School Medicine

website for further practice

sample questions

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Thanks for your attention……..

Any Questions…………….

EBM1 EVIDENCE-BASED MEDICINE Dr. Monica Hughes Clinical Research Registrar Department General Practice.

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