Evidence based medicine

Nikmah S Idris, MD, MMed (Paed), PhD

Department of Child Health Faculty of Medicine University of Indonesia/Cipto Mangunkusumo Hospital

I am here to learn EBM because

I am working in clinical practice

I am working on evidence resources (reviews, guidelines,

reports , )

I will help others use evidence

I plan to teach EBM

My boss told me I had to attend

Introductory lecture: objectives
What (Part I)
What is evidence-based medicine?
What does it look like in practice?
How (Part 2)
Formulate a well-built clinical question
Identify searching strategies
Appraisal of research
Useful resources

guides.mclibrary.duke.edu/ebmtutorial

www.cebm.net
What is EBM?
Evidence-based medicine is
the integration of best
research evidence with
clinical expertise and patient Best research
values into the decision evidence
making process for patient
care. (Sackett, 2002)

EBM Patient
Neither clinical expertise or values
best evidence alone is enough. Clinical
expertise
The EBM cycle

ASSESS the patient

ASK the clinical question

ACQUIRE the evidence

APPRAISE the evidence

APPLY: talk with the patient

Self-evaluation
Why do we need EBM?
A dilemma
p You are very ill
Life long learning
The hardest conviction to get into the mind of a
beginner is that the education upon which he
is engaged is not a medical course, but a
life course, for which the work of a few years
under teachers is but a preparation.

Sir William Osler (1849-1919), from: The Student

of Medicine
The Prognosis of Ignorance is Poor

Worse with duration in practice

Do we know the right things?
GP beliefs about prevention for a 52 yr male
*Measure blood pressure Effective

*Advise smokers to quit Effective

*Advise heavy drinkers Effective

Probable
Measure glucose level

Effective Really Do
*Measure cholesterol
Should Do
Ineffective
Screen for prostate cancer
Ineffective
Screen for lung cancer
Probable
*Tetanus immunisation
Effective
*Screen for colon cancer

0 20 40 60 80 100

EUROPREV Network Europe.Prev Med. 2005:595-601

Croatia Estonia Georgia Greece Ireland Malta Poland Slovakia Slovenia Spain Sweden
Rule 31 Review the World Literature Fortnightly*
*"Kill as Few Patients as Possible" - Oscar London

5,000?
2000000 per day
Year
perYear

1500000
ArticlesPer
MedicalArticles

1000000 1,500
per day
95 per
Medical

500000
day
0
Biomedical MEDLINE Trials Diagnostic?
Is keeping up to date Mission Impossible?

Bluegreenblog 2006
Coping with the overload:
three possible things you might try

A. Read an evidence-based
abstraction journal or set email
notifications for your core
journals

B. Keep a logbook of your

own clinical questions

C. Run a case-discussion journal

club with your practice
Part 2: The 4 steps of pull EBM
1. Formulate an answerable question (Ask)
2. Track down the best evidence (Acquire)
3. Critically appraise the evidence (Appraise)
4. Individualise, based clinical expertise and patient
concerns (Apply)
Step 1
Formulate an answerable clinical question
Structure of researchable
questions PICO-T

Population/Patients

Intervention

Comparison

Outcome

Time
Asking a well-built clinical question

PATIENT OR PROBLEM - How would you describe a group of

patients similar to yours? What are the most important
characteristics of the patient?

INTERVENTION, EXPOSURE, PROGNOSTIC FACTOR -

What main intervention are you considering? What do you
want to do with this patient?

COMPARISON - What is the main alternative being

considered, if any?

OUTCOME - What are you trying to accomplish, measure,

improve or affect?
Type of questions

Harm (aetiology or risk factors)

Diagnosis

Therapy

Prognosis
What are your clinical questions?
p A 35 year old man says his
brother recently died of a
ruptured cerebral
aneurysm.
He is worried about
whether he might have
one and what the chances
are that it would rupture.

-> PICO Table

 Types of question: stroke
Risk Factors Frequency Prognosis
Cohort Study Inception Cohort Study
Survey

CT Scan

Treatments Treatment Effect

Randomised Trial
Symptoms
Cause(s) Signs, Tests
Cross Sectional Study
Past current future
Question Structure: PICO

Patients
Intervention Comparison

Outcomes

Page 24
Risk Factors: Do patients with rheumatoid arthritis
have higher mortality?

Patients
Indicator Comparison

Outcomes

Predictors, Risk Factors, tests

Page 24
Treatment: Do patients with rheumatoid arthritis
benefit from methotrexate?

Patients
Intervention Comparison

Outcomes

Page 24
 The best evidence depends on the type of
clinical question
1. Is this a risk factor for the disease? (HARM/
AETIOLOGY)
Cohort or case-control study
2. Does this person have the problem? (DIAGNOSIS)
Random (or consecutive) sample with Gold Standard
3. How can we alleviate the problem? (INTERVENTION/
THERAPY)
Randomised controlled trial
4. Who will get the problem? (PROGNOSIS)
Follow-up of inception cohort
The best evidence depends
on the type of question
Level Treatment Prognosis Diagnosis

II Randomised Inception Cross

trial Cohort sectional

III
The best evidence depends
on the type of question
Level Treatment Prognosis Diagnosis

I Systematic Systematic Systematic

Review of Review of Review of

II Randomised Inception Cross

trial Cohort sectional

III
Your own health care problems
p Write down one recent patient problem

What were the critical questions?

2. Acquire: finding good answers?
Getting started

Define your topic and PICO

Determine keywords

Enter keywords into database search engine

Use modifiers as needed

 Examples
You would like to know whether isoniazid
(INH) prophylaxis is effective to prevent
the development of TB disease in HIV
adults

P = HIV adults

I = INH

C = none or placebo

O = TB disease prevention
 Search strategy

Pubmed, Embase, Cochrane Library

Type of studies: randomised trial

Filter out conference proceedings/abstract

 Search terms
(human immunodeficiency virus [TIAB] OR HIV [TIAB] OR acquired
#1
immunodeficiency syndrome [TIAB] OR AIDS[TIAB]
INH OR isoniazid[TIAB] OR ((INH [TIAB] OR isoniazid [TIAB]) AND
#2 (prevention [TIAB] OR prevention [TIAB] OR prevention [TIAB] OR
prophylactic [TIAB]))

#3 (TB[TIAB] OR tuberculosis[TIAB])

#4 randomise OR randomize OR randomization OR randomisation

#5 #1 AND #2 AND #3 AND #4

3. Rapid Critical Appraisal
Its peer-reviewed, therefore it must be OK?
Main elements of critical appraisal (VIA)

Validity

Importance

Applicability
Is a treatment study valid?

Random allocation or were patients randomised?

Allocation with concealment?

Completeness of follow up

Blinding
Critical appraisal worksheet (www.cebm.net)
Applying the evidence

Integrating best research evidence, clinical expertise, and

patient preference

Talk to your patients

Evaluate your practice

Thank you