Chapter 13 The Practice of Evidence-Based Medicine

Natasha Micah S. Paida

What is Evidence-Based Medicine?

 Evidence-based medicine or EMB combines

with the practitioners clinical expertise and the patients desire and values with the conscientious and judicious use of current best evidence from the clinical literature.

 Clinical expertise ones ability to identify

the patients diagnosis, risks and benefits, and specific clinical circumstances.
Patients values refer to the individual

patients concerns, expectations and preferences that must be integrated into clinical decisions.

The Three Components of Evidence-Based Medicine

The Five As of Evidence-Based Medicine

Assess the patient of information need Ask a focused clinical question Acquire the best available evidence to
answer the question

Appraise the quality of the evidence

Apply the new information to patient care

Assessing the Patient

A real clinical case

A 37-year old female patient is admitted to the hospital with

fever, jaundice, and a tender liver after a 1 week alcohol binge. She is diagnosed with alcoholic hepatitis. You are on rounds with the medical team caring for the patient, and they have reported that the liver specialist has recommended pentoxifylline therapy for the patient. The physicians have not used this treatment before and want to know whether it will really decrease the risk of mortality. They ask you to research this further and bring information to the team.

This is the first step. The team has done this together and has made the diagnosis of alcoholic hepatitis. During this assessment, they have identified an information need regarding pentoxifylline use in the setting of alcoholic hepatitis.

What is PENTOXIFYLLINE ?

Pentoxifylline is able to increase the flexibility of red blood cells, reduce blood viscosity, and increase the bloods ability to break down blood clots.

The overall effect is to make blood more liquid and to enable the red blood cells to travel deeper into tissues than they would normally be able to. This enables better oxygen delivery to tissues and improved circulation from smaller blood vessels

Asking Focused Clinical Questions : PICO Format

 An important part of an efficient EMB

exercise is to build a focused question out of the clinical need so that the research results are concise and the obtained information does not overwhelm the searcher. In order to do this

the PICO format is used.

- a word or phrase for the patient or clinical

problem

- the

intervention

- any comparison intervention being considered

- outcome of concern

 In your PICO format, the

terms become: P- alcoholic hepatitis I- pentoxifylline C- (none for this case) O- mortality

Acquiring Evidence: Different Resources For Different Information Needs

 We consult others for more specific

questions, such as aspirin for stroke prevention in a clinical trial from PubMed or in a consensus statement from a national neurology. In this section, we will discuss the general attributes, strengths, and weaknesses of a few evidence resources, using the preceding clinical case.

PubMed

 A service of U.S. National Library of

Medicine and free through the Internet, PubMed contains millions of biomedical citations, from MEDLINE and other life science databases, immediately upon their release.

 Strengths include that it is the most

current and comprehensive evidence resource, it has several tools to improve the accuracy of a search, and it is free without subscription

 For your alcoholic hepatitis patient, you

type into PubMed: alcoholic hepatitis and pentoxifylline and mortality. You obtain over a dozen articles- too many to read in their entirety and share with the team. Using the Limits function, you choose to limit your search to Randomized Controlled Trial because this is the best type of therapy trial.

ACP Journal Club

A product of American College of Physicians ( an internal medicine society ), ACP Journal Club is a journal that reviews over 100 other internal medicine journals in order to publish short summaries of those articles considered by EBM experts to be of the highest quality and greatest importance to the field of internal medicine

 Strengths include the ease of reading a

short summary rather than an entire article and the expert review provided. Weaknesses include the lag time required for identification and summarization of the important clinical trials and the subscription fee imposed. (Note that some institutions pay the subscription free, making online access free through their networks)

 You notice that the article you found was

published in 2000 and wonder whether it has been reviewed by the ACP Journal Club in the interim. You type the same search , alcoholic hepatitis and pentoxifylline and mortality, into ACP Journal Clubs search box and get one result. This is in fact, an expert review of your article, giving the synopsis and pertinent results!

UpToDate

 An online educational product begun in

19989, UpToDate contains thousands of chapters on basic pathophysiology and current treatment recommendations for diseases of interest to internists, family practitioners, gynecologists, and pediatricians.

 Strengths include its comprehensive and

easy-to-read listings with extensive bibliographies. Weaknesses include the high subscription price and the lag time required for its authors to search, summarize, and publish information. (Note that some institutions pay the subscription free, making online access free through their networks)

 You first search just the words alcoholic

hepatitis and come up with the several chapters describing the pathophysiology, diagnosis, and the treatment of the illness in addition to other aspects of alcoholic liver disease. Briefly scanning, you learn about the seriousness of this problem and its high mortality.

 Next you add the term pentoxifylline

and find a chapter containing a statement that one trial found this drug efficacious. You have learned a lot more about alcoholic hepatitis, but not whether pentoxifylline is definitely recommended.

National Guideline Clearinghouse

 A comprehensive database of evidence-

based clinical practice guidelines, National Guideline Clearinghouse is maintained by the federally funded Agency for Healthcare Research and Quality in order to disseminate clinical practice recommendations to health-care providers.

 Strengths include its concise and usually

evidence-rated recommendations, as well as that is free through the Internet at www.guidelines.gov. Weaknesses include the wide variety of guideline authors and the retention of some outdated guidelines.

 It occurs to you that perhaps a society of

liver specialists has published a guideline on the care of patients with alcoholic hepatitis. You enter your PICO terms in the search box of National Guideline Clearinghouse, but get no results. Because this search may be too specific, you enter only alcoholic hepatitis which produces 11 related guidelines. Reviewing the titles, you see that none specifically addresses your patients illness, so you abandon this resource for this particular occasion .

Cochrane Reviews

 Produced by a nonprofit EBM

collaboration, Cochrane Reviews are very high-quality, evidence-based reviews addressing well-researched clinical questions. Most often, multiple randomized controlled trials addressing the same clinical question are combined in a metaanalysis to produce these reviews.

 Strengths include the expert analysis used

to produce a single best summary of multiple trials; weaknesses include the lag time required to produce such a highquality summary, during which new evidence may be published. In this authors opinion, the Cochrane Web site is very complex to search, and the most, and the most efficient to find a Cochrane Review is through a PubMed limit, as illustrated in the following clinical context:

 To check for an expert Cochrane Reviews

on this topic, you type alcohol hepatitis into the PubMed search box and the select the Limits, you choose Search by Journal and type in Cochrane. Clicking on the choice revealed, which is Cochrane date-base of systematic reviews, you then click Go to repeat your search and get four different Cochrane Reviews.

 Two reviews address other agents for

alcoholic liver disease, anabolic-androgenic steroids and propylthiouracil, but neither is about pentoxifylline. To see whether steroids or propylthiouracil helped, you quickly review those two abstracts. Neither had a significant effect on survival according to the Cochrane expertsinformation you might mention when you present your pentoxifylline data to the team.

Comparison of Resources

 PubMed reveals the most recent data and

finds the clinical trials that match our question, if they have been done.

ACP Journal Club summarizes the

publication, if its quality and pertinence are high and UpToDate, National guideline Clearinghouse, and Cochrane Reviews provide summaries that place the trial in a broader clinical context.

 The searchers needs dictate which

resource is used; for example, a liver specialist might want only the most recent publications from the PubMed, while a pharmacy student might need to review pathophysiology and other treatment options in a source like UpToDate. With database familiarity, information from all them can be combined within a few minutes of searching.

 Notice that among the resources discussed

before, all but PubMed re prescreened,, tertiary databases; in other words, the evidence has been synthesized and summarized by others. This requires a considerable amount of time during which new evidence may become available.

 For this reason, searches in a screened date-

base should be typically followed by a search in PubMed to obtain any more recent publications. Additionally, the reader is probably aware of several resources that have not been discussed previously.

 The choices presented here are based on

their wide availability and complimentary attributes. The practice of EBM optimally includes an effort to be aware of new evidence resources as they become available.