EVIDENCE-BASED MEDICINE Dr. Gerry Gormley Clinical Research Registrar Dept. of General Practice QUB.
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Transcript of EVIDENCE-BASED MEDICINE Dr. Gerry Gormley Clinical Research Registrar Dept. of General Practice QUB.
OBJECTIVES
Define the term EBM
Understand the components involved
in EBM
Describe how to develop an
‘answerable question’
List several resources of evidence
List several methods of how to
evaluate your performance
How do we make clinical decisions?
Toss coins Guess "Do no harm." (Hippocrates) Ask colleagues Text books? Browse journals Searching bibliographic databases
What is EBM?
‘The process of systematically finding, appraising and using
contemporaneous research findings as a
basis for clinical decisions’.
WHY BOTHER?• New evidence is being produced every day
which could make major changes in the way that we care for our patients.
• Clinical governance / Revalidation.• Without keeping up-to-date our clinical
performance may deteriorate.• EBM has been shown to keep doctors up to
date and ultimately improve health care.• GMC regulations.• General public have greater access to health
care information eg the web, media etc.
How many minutes a week did you spend last week reading around your
patients?
• Medical students
• PRHOs
• SHOs
• SpRs
• Consultants
How many minutes a week did you spend last week reading around your
patients?
• Medical students
120mins
• PRHOs
• SHOs
• SpRs
• Consultants
How many minutes a week did you spend last week reading around your
patients?
• Medical students
120mins
• PRHOs
10mins
• SHOs
• SpRs
• Consultants
How many minutes a week did you spend last week reading around your
patients?
• Medical students
120mins
• PRHOs
10mins
• SHOs 30mins
• SpRs
• Consultants
How many minutes a week did you spend last week reading around your
patients?
• Medical students
120mins
• PRHOs
10mins
• SHOs 30mins
• SpRs 45mins
• Consultants
How many minutes a week did you spend last week reading around your
patients?
• Medical students
120mins
• PRHOs
10mins
• SHOs 30mins
• SpRs 45mins
• Consultants
60mins
WHAT ARE THE IMPORTANT ELEMENTS OF
EBM? ‘EBM begins and ends with patients’
1) Convert patient health care needs
into answerable questions.
2) Track down the best evidence.
3) Critically appraise evidence.
4) Apply the results into clinical practice.
5) Evaluate your performance.
ASK CLINICAL QUESTIONS THAT YOU CAN ANSWER
‘Answerable questions are the backbone of practising EBM’
In practice, good questions usually include:-
• Patient’s clinical needs• Intervention(s)• comparison intervention• clinical outcome(s)
• John, a retired 78yr old gentleman is your last patient of the day. He has a long history of AF and asks you ‘my friend has atrial fibrillation and he is on warfarin - should I be on warfarin?’
ELEMENT EXAMPLEPATIENT In patients with
AF and who are >65….
INTERVENTION ….would adding
warfarin….
COMPARSION ….when compared with
aspirin ….
OUTCOME ….lead to lower mortality or morbidity from VTE. Is this enough to be worth the increased risk of bleeding?
EVIDENCE SEARCH
General search strategy:-
• Define searchable question
• Select evidence resource
• Design search strategy
EVIDENCE RESOURCES
• Up-to-date text books
• Journals
• Databases print
electronic
• Consult experts
• Department of health
bulletins
EVIDENCE RESOURCES
• Up-to-date text books
• Journals
• Databases print
electronic
• Consult experts
• Department of health
bulletins
EVIDENCE RESOURCES
• Up-to-date text books
• Journals
• Databases print
electronic
• Consult experts
• Department of health
bulletins
EVIDENCE RESOURCES
• Up-to-date text books
• Journals
• Databases print
electronic
• Consult experts
• Department of health
bulletins
EVIDENCE RESOURCES
• Up-to-date text books
• Journals
• Databases print
electronic
• Consult experts
• Department of health
bulletins
COMPUTER BASED SEARCHES
• Permit evidence search in real time.
• Hierarchy of resources:
Cochrane collaboration Bandolier web siteUK Primary care EB
databaseMedlineLycos, yahoo etc.
CRITICALLY APPRAISE EVIDENCE
Hierarchy of study designs:-
• Systematic reviewMeta-analysisRCT (DB/SB)Cohort studyCase controlled studyCross sectional studyCase series
CAN YOU APPLY THIS EVIDENCE INTO CLINICAL
PRACTICE?• Can the results be extrapolated to your
patient?
• Availability of tests/treatment
• Affordability of tests/treatment
• Are there adverse risks?
• Are there alternatives?
• What are the patient preferences?