Evidence Based Medicine

An integration of
The best research evidence

Clinical expertise
Patient values
Sacket DL, et. al. Evidence-based medicine: how to Teach and Practice EBM. 2nd ed. Edinburgh: Churchill Livingston, 2000

Best evidence

EBM
Clinical expertise

Clinical values & expectations

Starting in EBM (5 As)

Assess Apply Appraise Acquire Ask

Asking answerable questions

The 4 main elements of a well formulated clinical question are:

Patient / Problem Intervention Comparison intervention Outcome

PICO process

e.g. Adult with human bite, does antibiotic treatment to no treatment reduce infection

Bite

Antibiotic

Infection

Patient, Population, Problem

Patient or patient group (gender, race, age) Disease or condition Stage of the illness Care setting

Intervention
Type of treatment (drug, procedure, therapy) Intervention level (dosage, frequency) Stage of intervention (preventative, early, advanced) Delivery (who delivers the intervention? where?)

Comparison
Alternative interventions (standard treatment, placebo, another intervention) There may not always be a comparison

Outcome
The outcome or effects you are interested in, for example Improvement of symptoms, healing Side effects Improved quality of life Cost effectiveness and benefits for the service provider

Types of clinical question

(1) INTERVENTION

- What should I do about this condition or problem??? - How to treat a disease or condition?

EX : A 64 year-old obese male who has tried many ways to lose weight presents with a newspaper article about fat-blazer (chitosan). He asks for your advice.
PPOPULATION = I .INTERVENTION = CCOMPARATOR/CONTROL = OOUTCOME = Question??

PPOPULATION = obese patients

I .INTERVENTION = chitosan CCOMPARATOR/CONTROL = placebo OOUTCOME = decrease weight

In obese patients, does chitosan, compared with a placebo, decrease weight?

(2)etiology

- What causes the problem? - What are the risk factors?

Ex: Suzan is expecting her first baby in 2-months. She has been reading about the potential benefits and harms of giving newborn babies vitamin K injections. she is alarmed by reports that vitamin K injections in newborn babies may cause childhood leukaemia. She asks you if this is true .

PPOPULATION = I .INTERVENTION =. CCOMPARATOR/CONTROL =

OOUTCOME= QUESTION ?????

 PPOPULATION = newborns babies

I .INTERVENTION = receiving vit. k inj.

CCOMPARATOR/CONTROL = not receiving vit.K inj. OOUTCOME = childhood leukaemia

In newborn babies, do receiving vit k injection (compared to not receiving vit k injection) may cause childhood leukaemia?

(3)Diagnosis

- Does the patient have the condition or problem? - How accurate a diagnostic test is in various patient groups and in comparison with other related tests?

Ex: As part of your clinics assessment of elderly patients, there is a hearing check. Over a tea-room discussion ,it turns out that some people simply ask, while others use a tuning fork, but you claim that a simple whispered voice test is very accurate. challenged to back this up with evidence ,you promised to do a literature search before tomorrows meeting.

PPOPULATION = I .INTERVENTION =.

CCOMPARATOR/CONTROL =
OOUTCOME= QUESTION ?????

 PPOPULATION = Elderly patients

I .INTERVENTION = simple whispered voice test

CCOMPARATOR/CONTROL = simple asking or using tuning fork

OOUTCOME = more accurate in hearing check

In elderly patients, is simple whispered voice test is more accurate than simple asking or using tuning fork in the clinics assessment of elderly patients?

(4)Prognosis (prediction)

- Who will get the condition or problem?

- How likely an outcome is for a population with certain risk factors ?

EX: Childhood seizures are common and frightening for the patients, and the decision to initiate prophylactic treatment after a first fit is a difficult one. To help parents make their decision, you need to explain the risk of further occurrences following a single seizure of unknown cause.

PPOPULATION =
I .INTERVENTION =. CCOMPARATOR/CONTROL =

OOUTCOME= QUESTION ?????

 PPOPULATION = children who had one

seizure of unknown cause

I .INTERVENTION = CCOMPARATOR/CONTROL = OOUTCOME = Further seizures

In children who have had one seizure of unknown cause, what is the long-term risk of further seizures?

(5)Phenomena

- What are the types of problems? - Related to the quality of health care.( e.g.: barriers to lifestyle change )

Ex: Mary is a mother who is concerned about her 3-year-old child. He has a fever After you have examined him, you conclude that he probably has a viral infection. Mary asks: But what if he has a fever again during the night, doctor? You want to understand her principle underlying concerns so that you can reassure her.

PPOPULATION =

I .INTERVENTION =.
CCOMPARATOR/CONTROL =

OOUTCOME= QUESTION ?????

 PPOPULATION = mothers of children with fever I .INTERVENTION = CCOMPARATOR/CONTROL = OOUTCOME =principal concerns

For mothers of children with a fever,what are the principal concerns?

ACQUIRE
Drilling for the Best Information
Cochrane Library
Clinical Evidence
Specialty-specific POEMs

Usefulness

Best Evidence Textbooks, Up-toDate, 5-Minute Clinical Consult Journals/ Medline

Evidence Pyramid
MOST evidence

Only a small amount of the medical literature contains best evidence!

LEAST evidence
From SUNY Downstate Medical Research Library http://servers.medlib.hscbklyn.edu/ebm/2100.htm

Systematic Review:
An article in which the authors have systematically searched for , appraised, and summarized all of the medical literature for a specific topic qualitative summary of effect Not all systematic reviews are meta-analyses

Meta-analysis:
A systematic review which uses quantitative methods for to summarize the results using statistical methods to combine the results of different studies quantitative summary of effect ALL meta-analysis are systematic reviews

EBM Step(2): Track down the Best Evidence

>>> WHERE TO SEARCH ?

>>> HOW TO SEARCH?

Useful sites
1. 2. 3. 4. www.ncbi.nlm.nih.gov www.sumsearch.uthscsa.edu www.ahrq.gov www.guidelines.gov

5. www.update-software.com 6. www.cochrane.com

Searching warm up:

>>> Create a searching strategy : Your question in PICO format >>> Convert this question to search strategy - choose keywords - Think of Truncations,Synonyms,Spelling

OR finds studies containing EITHER of the

specified words

(infants OR babies OR Newborns) AND. finds studies containing BOTH of the

specified words

( child AND adolescent)

* TRUNCATION
(child*)

PPOPULATION = obes* OR overweight

I .INTERVENTION = chitosan CCOMPARATOR/CONTROL = placebo OOUTCOME = decrease weight

pubmed search:

(obese* OR overweight) AND chitosan

The Gold Standard

A resident walks up to your desk and has that there is a patient in her practice coming in today with acute maxillary sinusitis. What does the evidence suggest about a course of antibiotics?

Check out the Cochrane Library via Update Software http://www.update-software.com/

Systematic Reviews: A Higher Level of Evidence

An 82 year old female presented a month ago with a vesicular rash along her right chest wall. You diagnosed H. Zoster, but she comes back in pain. Your intern wants to know the best evidence on treating post herpetic neuralgia. AND You dont subscribe to the Cochrane!

http://pubmed.gov

AND

You get a call from an NP in the Ambulatory Clinic. A 38 year old patient wants a to be checked for Ovarian Cancer, as her friend was recently diagnosed. Your resident wants to do something.
Send her to http://www.ahrq.gov to check out the evidence.

http://www.ahrq.gov

Evidence-Based Guidelines
An orthopaedic attending sends you an e-mail and wants to know if his professional society or any other organization has written guidelines for knee arthroplasty. You use the National Guideline Clearing house to conduct a search http://www.guidelines.gov

Primary Resource: A medical student comes into your library looking for an article on Plantar Fascitis.

She proudly recalls a study About using Ultrasound from JAMA, but cant remember the findings. You decide to send her to MedLine, Via PubMEDs CQ To Refresh her Memory..

http://pubmed.gov

Meta-Search Engines
A researcher is looking for a way to quickly identify evidence from all sources on TB resistance.

Tell him to try SumSearch

http://sumsearch.uthscsa.edu

Synthesized Resources:

eMedicine UpToDate FIRSTConsult others

Evidence Based Review Vary with User Friendliness

Clinical Scenario
One of your regulars comes in. One of his patients is a healthy, active 76 year old male comes in for a check up.

What Health Maintenance interventions are indicated for this person?

Synthesized Resources

Expert in the field; Provide the reader with: EBM Review Consultants Advice Simple Search Interface Web, Desktop, CDROM, Pocket PC

-Web, PDA, Desktop -Updated Every 4 Mon -EASY to use

-Comprehensive -Current -Convenient

 Appraisal

UpToDate:

Comprehensive and Current

Comprehensive Nearly 3,000 Expert Physician Authors 6,000 topics, 60,000 pages, 100,000+ abstracts 10,000 pictures, 150+ movies Drug Database CME creditsCredit for Your Work Patient Information Current Completely updated every four months

HEART STUDY
4O81 asymptomatic men, aged 40-55 years, with dyslipaemia were enrolled in a 5-year double-blind randomized study to compare gemfibrozil 600 mg twice daily with matched placebo. The number of events (fatal and non-fatal myocardial infarction and other cardiac death) was measured. Gemfibrozil Control Number of events 56 84 Number of subjects 2051 2030 Event rates 56/2051 = 2.73% 84/2030 = 4.13%

 Relative Risk (RR) = 2.73/4.13 = 0.66 i.e. gemfibrozil was associated with less risk of an adverse event Relative risk reduction (RRR) = (4.13 - 2.73)/4.13 = 33.9% i.e. there was a large relative reduction (33.9%) in risk Absolute risk reduction (ARR) = 4.13 - 2.73 = 1.41 % i.e. only a small number of cases will benefit from the decreased risk Number needed to treat for 5 years to prevent one event (NNT) = (1/1.41 %) = 100/1.41 = 70.9 i.e. 71 patients need to be treated with gemfibrozil for 5 years to see an effect in one patient

CONCLUSIONS
although RRR gemfibrozil was large (33.9%) the numbers of patients normally suffering such events is very small, so the resulting is small (1.41 %).
Thus, a large number of patients (70.9) must be treated over 5 years in order for one patient to avoid an adverse event. In addition, 2.4% of cases taking gemfibrozil suffered from moderate to severe upper GIT symptoms, as opposed to 1.2% of cases taking placebo. Taking side-effects and cost into account, many hospitals may decide that the efficacy is not sufficient to justify the cost and increased risk of side-effects

Thank you