Académique Documents
Professionnel Documents
Culture Documents
Dubai, UAE
Karachi, Pakistan
October 2003
1. Definition of EBM
2. Basic Steps
3. Trials, Studies and Reports
4. Pros, Cons and Limitations
5. EBM in Developing Countries
6. EBM Library
7. Advanced EBM
But first, a test…
WHAT IS THE BASIS OF YOUR
MEDICAL PRACTICE?
EXCELLLENT!
A. Training, clinical experience and consultation
with other professionals
FANTASTIC!
ARTICLES ADVERTISEMENTS
WHAT IS THE BASIS OF YOUR
MEDICAL PRACTICE?
WONDERFUL!
A. Training, clinical experience and consultation with other
professionals
WOW!!! SUPERB!!!
A. Training, clinical experience and consultation with other
professionals
1. Definition of EBM
2. Basic Steps
3. Trials, Studies and Reports
4. Pros, Cons and Limitations
5. EBM in Developing Countries
6. EBM Library
7. Advanced EBM
“What is Evidence Based Medicine?”
“And where did it come from?”
A BRIEF HISTORY
1980’s: McMasters University in Ontario, Canada
Dr. David Sackett and colleagues proposed Evidence
Based Medicine (EBM) as a new way of teaching, learning
and practicing medicine.
Question
or
Problem
PHYSICIAN
INFORMATION
THE ADDED DETAILS
PATIENT
Values, Concerns Preferences,
Expectations
Life predicament
EBM
PHYSICIAN INFORMATION
Training & Experience Clinically relevant
Current Expertise Proven by research
Continued learning Best up-to-date
Demand for proof evidence
OPTIONAL
COMPONENTS
PATIENT
TO BE ADDED BY
THE PHYSICIAN Values, Preferences
Concerns, Expectations
Life predicament
HUMILITY CHARITY
Non-authoritarian EBM is not a
practice required practice
(yet)
EBM
PHYSICIAN
Training INFORMATION
Expertise ENTHUSIASM Clinically relevant
Continued Learning Challenge, Variety, Proven by research
Demand for proof Change Current, up to date
“Isn’t this the way “Aren’t these just the
we have always same old ingredients
practiced medicine?” tossed into a new
recipe?”
Or is he about
to FIRE me?
Lee, exactly how
much time did you
spend on that big
project?
A GOOD QUESTION…
• Is focused and relevant
• Provides clear
communication
• Clarifies your goal or need
• Will reduce the amount of
time needed to obtain the
answer
WHEN PRACTICING EBM, ACTUAL CASE SCENARIO
a good question must also: Large cauc male, age 40
2mo ago: Presented with classic
• Be specific
nephrotic syndrome, significant
Identify the problem, clarifiy
symptoms. Bx showed IgAN. Cr
the clinical issue
1.4, incr to 2 range, now 1.6
Regards,
Dr. Paulose P. Thomas
Nephrologist - Belhoul Apollo Hospital, Dubai, UAE
BACKGROUND and FOREGROUND QUESTIONS
(all part of EBM)
FOREGROUND QUESTIONS
NEW POSSIBILITIES
INDEFINITE ANSWERS
“Where do we want to go,
and how else might
we get there?”
1. QUESTION
• Who, What, Where, When, Why, How
2. VERB
• is, causes, does, treats, reduces, cures, prevents, affects
COMPARISON INTERVENTION
OUTCOMES
Example:
MAJOR CATEGORIES
1. Diagnosis
2. Prognosis
3. Therapy/ Treatment PICO
4. Harm (iatrogenic, other) PEO
MISCELLANEOUS
• Quality of care
• Health economics
• Office Management
• Etc.
THE PATIENT’S QUESTIONS
Must be considered!
• Diagnosis
• Prognosis
• Therapy
• Harm
WHAT STUDY DESIGN FITS IT BEST?
There are MANY study designs!
EXPERIMENTAL TRIALS
(Answers questions of diagnosis or treatment)
Randomized Controlled Trials (RCTs)
Controlled studies
Blinded vs Open
ETC.
OBSERVATIONAL STUDIES
Descriptive reports
Retrospective studies
Cohort studies
Case Control
ETC.
EXAMPLE
Still not always the right intervention for individual patient at that particular time and
place
What type of evidence best addresses the question, problem or issue?
CLINICAL PRACTICE APPROPRIATE DESIGN FOR CLINICAL RESEARCH
Exceptions:
When treatment may be successful in an otherwise fatal condition
When no studies are available (rare conditions, new treatments, etc.)
OTHER INFORMATIONAL
Explore hypothesis Qualitative research
History-taking Case control study
Individual trial & error n of 1 trial
Following clinical course Cohort study
Recordkeeping Systematic registry-based (computer supported) research
Quality of Care research Individual peer review, Process Evaluation
Case report
Controlled Trial
Systematic review
Meta-analysis
Clinical guidelines
etc.
LITERARY SEARCH: NEXT STEP
IDENTIFY YOUR RESOURCES
Colleagues
Consultation, Discussion
(Caution: Response may be an outdated “This is what we do”)
Paper resources
books, reports, journals
Electronic databases
SPECIALIZED PERSONNEL
• track down information, textbooks, articles,
guidelines
• may provide electronic search support or training
EXAMPLES
• Medical Librarians
• Medical Informatics Specialists
• Specially trained staff member
LITERARY RESOURCES
• META-ANALYSIS
Bibliographic Database
Example: Medline, PubMed
Review Services
Subjective
Systematic Reviews
Meta-analysis
Examples:
• Cochrane,
• Best Evidence,
• Up to Date
MORE GREAT INTERNET RESOURCES
Websites
cyberNephrology, National Kidney Foundation. NIDDK,
American Heart Association, American Cancer Society.
National Institutes of Health, etc
Tapes
Videos
CD-ROMs
Specialty seminars
Catalogs articles from approx 4000 world journals (of estimated 12-15k total)
SEARCH METHODS
Any word or words (title, abstract, content, author name, institution, etc.)
BENEFITS
Free
Vast database
LIMITATIONS
Not all articles are indexed on Medline (only 1/3 of approx 10 million!)
Much material listed and described on Medline can only be accessed through
journal article
MEDLINE: ELECTRONIC SEARCH STRATEGIES
Search filters
Search by a text word can supplement a MeSH search
Boolean search: “and”, “not”, etc.
To increase sensitivity
• use “explode” command
• avoid using subheadings
Etc.
BEST EVIDENCE
Electronic version of two publications:
IMPORTANT!
You do NOT have to become a researcher,
epidemiologist, or statistician to practice EBM.
HOWEVER…
STUDY DESIGNS
THE TIME FACTOR
When was the study done?
What was its duration?
In what time direction is it headed?
RETROSPECTIVE PROSPECTIVE
THE TIME FACTOR
RETROSPECTIVE PROSPECTIVE
RETROSPECTIVE PROSPECTIVE
PRO
•Lower risk of bias
PRO
•May provide good
CON:
direction for future study
May get faulty results based
“Hind Sight is 20/20”
on incomplete data or
CON: insignificant subgroups
•Prone to Bias
(Example of Error: Untreated
•A“Fishing Expedition” for hypertension unlikely to cause
positive results cardiac event in child, so treatment
PRESENT is unnecessary below age 18yrs)
“Was there a similar comparison group?”
No comparison group
All subjects receive Experimental Intervention
Experimental
Intervention
UNCONTROLLED STUDIES
NO EVENT
Experimental
Intervention
OUTCOME
EVENT
SMALLPOX VACCINE
1. 1796: Edward Jenner inoculates 8yr-old James Phipps with cowpox virus
from a milkmaid’s hands.
Child develops illness, recovers.
2. Two weeks later, inoculates same child with smallpox virus.
Child survives, no illness.
(Centuries later, smallpox eradicated!)
n=1
UNCONTROLLED TRIALS: “TRIAL AND ERROR” n=1
Example #2 NO
OUTCOME
Drinks culture of
H.pylori
Dr. Marshall SEVERE
Microbiologist GASTRITIS
Experimental
Intervention
Present
FUTURE
STRONGLY PREFERRED! Reduces BIAS. Provides stronger results.
Experimental
Intervention
Control
Group
CONTROLLED STUDY
Only the TEST group receives the Experimental Intervention
ExperimentalI
ntervention
Nothing IMPORTANT
Placebo All other differences
should be minimized or
Observation only
eliminated to reduce
Other potential BIAS
Gold Standard
Treatment
RANDOMIZED CONTROLLED TRIAL (RCT)
“The Gold
Standard”
Experimental
Intervention
Control
Group
THE FIRST RANDOMIZED CONTROLLED TRIAL
By Sir Austin Bradford Hill
Streptomycin
(n=50)
(BLINDED)
Bedrest
(n=50)
Experimental
Intervention
OPEN
Control
Group
OPEN vs BLINDED STUDIES
BLINDED
TRIAL
BLINDED
BLINDED
TRIAL
BLINDING
SINGLE BLINDED:
Pt unaware of what group s/he is in
DOUBLE BLINDED:
Pt and MD unaware
OPEN LABEL:
Everyone is aware
RANDOMIZED vs NON-RANDOMIZED TRIALS
Experimental
Intervention
How is this
group divided?
Control
Group
NON-RANDOMIZED
Experimental
Intervention
Assigned to
groups, usually
by the
researcher
Control
Group
Experimental
Intervention
Random method of
assignment used
Control
Group
Experimental
Intervention
Control
Group
Present
FUTURE
One patient, series of tests n=1
TRIAL SERIES FOR INDIVIDUAL PATIENT
GOOD GOOD
Experimental Experimental
Intervention Intervention
Trial of Medicine Trial of Medicine
1 2
Or placebo Or placebo
NO CHANGE NO CHANGE
OR BAD OR BAD
Why a TRIAL SERIES for one patient?
BENEFIT
Produces data most applicable to the individual patient
EXAMPLES:
Trial of different medications and/or placebo for child reported
to have ADHD symptoms that are not clinically apparent
Trial of different analgesics for patient with chronic pain from
a combination of diseases not previously studied
PATIENT PHYSICIAN
•Must be blinded •May need to be blinded (enlist help
•Must keep diary or complete of pharmacist!)
questionnaire •Must treat patient as usual in all
other respects
CROSSOVER TRIALS
ONE GROUP, MULTIPLE TESTS
Intervention Intervention
A A
Intervention Intervention
B B
ASSESS ASSESS
OUTCOMES #1 OUTCOMES #2
COMPARE OUTCOMES
CROSSOVER TRIALS PROS & CONS
Fewer participants needed than a RCT!
Intervention Intervention
A A
Intervention Intervention
B B
ASSESS ASSESS
OUTCOMES #1 OUTCOMES #2
Intervention Intervention
A A
Intervention Intervention
B B
ASSESS ASSESS
OUTCOMES #1 OUTCOMES #2
RISK FACTOR?
(PAST) Present
CASE CONTROL
(“A LOOK BACK”)
HEALTHY
NEVER
SMOKED
RISK FACTOR
LUNG CANCER
SMOKER
(PAST) Present
CASE CONTROL
(“A LOOK BACK”)
NON-DIABETIC
NORMAL
WEIGHT
RISK FACTOR
DM TYPE II
OBESITY
Present
COHORT“FOLLOWUP DESIGN”
IS RISK
FACTOR
PRESENT?
(Exclude those
with outcome
already!) Future Outcome
TO INVESTIGATE ETIOLOGY
COHORT OR HYPOTHETICAL CAUSE
OF DISEASE/OUTCOME
IS RISK
FACTOR
PRESENT?
“FOLLOWUP DESIGN”
Present Future Outcome
COHORT EXAMPLE
RISK FACTOR
Hgb <9
DIALYSIS PATIENTS
A look back
CROSS SECTIONAL DESIGN
OTHER CAUSES
RISK = SLEEP PRONE
INFANT
SIDS DEATHS DEATHS
Problems of looking back
NON-SIMILAR
CONDITIONS
Social VARIATION IN
Personal TREATMENT
Comorbid conditions OR METHOD
Other treatments
Etc.
CURRENT
GROUP OF
NO PATIENTS
Not usually
CONTROL
accepted by
OVER
medical journals
CONTROL
(accepted in
GROUP
popular press,
not reviewed)
RANDOMIZED & CONTROLLED TRIAL (RCT)
Experimental
Intervention
MAY BE
BLINDED
Control
Group
PROSPECTIVE
START WITH YOUR TARGET POPULATION
START WITH YOUR TARGET POPULATION
SIDE NOTES…
Study should be approved by an
Ethics Committee
Informed consent should be
obtained from study participants
SAMPLE GROUP MAY BE SUBDIVIDED FURTHER
STRATIFICATION
Divide into subgroups based on
important similar characteristics
RANDOMIZATION
Divide into sub-groups based on
unknown confounders
STRATIFICATION
Examples:
• Male or Female
• Age
• Stage of illness
• Prior illness or treatment
• Hospital vs Office groups
• Comorbid condition
• Etc.
EXAMPLE OF
STRATIFICATION
FEMALE
MALE
RANDOMIZATION
“unknown confounders”
Examples:
• Postal code
• Month of birth
• Random number
• Etc.
EXAMPLE OF
RANDOMIZATION
DX IN JANUARY-JUNE
DX IN JULY-DECEMBER
Next… Divide your sample group(s) into STUDY GROUPS
Experimental
Intervention
“Test Group”
Control
Group “Baseline Group”
Next… Divide your sample group(s) into STUDY GROUPS
“Test Group”
Experimental
Receives Experimental
Intervention Intervention
“Baseline Group”
• Nothing
• Observation
Control • “Same” miscellaneous
Group intervention (non-
experimental)
• Placebo
• “Gold Standard” therapy -
especially if unethical to do
otherwise!
ASSIGN PATIENTS TO STUDY GROUPS
Experimental
Intervention
Control
Group
usually assigns
patients to study
groups.
Experimental
Intervention usually has a
personal preference
for the treatment or
patient
might unconsciously
“work harder” to
Control make the study work
with non-preferred
Group candidates
= POTENTIAL FOR
BIAS
RANDOMIZED CONTROLLED TRIAL (RCT)
Experimental
Intervention
Use random
separation
and assignment!
Control
Group
RANDOMIZED CONTROLLED TRIAL (RCT)
Experimental
Intervention
Control
Group
RANDOMIZED CONTROLLED TRIAL (RCT)
Experimental
Intervention
Control
Group
Present
Proceed with study
FUTURE
RANDOMIZED CONTROLLED TRIAL (RCT)
Experimental
Intervention
EXPERIMENTAL EVENT
RATE (EER)
Control
Group CONTROL
EVENT RATE
(CER)
RANDOMIZED CONTROLLED TRIAL (RCT)
“The Gold
Standard”
Experimental
Intervention
EXPERIMENTAL EVENT
RATE (EER)
Control
Group CONTROL
EVENT RATE
(CER)
Present
FUTURE
Disadvantages of RCT
Expensive
large # pts needed
Prolonged recruitment and follow-up time needed
Funding difficult to obtain except w/support of
pharmaceutical companies (problematic!)
RETURN FROM DETOUR
THE FIVE BASIC STEPS OF EBM
1. Clinical Question
Patient-focused, problem-oriented
2. Find Best Evidence
Literary Search
3. Critical Appraisal
Evaluate evidence for quality and usefulness
4. Apply the Evidence
Implement useful findings in clinical practice
5. Evaluate
The information, intervention, and EBM process
CRITICAL APPRAISAL
Quality
Usefulness
…BY ASSESSING
Validity
Reliability
Relevance
Clinical importance
Critical Appraisal: VALIDITY
By whom?
• credentials?
• affiliations?
Sample population
Did the subjects represent an appropriate test group?
How were they selected?
Were controls used?
Were groups similar for important prognostic characteristics?
VALIDITY
How was the information gathered and processed?
Were groups treated equally except for trial therapy?
Were appropriate criteria used to measure results?
Were criteria applied rigorously?
Results
Are the results believable?
To what degree of confidence?
Ex: Disagreement is not uncommon on angiograms, EKGs, radiographs, pathology, PAP
tests, etc.
VALIDITY
Comprehensiveness
Size: Was it large enough to yield credible results?
Thoroughness: Was it complete enough?
Duration: Was it long enough?
CRITICAL APPRAISAL: RELIABILITY
2. REPRODUCEABILITY
3. INTERPRETATION OF RESULTS
4. BIAS
RELIABILITY
Was the type of study design used proper for the question?
Example:
RCT would be choice for questions on TREATMENT
RELIABILITY
Are the Measurements and Results reproducibile?
Different determinations may be caused by:
• Variation in measurement methods
• Different interpretation of results
• Lack of agreement
Example:
BP checks on same patient may vary. Are differences result of pt factor, examiner
factor, treatment factor, normal variance
INTERPRETATION OF RESULTS
Is there consistency among researchers?
EXAMPLE:
BANFF CONFERENCE - Setting standards in Transplant Pathology
established by Kim Solez, MD
• PATIENTS
• RESEARCHERS
PATIENT BIAS
Hawthorne Effect
Biased goal?
To satisfy editors and reviewers… rather than solve
real life clinical problems
RESEARCHER BIAS
Criteria bias?
Risk-avoidance by researchers
(will focus energy on topics that produce positive results)
Data analysis
• Were all potential subjects included in denominator or otherwise
accounted?
• Were they evaluated in originally designated group?
(INTENTION TO TREAT)
REDUCING OR ELIMINATING BIAS AND ERROR
VALIDATING INSTRUMENTS
• Repeat screening to check for correct answers on surveys
• More frequent evaluations or surveys prevent guesstimates common to less
frequent evaluation
NEXT STEP IN CRITICAL APPRAISAL:
RELEVANCE
Problem?
“Does it address the questions raised?”
Patient(s)?
“Will my patient respond like those in the study?”
Practice?
“Can it be done within my practice or circle?”
ARE THE STUDY PATIENTS
• Comparable to you?
CLINICAL IMPORTANCE
• weight of results
HEIERARCHY OF EVIDENCE
(value of study design to maximize wt, minimize bias)
1. Systematic Review of all relevant RCTs
2. At least one properly designed RCT
3. Trials and case studies
4. Well-designed Controlled Trial without Randomization
5. Well designed Cohort or Case Control Studies, preferably from >1
centre or group
6. Multiple Time series with or without intervention
7. (Exception: Dramatic results in uncontrolled trials, such as
introduction of PCN in the 1940s)
8. Opinions of respected authorities, based on
9. Clinical expertise
10. Descriptive studies
11. Reports of Expert Committees
RANDOMIZED CONTROLLED TRIAL (RCT)
Evaluation of RCT
Were all clinically appropriate outcomes measured?
7/10/03 10:17:12AM
Dear Nephrolers,
Mario Cuba, MD
Servicio de Nefrologia
Hospital Lucia Iniguez Landin
Holguin, Cuba
INCIDENCE & PREVALENCE
M.Jadoul, M.D.
PREVALENCE
B
B PREVALENCE = 10%
B
B
B
B B
B
B
INCIDENCE
B B
1 year period
B
90 HBsA(-) at start of study
B 5 new cases B
5 / 90 = 0.06
B
B
B B
B B B
B
B B
COMPARISON STUDIES: NEW DIAGNOSTIC TESTS
COMPARING A NEW TEST AGAINST THE GOLD STANDARD TEST
DISEASE
NO DISEASE
PRESENT
EXPERIMENTAL TEST
TEST
POSITIVE
TRUE (+) FALSE (+)
a+b a b
TEST
NEGATIVE FALSE (-) TRUE (-)
c+d
c d
ACCURACY OF TEST - COMPARE TO GOLD STANDARD
What is the usefulness of the test in various groups and subgroups of pts?
TEST
POSITIVE a b a+b
TEST
TEST
POSITIVE a b a+b
SENSITIVITY
TEST
SPECIFICITY = d / (b + d)
PATIENT (-) TEST (-)
PREVALENCE = (a + c) / (a + b + c + d)
ACCURACY = (a + d) / (a + b + c + d)
Proportion of results that correctly identify pts with and without disease
(True + and True - as proportion of all results)
Sensitivity
divided by
100% - Specificity
DISCRIMINATION = ZERO IF LR = 1
EVALUATING STUDY RESULTS
Example:
Mortality rates in 4444 pts x 5.4 trial years:
11.5% Placebo
8.2% Medicine
WARNING
PROBABILITY should
NOT
be confused with
CHANCE!
PROBABILITY
A Study in Probability…
QUESTION #1:
What percentage of patients will develop diarrhea while
taking Antibiotic A?
QUESTION #2:
Will the results be the same, better or worse on
Antibiotic B?
QUESTION #1:
What percentage of patients will develop diarrhea while
taking Antibiotic A?
50 20 study
50 groups
50
50 50
50
50 50 pts each
50 50 50 study
50
50 50 50 50
1000 patients
50 50 50 total
50 50
QUESTION #1:
What percentage of patients will develop diarrhea while
taking Antibiotic A?
Conduct
NUMBER OF STUDIES
studies
Organize
results
NUMBER OF STUDIES
The Bell Curve
(75%!)
determined?
My head is
starting to feel
heavy…
How is it determined?
Let’s use our study on “Antibiotic A” as the example
20 groups were tested.
Only 1 of 20 groups landed at each end of the Bell Curve….
WHY?
NUMBER OF STUDIES
SAMPLE
VARIATION?
or CHANCE?
But that
would NOT
be a correct
statement!
Why?
Because
CHANCE
can not be
used to
predict
future
results!
1 in 20 1 in 20
chance chance
1 in 20 5%
Translates into
chance probability
There is a There is a
5% probability 5% probability
that 4% of that 16%of
patients will patients will
develop develop
diarrhea on diarrhea on
Antibiotic A. Antibiotic A.
1 in 20 Probability
chance = 5%
FRACTION PERCENTAGE
p = 0.05
DECIMEL
1 in 20 Probability
chance = 5%
FRACTION PERCENTAGE
1 in 20 Probability
chance = 5%
FRACTION PERCENTAGE
p = 0.05 “p value”
1 in 20 Probability
“chance” = 5%
4% 6 8 10 12 14 16%
PROBABILITY vs CHANCE
…but PROBABILITY is
very important!
It tells us the likelihood that
something will happen.
NUMBER OF STUDIES
So, CHANCE
has ZERO
significance
p = 0.05 p = 0.05
p = 0.05 p = 0.05
p = 0.01 p = 0.01
4 6 8 10 12 14 16%
THAT IS A LOW PROBABILITY!
Anything less than 5% (p= 0.05) MAY be due to chance.
Anything less than 1% (p= 0.01) is MOST LIKELY due to chance.
p = 0.05 p = 0.05
p = 0.01 p = 0.01
4 6 8 10 12 14 16%
But when compared to another study…
(p= 0.05) becomes VERY SIGNIFICANT
And (p= 0.01) becomes HIGHLY SIGNIFICANT!
4 6 8 10 12 14 16 18%
But when compared to another study…
(p= 0.05) becomes VERY SIGNIFICANT
And (p= 0.01) becomes HIGHLY SIGNIFICANT!
4 6 8 10 12 14 16 18%
Antibiotic A
NUMBER OF STUDIES
4 6 8 10 12 14 16 18%
The P value
Measures Probability
How often is this finding expected to occur?
Meaningful ranges
p >0.05 Not significant
p <0.05 Statistically SIGNIFICANT
p <0.01 HIGHLY SIGNIFICANT!
LIMITATION
The p value determines LIKELIHOOD… Not proof!
CAUTION
Statistical significance does not necessarily imply any clinical
significance!
EXAMPLE: Looking through a pinhole will improve vision in most people… But would
this be an appropriate treatment for your myopic patients? (Key Topics in EBM )
MISCELLANEOUS STUFF
THE FIVE BASIC STEPS OF EBM
1. Clinical Question
Patient-focused, problem-oriented
2. Find Best Evidence
Literary Search
3. Critical Appraisal
Evaluate evidence for quality and usefulness
4. Apply the Evidence
Implement useful findings in clinical practice
5. Evaluate
The information, intervention, and EBM process
PATIENT
Question
or
Problem
PHYSICIAN INFORMATION
PHYSICIAN INFORMATION
PATIENT
PATIENT
“A METHODOLOGICAL
MINEFIELD”
PATIENT
“A
METHODOLOGICAL
Difficult time
Personal MINEFIELD”
priorities may understanding
conflict with background
yours information
PHYSICIAN INFORMATION
PATIENT
Recognize:
Needs
Choices
Preferences
Values
Socioeconomic
concerns
CONFLICT?
SEPARATE THE ISSUES!
Respect the Help the patient to
Help the patient
personal to negotiate a understand and
priorities of the decision on interpret available
patient intervention, information
treatment
PHYSICIAN INFORMATION
PATIENT
PHYSICIAN INFORMATION
KEY POINTS
PARADIGM SHIFT
The “ideal” course of action is not necessarily best for THIS patient.
INTERVENTION
Patient response or acceptance?
Ease or Difficulty of Application?
Clinical outcomes?
EBM PROCESS
EFFECT ON PRACTICE
Will this particular experience change our thinking or practice?
SELF EVALUATION
How did we do? (Question, Search, Appraise, Apply)
How could we improve our own EBM performance?
EBM: PROS, CONS and LIMITATIONS
PROS
Clinicians update knowledge base routinely
OK to be uncertain
OK to be skeptical
OK to be flexible
Information overload
computers, peripherals
Internet costs
Lack of time to learn and practice EBM (promotes lifelong learning thru
better focus)
NON-TEXTBOOK CASE
co morbidity, additional risk factors
LIMITED RESOURCES
May help to eliminate unnecessary or poor quality
screening tests (ie: resting EKG to screen for
CAD = high false negative and false positive
rates)
Check…
• Are there pathophysiologic differences?
• Will patient differences diminish the treatment response?
• Patient compliance issues?
• Provider compliance issues?
• Co-morbid conditions which will alter the benefits or risks?
EBM IN DEVELOPING COUNTRIES
TRY THESE!
Combine efforts to learn more and practice EBM with handful of
colleagues (small group learning)
Ask about basis for information provided by drug reps, medical supply
companies, etc. It will prompt them to provide you with on the spot
teaching and better information, too!
EBM LIBRARY
BASIC REQUIREMENTS
Convenient – easy access at point of contact with patient if
possible
Best Evidence
TEXTBOOKS
most obsolete!
Some updated yearly, plus heavy references and scientific
evidence for support
PATIENT RESOURCES
Medical treatments www.nlm.nih.gov/medlineplus
Medical guidelines www.guideline.gov
THE NEXT LEVEL: ADVANCED EBM
SHARING INFO
Local Colleagues
Author paper
TEACHING
New skills or treatments
EBM practices
OTHER APPLICATIONS
Care of the individual patient
Team protocols
Hospital or practice guidelines
EBM in Medical Education
Message to medical educators from Trisha Greenhalgh, MD,
co-author of Evidence Based Health Care Workbook:
Week-long workshops
Dubai, UAE
Karachi, Pakistan
October 2003
Dubai, UAE
Karachi, Pakistan
October 2003