OBJECTIVES

• Introduction
• What Is EBM
• Important Of EBM
• Level & Strength Of Evidence
• CLINICAL QUESTION WORKSHEET
• Formulate a clinical question
• Search the literature
• Efficiently
• Confidently
• Appraise the evidence
• Apply the evidence
 At The Start
Two Fundamental Questions…
• What Is The Purpose Of Medicine?
• How Do I Decide What To Do?

You Have To Know Where You’re Going Before Deciding How To Get There…
 WHAT IS THE PURPOSE OF MEDICINE?
•Patient care
•Public health
•Research

Improving The Quality Of Patients’ Lives…

 How Do I Decide What To Do?

How do I make decisions?

•Dogma A-priori Set Of Beliefs : “natural is best”
•Tradition: “we’ve always done it that way”
•Convention: “everyone does it this way”
•Evidence-based: “evidence supports this way”
The Integration Of The Best Research Evidence With Clinical Expertise And
Patient Values
In other words(Tracking down the best external evidence with
which to answer our clinical questions…

It reflects a systematic approach to clinical

problem solving.
why do we need to use evidence efficiently?

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Biomedical MEDLINE Trials Diagnostic?

EBP: informing decisions with the best up-to-date evidence

“The practice of evidence-based medicine is a process of lifelong,
self-directed, problem-based learning in which caring for one's own
patients creates the need for clinically important information about
diagnosis, prognosis, therapy and other clinical and health care
issues.”
(Bordley, D.R. Fagan M, Theige D. Evidence-based medicine: a powerful educational tool for clerkship
education. Am J Med. 1997 May;102(5):427-32.)
 Evidence-based Practice

Ask clinical Acquire the

Questions best evidence

Assess
Appraise
Patient & 5A’s !!
effectiveness,
efficiency of EBM the evidence
process

Apply
evidence to
your patient
 THE EVIDENCE BASED MEDICINE PROCESS

• Start with the patient -- a clinical problem or question arises out of the care
of the patient
• P I C O
Patient Intrvention Comparison Outcome
Who? What? Alternatives outcomes
• How would I describe a • Which treatment , test or • Compared to what other • What is the patient
group of patients similar other intervention ? treatment, test, or do oriented out come, better
to this particular patients nothing prognosis rate of cure
 In patients with • Does early treat- • Compared to • Decrease cardio-
Ment with a statin Vascular mortality?
acute MI Placebo
In women with • what is the • For diagnosing
suspected accuracy of • compared to
Exercise ECG significant
coronary disease exercise ECHO CAD?
In post- • Does hormone • Compared To • Increase the Risk of
menopausal Replacement Therapy No Hrt Breast cancer?
women
 The 5 Steps Towards Evidence Based Practice
1. Ask The Right Clinical Question:
Formulate A Searchable Question
2. Collect The Most Relevant Publications:
Efficient Literature Searching
Select The Appropriate & Relevant Studies
3. Critically Appraise And Synthesize The Evidence.
4. Integrate Best Evidence With Personal Clinical Expertise, Patient Preferences And Values:
Applying The Result To Your Clinical Practice And Patient.
5. Evaluate The Practice Decision Or Change:
Evaluating The Outcomes Of The Applied Evidence In Your Practice Or Patient.
Ask clinical question
 Types Of Questions
Best Answered By EBM Resource
Type Of Question Question
Therapy question A question concerning the
effectiveness of a treatment or
preventative measure
Prognosis question A question concerning
outcome of a patient with a
particular condition
Diagnosis question A question concerning the
ability of a test to predict the
likelihood of a disease
Harm question Concerning the likelihood of
an intervention to cause harm
Example Outcome
In patients with migraine For prophylaxis of
headaches without auras, is headaches
depakote more effective than
inderal
In diabetic patients with foot Predictive of healing
ulcers, is the diagnosis of
osteomyelitis with MRI as an
audible pulse on doppler
examination
Is duplex ultrasound as good In detecting significant carotid
as MR angiography stenosis
For pregnant patients, does the Increase the rate of
consumption of large amounts spontaneous abortion
of coffee, (compared to non-
coffee drinkers)
Acquire The Best Evidence
 The 6 Prerequisites for successful Literature Searching
1
• Know how to use a computer/electronic device.

2
• Know the Internet Jargon of Terms.

3
• Know the EBM Jargon of Terms.

4
• Know how to formulate your question.

5
• Know where to go.

6
• Know what to do when you get there: the site’s technical language/know-how.
 EBM Terminology

• Knowledge: Foreground/Background
• Types of Literature Articles: Primary (Original)/Secondary (Pre-appraised)
• Clinical Outcomes: Patient-oriented vs Disease Oriented Outcomes
• Reviews: Systematic/Non-systematic (Narrative)
• CAT: Critically Appraised Topic
• Clinical Practice Guidelines
• Levels of Evidence: Hierarchy Pyramid
• Sources of Evidence: Point-of-care etc
• Knowledge Translation Resources
 Research Design
• Diagnostic tests • Cross sectional study
• Prognosis • Cohort study
• Therapy • RCT
• Patients’ preferences • Qualitative research
• etiologic • Case Control study

BMJ 1997;315:1636
 Appraise That Evidence
(closeness to the truth)
• The validity of an individual study based on an
assessment of its study design. The essence of levels of

Level of Evidence evidence is

• controlled studies > uncontrolled studies,

(LOE): • prospective studies > retrospective studies,

• randomized studies > nonrandomized studies

Strength of
• The strength of a recommendation for clinical practice
(guideline.) based on a body of evidence, usually based

Recommendation
on more than one study
• A value of the confidence in the recommendation based

(SOR)
on the quality of research
 Strength of Recommendation

A: There Is Good Research-based Evidence To Support The

Recommendation.
B: There Is Fair Research-based Evidence To Support The
Recommendation.
C: The Recommendation Is Based On Expert Opinion And Panel
Consensus.
X: There Is Evidence Of Harm From This Intervention.
 What is Critical Appraisal?

• Critical appraisal:
• The process of assessing and interpreting the evidence by systematically
considering its validity, results and relevance to the area of work considered.
• It answers 3 important questions:
• How well is this study performed?
• What does it show?
• Can I use it?
 Critically-Appraised Topic (CAT)
A standardized one-page summary of the evidence. The CAT
(Critically Appraised Topic) is a structured one-page summary and
critique of the best available evidence on a focused question.
It consists of :
1. Declarative title
2. The clinical question (PICO),
3. Search terms,
4. Summary of the study methods,
5. Clinical bottom line,
6. Table summarizing the key results and additional comments
Guideline for CAT Evaluate
how close
the
PICO of the
study

Results (reliable, valid) 1st step in CAT Type of study and SOR

Compared to
the PICO of the
clinical
Question
 Now a day
http://libguides.rug.nl/CAT_guide/pico
A computer-assisted critical
appraisal tool has been
designed to facilitate the
Oxford Center for Evidence-based
process of creating CATs and
Medicine
help clinicians save time
CAT maker assists
http://www.tripdatabase.com/
http://www.crd.york.ac.uk/crdweb
http://www.dynamicmedical.com/)
http://www.essentialevidenceplus.com/)
http://www.cochrane.org
(www.clinicalevidence.com
 Acquire the
best evidence

Acquire: Select “best evidence” resources to answer clinical questions using criteria of:
Validity – Can I trust the evidence?
Relevance – Does the evidence apply to my patient?
Time efficiency – Can I get the evidence fast?
 EBM advanced skills
EBM Hunting Tools EBM Resources

Point of Updates Evidence-

Decision Critical Evidence-Based
Care Based
New Support Appraisal Quality
Clinical Guidelines &
Evidence Systems Tools Improvement
Resources Policies
• Mc Master • Open • EBM toolbox • National
•DynaMed • AHRQ
Clinical • CATmaker Guidelines
•Essential Plus: STAT • Institute for
Dxplain • Evidence Clearinghouse
Evidence Plus REF • Emergency
Healthcare
based medicine • NHS Evidence
•First Consult • BMJ Medicine on
Improvement
toolkit • ICSI Institute • Knowledge
•UpToDate Evidence the Web • EBM for Clinical Translation
•Clinical Updates/Alert • Clinical Calculator Systems Clearinghouse
Evidence • ACP Decision Improvements • NICE
Journal Club Making
•ACP PIERS Calculators
•Effective therapies might be rejected on the basis of
“absence of evidence” of efficacy rather than “evidence of
absence” of efficacy.
•“Cook book” medicine
•Can take a long time to gather the evidence
•When is it appropriate to generalise across populations?
•Use of surrogate markers, class effects
 CASE SUMMARY

EG: 35 Year Old Male Patient With Generalized Erythematous Scaly

Plaques And Joint Pains
Clinical Diagnosis –Psoriasis, Psoriatic Arthritis
Confirmed By Skin Biopsy
 PICO - QUESTION

Is Methotrexate Better Than Retinoid For Prevention Of

Contractures In Psoriatic Arthritis In Young Male Patients With
No Other Comorbidity?
 SEARCH FOR EVIDENCE

• Which Type Of Studies (Eligibility/Inclusion/Exclusion Criteria)?

• Which Database (Eg:pubmed – Clinical Queries)?
DISCUSSION OF STUDIES (AT LEAST 4
STUDIES)

• STUDY 1
STUDY 2
STUDY 3
STUDY 4
CRITICAL REVIEW /SUMMARY
REFERENCES
Topic No Type of study strength recomendation
 PICO-CAT evaluation sheet
student Name Student ID
SN Date Block

objectives Mark Mark comment

Choose a appropriate patient / case or population 0.5
Patient
Determine the patient characteristics 0.5

Ask a related clinical Question 1

1- Clinical Q
Determine the type of question 0.5

2- evidence Determine the evidence 0.5

Mention the site of search 0.5
3- studies Study 1 Study 2 Study3 Study 4 0.5
Strength and recommendation
1
level(0.25)
Type of study (0.25) 1
Results (0.25) 1
Conclusion (0.25) 1
Comment (0.25)
5-Clinical bottom line & references 1
6- Written in clear and understandable
1
language
Total 10
Score Not pass < 6 Pass 6-7 Good >7-8 V. Good >8-9 Outstanding > 9

Faculty Name : Date:

Signature:
• EBM is recently widely applied in clinical practice
• PICO - cat is the mean process for applying EBM .
• Critical appraisal topics now days can be perform through several internet resources
• Systemic review (meta analysis) and RCT is the best recommended evidence
• In year 5 You are requested to practice at least 2 PICO-CAT forms that will be summarized in
PPT presentation and soft copy forms to be assessed by block member staff you belong
according to Roaster
 References
• Sackett DL, Strauss SE, Richardson WS, Et Al. Evidence-based Medicine:
How To Practice And Teach EBM. 2nd Ed. London: Churchill-livingstone,2000)
• Slawson DC, Shaughnessy AF. Teaching evidence-based medicine: should we be teaching
information management instead? Acad Med. 2005 Jul;80(7):685-9.