ebm evidence based medicine,

7/28/2019 EBM evidence based medicine,

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Assistant ProfessorHanan abas abdo abdel rahman

Family MedicineSuez Canal University


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1. What What is evidence-based medicine?

What does it look like in practice?

2. How Formulate Clinical Questions

1. Search for Evidence2. Appraisal of research

3. Apply to clinical problem


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1. I am working in clinical practice

2. I am working on evidence resources (reviews,guidelines, reports , )

3. I will help others use evidence

4. I plan to teach EBM

5. My boss told me I had to attend


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Review the World LiteratureFortnightly*

*"Kill as Few Patients as Possible" -Oscar London


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Evidence-based medicine is the integration of bestresearch evidence with clinical expertise andpatient values

- Dave Sackett

Patient

Concerns

ClinicalExpertise

Best researchevidence

EBM


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only a tiny proportion of all research isready for application

only a tiny fraction of the ready research

is relevant to the practice of a givenclinician

only a tiny proportion of the relevantresearch for a given practitioner is

interesting in the sense of beingsomething new, important, and actionable.


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Toward

curiosity

Prove colleagues wrong

Keeps coming up Risk of patient harm

Want to do better

Anxiety

Avoid litigation

Internet informedpatient

AwayTimeWe already know the answerFatigueAccessInferiority complex-anxiety-

afraid of admittingknowledge gaps

CynicalLaziness

Lack of supportPrevious failure at searchingLack of resourcesNoone else does itFear of change


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Ready to Feeling Behaviors

Flee Fear Leave

Invisible

Fight Anger Disrupt

Undermine

Cry for help Distress Stop tryingBody stress

Withdraw Sadness Inattention

Detachment


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Satisfaction: Self image of knower

Curiosity:

Joy: knowing and/or learning brings benefits

to others


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Ask

Acquire

Appraise

Apply

Act & Assess

Patientdilemma

Principles of

evidence-basedpractice

Evidence alone does notdecide combine with other

knowledge and values

Hierarchyof evidence

Process of EBP


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*Allen, Glasziou, Del Mar. Lancet, 1999

10 trials of bed rest after spinal puncture

no change in headache with bed rest

Increase in back pain

Protocols in UK neurology units - 80%still recommend bed rest after LP

Serpell M, BMJ 1998;316:170910

evidence of harm available for 17 yearspreceding...


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Shift focus to current patient problems(just in time education) Relevant to YOUR practice

Memorable and behaviour changed!

Up to date Skills and resources for best current answers

Dave Sackett


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A. Read an evidence-based

abstraction journal

(and cancel other journals)

B. Keep a logbook of yourown clinical questions

C. Run a case-discussion journal

club with your practice


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Introductionof new ideas

Presentingnew material

and concepts

Practice andconsolidation

Using realexamples,

real language

Debriefingand

Reflection

Evidence

Learning

cycle


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1. ASK a focussed question2. ACCESS - search for epidemiological evidence to help

answer question3. APPRAISE the evidence for its validity, effect size,

precision)4. AGGREGATE the evidence with patient/community,

clinical/hlth & policy issues & make an evidence-based decision

5. APPLY your decision

6. [AUDIT your practice (i.e. check your actual practiceagainst evidence-based practice on a regular basis)].


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About patient care decisions and actions

4 (or 3) components:

a. patient, problem, or population

b. intervention, exposure, or maneuver

c. comparison (if relevant)

d. clinical outcomes (including time)


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1. Formulate an answerable question

2. Track down the best evidence

3. Critically appraise the evidence

4. Individualize, based clinical expertise and patientconcerns


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Structure of researchablequestions PICO-T

Population/Patients

Intervention

Comparison

Outcome

Time


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Outcomes ?

Patients

Qualitative Research


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A 35 year old man says hisbrother recently died of aruptured cerebral

aneurysm.He is worried aboutwhether he might have oneand what the chances are

that it would rupture.

-> PICO Table


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12 occupational therapy questions

E.g., Is a 38-year old sewage worker subject to ahigher risk of contracting Hepatitis A as a result ofoccupational exposure? (No)

Obtain advice from 2 professionals on 3 caseseach.

37% wrong answers

17% wrong if based on literature

65% wrong if not

Schaafsma BMC Health Services Research 2005


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Patient / Problem / Population

InterventionComparison

Outcome


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Youre a community midwife running and

antenatal group.

Following the recent appearance on television

and newspapers about celebrities smokingduring pregnancy , one of the women asks for

advice on using nicotine patches to help her

give up smoking for the rest of the pregnancy.


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P: Pregnant smokers

I: nicotine replacement

C: N/AO: cessation

Is nicotine replacement therapy an effectiveand safe smoking cessation treatment inpregnant women?


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P P I OPregnant

Pregnancy

maternal

Smoking

Smoker

Nicotinereplacement

Nicotine patch

Nicotine gum

Cessation

Stop

Quit


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Its peer-reviewed, therefore it must be OK?


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What do the resultsmean on average?

What do they mean

for this individual?


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Participants

Exposure Group Comparison Group

OutcomesTime

P

E C

O

T

All epidemiological studies can be hung on the GATE frame


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1. Participants (patient(s) you want to treat)

2. Exposure (an intervention if about therapy)

3. Comparison (there is always an alternative! -another therapy, nothing

4. Outcome (usually a disease or condition you wantto prevent or manage)

5. Time frame (over which you expect a result)


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1. Determine best practice (EBP Steps 1-4)

2. Assess current practice: survey

3. Compare with best practice - is there a gap?

4. Consider reasons for gap, identify processes to

reduce gap & implement

5. Re-survey: is there any improvement?

= quality improvement / audit

The evolution of information resources for


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Systems

Summaries

Synopses

Syntheses

Studies

Examples

Computerized decision

support

Evidence-based

textbooks

Evidence-based journal

abstracts

Systematic reviews

Original journal articles

The evolution of information resources forevidence-based decisions


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Can the new incretin therapies (eg,exenatide, pramlintide or sitagliptin)

help?


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Harrisons Textbook nothing

Books@Ovid nothing

Kelleys Textbook - nothing


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TRIP

SUMSEARCH

CLINICAL QUERIES

A CAT documents the steps for a specific question

Download from www.epiq.co.nz


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Groups of 2 3

Discuss >1 question

from recent work Write it down

Be ready to report to

group Return in 2 minutes


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In woman immediately postpartum, notlactating, when should she begincontraception

50 yr old pt with htn, how effective is ASA inreducing CV risk

When can a 55 yr old nurse with RA return towork


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In pt with cough, chills, fever, does ct scan comparedwith x-ray confirm the dx

In pt with cough, chills, fever, does multidisiplinaryconsultation improve outcome compared withprimary care clinician

In a pt with cough, chills, fever will ct scan changerisk of death

In pt with cough, chills, fever do 3 antibiotics speedrecovery compared with single therapy

In 1st yr residents, does teaching EBM improvelearning and practice compared with traditionallearning

In pts with pneumonia is outcome better with 3 vs 1physicians


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Consider:

What is illness?

What is role? What are

learning needs?

What areavailableresources?

Of these, select:

Most urgent

Most interesting Most feasible to

answer

Most likely torecur


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1. Work through the first step of EBP.

2. Allocate sources of evidence to participants.

3. Give them 10 minutes to find the evidence.

4. Compare experiences.


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Teaching EBM wikihttp://tebm-libs.wikispaces.com/

Wetpaint EBM Librarian wikihttp://ebmlibrarian.wetpaint.com

Teaching on the Run series by Medical Journal of

Australiahttp://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/

Create your own EBM sitehttp://www.ebmpyramid.org/home.php

Exploring the evidence basehttp://clinicallibrarian.wordpress.com/2008/08/ Evidence-based nursing resources useful for all

disciplineshttp://:muhc.ebn.mcgill.ca/EBN_tools.htm

CEBM : centre for evidence based medicine
http://tebm-libs.wikispaces.com/http://ebmlibrarian.wetpaint.com/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://www.ebmpyramid.org/home.phphttp://clinicallibrarian.wordpress.com/2008/08/http://muhc.ebn.mcgill.ca/EBN_tools.htmhttp://muhc.ebn.mcgill.ca/EBN_tools.htmhttp://clinicallibrarian.wordpress.com/2008/08/http://clinicallibrarian.wordpress.com/2008/08/http://clinicallibrarian.wordpress.com/2008/08/http://clinicallibrarian.wordpress.com/2008/08/http://clinicallibrarian.wordpress.com/2008/08/http://www.ebmpyramid.org/home.phphttp://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://ebmlibrarian.wetpaint.com/http://tebm-libs.wikispaces.com/http://tebm-libs.wikispaces.com/http://tebm-libs.wikispaces.com/


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