Levels of Evidence

Dr Saurav Chakravartty

Evidence based medicine

Definition

Conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

Evidence Based Practice

An approach to health care that promotes:
Collection,interpretation,integration of Valid, important, applicable Patient reported Clinician observed Research derived medicine

 Is the evidence valid?

Is it important? Is it applicable to the patient in

front of me?

Levels of Evidence - why?

Ranking the validity of evidence Standardisation

Proper evaluation
Encouraging acceptance

Levels of Evidence -From the Centre for Evidence-Based Medicine, Oxford

1a:
1a-: 1b: 1b-: 1c:

Systematic reviews (with homogeneity ) of randomized controlled trials Systematic review of randomized trials displaying worrisome heterogeneity Individual randomized controlled trials (with narrow confidence interval) Individual randomized controlled trials (with a wide confidence interval) All or none randomized controlled trials

Contd..
2a:
2a-: 2b: 2b-: 2c:

Systematic reviews (with homogeneity) of cohort studies Systematic reviews of cohort studies displaying worrisome heterogeneity Individual cohort study or low quality randomized controlled trials (<80% follow-up) Individual cohort study or low quality randomized controlled trials (<80% follow-up / wide confidence interval) 'Outcomes' Research; ecological studies

Contd..
3a: Systematic review (with homogeneity) of casecontrol studies

3a-: 3b:

Systematic review of case-control studies with worrisome heterogeneity

Individual case-control study

Contd..
4:
Case-series (and poor quality cohort and case-control studies)

5:

Expert opinion without explicit critical appraisal, or based on physiology, bench research or 'first principles'

Grades of Recommendation
A B C D consistent level 1 studies consistent level 2 or 3 studies or extrapolations from level 1 studies level 4 studies or extrapolations from level 2 or 3 studies level 5 evidence or troublingly inconsistent or inconclusive studies of any level

Evidence

Knowledge explosion

Technique of meta-analysis
Evolution of systematic review International Cochrane Collaboration

Randomised Control Trial

The good:
Gold standard of clinical research purest of gold has double blind placebo

control
Drawbacks
Fine for drug trials Placebo surgery not possible

Systematic reviews
Thorough search of all available evidence
Grading evidence by quality & relevance Eg: Cochrane review

Meta-analysis
For

Summation of several trials

Against

Errors compounded Selective publication greatest bias

Pitfalls
Lack of evidence of efficacy should not be

confused with evidence of lack of efficacy.

The more data is pooled the less relevant it

becomes to individual patients.

Meta-analysis is a useful tool but it has

some important limitations.

Pitfalls
The evidence-based approach more

applicable to the use of drugs than to other treatment modalities.

Case study methodology focuses on

individual patients rather than populations

Conclusion
Levels of evidence are our guide
A good doctor uses both individual clinical

expertise and the best available external evidence, and neither alone is enough.

"The extent to which beliefs are based on evidence is very much less than believers suppose." - Bertrand Russell

Thank You