Knowledge Deteriorates in Time

EVIDENCE BASED
MEDICINE
NOEL L. ESPALLARDO, MD, MSc

. ..
Current
knowledge
on best
care

. . ........
...

r = -0.54
p<0.001

...
.... ...
.... ..

Years since graduation

CME Activities are Mushrooming

Results of an RCT About CME

Quality of care rose slightly (statistically, but
not clinically significant) in the Experimental
Practices

Big, and getting huge.

Usually instructionally (knowledge) oriented.

An identical rise was observed in Control

Practices !

Celebrity Marketing
Cybill Sheperd on
menopause

Press Marketing
Communications firm CCA

Kelsey Grammer on irritable

bowel syndrome
Richard Gomez and David
Buenevasc on vitamin E

Pharmaceutical Influence

Political Endorsement
140

GMA mulls sanctions vs

drug companies

120
100
80

only . . . is producing
low priced drugs and
only . . . is selling
them.
Philippine Star, Jul 22, 2002

60
40
1ST COURSE

20

Pharmaceutical Influence

12 15 18 21

24 27 30 33 36 39 42

Pharmaceutical Influence

140

140

120

120

100

100

80

80

60

60

40

2ND COURSE

40
1ST COURSE

20

2ND COURSE

1ST COURSE

20

INVITATION

2ND COURSE

0
0

12 15

18 21

24 27 30 33 36 39 42

Prescribing Practice
Inappropriate prescription for cardiovascular diseases
was very high
Overutilized Drugs of Unproven Benefit
calcium channel blockers
anticholesterol drugs
antioxidants

12 15 18 21

24 27 30 33 36 39 42

What is Evidence-based Medicine

Evidence-based medicine is the
conscientious, explicit and judicious use of
current best evidence in making decisions
about the care of individual patients.

Underutilized Drugs of Proven Benefit

Beta blockers and diuretics
aspirin

Evidence-based Medicine

EBM CYCLE

The practice of EBM requires the integration of

Case
Scenario

individual clinical setting and expertise

with the
best available external clinical evidence from
systematic research

Apply
Evidence

and the

Decision Making
in the Old Paradigm

The Patient

What advise will you give to her?

Pathophysiology
Hypercholesterolemia promotes coronary artery
disease thus cholesterol is a risk factor
Common sense
Lowering cholesterol also lowers the risk of
coronary artery disease
Experience
If cholesterol is elevated by laboratory
examination, it can be lowered by drugs
Experts
National Cholesterol Education Program: screen
all adult patients and intervene when necessary

The EBFCP Practitioner

EBFCP practitioner
Among elderly patients who have elevated
cholesterol will anti-cholesterol drug be
beneficial?
The search
MEDLINE
Randomized trial of cholesterol lowering in 4444
patients with coronary heart disease: the
Scandinavian Simvastatin Survival Study

Literature
Search
Critical
Appraisal

patients preference

A 72 year old female consulted in your

clinic for hypertension and elevated
cholesterol. During your discussion on
cardiac risks, she inquires about the need to
take an anti-cholesterol drug.

Clinical
Question

Evaluate
Application

Are the Results Valid

Was the assignment of patients to treatments randomized?
YES

The title, abstract and the methodology section stated

that the study was a double-blind randomized
controlled trial

Were all patients who entered the trial properly accounted for and
attributed at its conclusion?
YES

4,444 patients were randomized and analyzed

according to intention-to-treat principle. In the table
for the main analysis, the sum of patients in each
group totaled 4,444, the number who were randomized

Can the Results Help Me

in Caring for My Patient

What are the Results

How large was the treatment effect?
Plac
Tx
Mortality 12%
8%

RR
RRR
ARR
NNT

.70
.30
.04
25

How precise was the estimate of the treatment effect?

95% CI for relative risks of the different outcomes are less
than 1

Alternative Use of P 3.65 M

For secondary
prevention of death
with anti-cholesterol
drug
3.65 M per life saved

Other use of 3.65 M

7 coronary by-pass
surgery
100 coronary
revascularization
(streptokinase)
procedure in the ER
including cost of
ICU admission

Avoid Nihilism

Can the results be applied to my patient care?

YES
Subjects included in this study were patients
with angina or MI and elevated cholesterol
Were all clinically important outcomes considered?
YES
The main outcomes considered were new onset
of MI, coronary death and overall cause of death

Are the likely treatment benefits worth the potential harm and
cost?
NO
The cost per life saved is 3.65 million

What Advice Will You Give

to the 72 year old Woman
A 72 year old female consulted in your
clinic for hypertension and elevated cholesterol.
During your discussion on cardiac risks, she
inquires about the need to take an anticholesterol drug.

I would rather not give an anti-cholesterol

drug. The benefit is too small for the cost it will
take.

EBFCP is Not About Statistics

Are you the doctor who
called my wife a
standard error ? ! ? #

Non-pharmacologic Intervention

RCT on Critical Appraisal

85
80

Study Design, Setting and Subjects

Randomized controlled trial (cluster)
Department of Family and Community Medicine Philippine
General Hospital
Medical interns

75
70

Mean Scores

65
60
55
50
45
40
35
EBM Workshop

30
Baseline

Outcomes
Knowledge
Practice (scores and conformance to recommendations)
history taking skills
physical examination skills
diagnostic skills
appropriateness of non-pharmacologic intervention
appropriateness of pharmacologic intervention

Didactic Lecture

Af ter Interv ention

Linear Regression Adjusted f or Clusters and Baseline Skills (p < 0.001)

85
80
75
70

Mean Scores

65
60
55
50
45
40
35
EBM Workshop

30
Baseline

Didactic Lecture

Af ter Interv ention

Linear Regression Adjusted f or Clusters and Baseline Skills (p = 0.113)

Pharmacologic Intervention

EBM in Residency Training

EBM in Residency Training

DFCM, U-PGH

DFCM, U-PGH

EBFCP CONFERENCE (Thursdays 7-8)

Case presentation
Questions about history and physical examination
Diagnosis and differential diagnosis
Disposition
Formulate questions about the case
Assign a reporter and facilitator for the following
Thursday (educational prescription)

Can Appraisal of Guideline Improve

Practice?
Appraisal of CPG at DFCM had mixed results
Appropriate
Non-pharmacologic Treatment
30%

Appropriate
Pharmacologic Treatment
43%
32%

7%

Before
After
Dissemination

EBFCP CONFERENCE (Thursdays 7-8)

Recall question
How the search was done
Appraisal of the searched article
Resolution of the problem

EBM and Quality of Care

% Improvement in Appropriateness

Diagnosis
History
Physical Examination
Endoscopy Request + 3
Treatment
Follow-up Advice

Feedback
0
+ 10
+ 13
10
+ 25
+ 15

No Feedback
0
0
-3
-3
-8

Before
After
Dissemination

EBM Program Evaluation

EBM Acceptability Survey

Objectives

68% perceived that the objectives are attainable.

EBFCP
ACTIVITIES

RELEVANCE TO RESIDENCY

RELEVANCE TO FUTURE
PRACTICE
BEFORE
AFTER
p-value

BEFOR
E

AFTER

p-value

Formulating
question

36.54

37.50

.917

32.70

41.67

.038

Searching
literature

37.57

36.39

.789

35.34

38.80

.436

Critical
appraisal

37.46

36.50

.824

35.76

38.34

.573

Computation of
stat

36.30

37.76

.754

36.72

37.30

.904

Applying to
patients

35.71

38.40

.430

33.07

41.27

.044

Presenting

38.12

37.71

.624

39.00

34.83

.387

100% perceived EBFCP-QA-Research activities as relevant

97% would advocate the use in patient care
82% believed that EBFCP-QA activities were adequately applied
in daily activities

Areas for improvement

clarify objectives, emphasizing applicability in actual practice,

skills training, upgrading both the faculty skills and resource
materials

Pathophysiology and Common Sense is

Not Enough

Decision Making: Old Paradigm

Relevance and effectiveness of the activities

Pathophysiologic understanding
Common sense
Experience
Experts

Plac

Treat

Cholesterol
Non-fatal MI
Total MI

1.0
0.72
0.89

-9.0
0.58
0.74

Deaths

0.52

0.62

Others?

Experts Cannot Agree on

Effectiveness of Treatment

Experts vs. Evidence

Management of asthma in
general practice

9
7

Steroids consider as first

line maintenance

5
3
1
0%

20%

40%

60%

80%

PEFR monitoring should

be done

Experts Are Not Up-to-date

65

143

4
7
10
11
15
17
22
23

316
1783
2544
2651
3311
3929
5452
5767

27
30
33
43
54
65
67
67

6125
6346
6571
21059
22051
47185
47531
48154

1965

Steroids confer minimal benefit

but significant increase in cost to
asthma patients in general
practice

1970

1975
1980

PEFR monitoring is as good as

symptom monitoring in general
practice

1985
1990

p < 0.01
1
1
2
p < 0.001
p < 0.0001
5
15
6
Favors Tx

Decision Making
in the New Paradigm
Medical Evidence

Pathophysiologic understanding
Common sense
Experience
Experts

1
1
1
2
8
1

8
7
2

Not
Mentioned

2.0
Experimental

1960

1.0

23

Routine

Rare/Never

0.5

Management of asthma in general

practice

Specific

Experts vs. Evidence

21
5
10
2
8
7
8
12
4
3
1
6

Favors Ctrl

Keep on Asking
Keep on Searching
Keep on Learning

Others?