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Assistant ProfessorHanan abas abdo abdel rahman
Family MedicineSuez Canal University
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1. What What is evidence-based medicine?
What does it look like in practice?
2. How Formulate Clinical Questions
1. Search for Evidence2. Appraisal of research
3. Apply to clinical problem
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1. I am working in clinical practice
2. I am working on evidence resources (reviews,guidelines, reports , )
3. I will help others use evidence
4. I plan to teach EBM
5. My boss told me I had to attend
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Review the World LiteratureFortnightly*
*"Kill as Few Patients as Possible" -Oscar London
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Evidence-based medicine is the integration of bestresearch evidence with clinical expertise andpatient values
- Dave Sackett
Patient
Concerns
ClinicalExpertise
Best researchevidence
EBM
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only a tiny proportion of all research isready for application
only a tiny fraction of the ready research
is relevant to the practice of a givenclinician
only a tiny proportion of the relevantresearch for a given practitioner is
interesting in the sense of beingsomething new, important, and actionable.
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Toward
curiosity
Prove colleagues wrong
Keeps coming up Risk of patient harm
Want to do better
Anxiety
Avoid litigation
Internet informedpatient
AwayTimeWe already know the answerFatigueAccessInferiority complex-anxiety-
afraid of admittingknowledge gaps
CynicalLaziness
Lack of supportPrevious failure at searchingLack of resourcesNoone else does itFear of change
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Ready to Feeling Behaviors
Flee Fear Leave
Invisible
Fight Anger Disrupt
Undermine
Cry for help Distress Stop tryingBody stress
Withdraw Sadness Inattention
Detachment
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Satisfaction: Self image of knower
Curiosity:
Joy: knowing and/or learning brings benefits
to others
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Ask
Acquire
Appraise
Apply
Act & Assess
Patientdilemma
Principles of
evidence-basedpractice
Evidence alone does notdecide combine with other
knowledge and values
Hierarchyof evidence
Process of EBP
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*Allen, Glasziou, Del Mar. Lancet, 1999
10 trials of bed rest after spinal puncture
no change in headache with bed rest
Increase in back pain
Protocols in UK neurology units - 80%still recommend bed rest after LP
Serpell M, BMJ 1998;316:170910
evidence of harm available for 17 yearspreceding...
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Shift focus to current patient problems(just in time education) Relevant to YOUR practice
Memorable and behaviour changed!
Up to date Skills and resources for best current answers
Dave Sackett
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A. Read an evidence-based
abstraction journal
(and cancel other journals)
B. Keep a logbook of yourown clinical questions
C. Run a case-discussion journal
club with your practice
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Introductionof new ideas
Presentingnew material
and concepts
Practice andconsolidation
Using realexamples,
real language
Debriefingand
Reflection
Evidence
Learning
cycle
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1. ASK a focussed question2. ACCESS - search for epidemiological evidence to help
answer question3. APPRAISE the evidence for its validity, effect size,
precision)4. AGGREGATE the evidence with patient/community,
clinical/hlth & policy issues & make an evidence-based decision
5. APPLY your decision
6. [AUDIT your practice (i.e. check your actual practiceagainst evidence-based practice on a regular basis)].
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About patient care decisions and actions
4 (or 3) components:
a. patient, problem, or population
b. intervention, exposure, or maneuver
c. comparison (if relevant)
d. clinical outcomes (including time)
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1. Formulate an answerable question
2. Track down the best evidence
3. Critically appraise the evidence
4. Individualize, based clinical expertise and patientconcerns
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Structure of researchablequestions PICO-T
Population/Patients
Intervention
Comparison
Outcome
Time
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Outcomes ?
Patients
Qualitative Research
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A 35 year old man says hisbrother recently died of aruptured cerebral
aneurysm.He is worried aboutwhether he might have oneand what the chances are
that it would rupture.
-> PICO Table
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12 occupational therapy questions
E.g., Is a 38-year old sewage worker subject to ahigher risk of contracting Hepatitis A as a result ofoccupational exposure? (No)
Obtain advice from 2 professionals on 3 caseseach.
37% wrong answers
17% wrong if based on literature
65% wrong if not
Schaafsma BMC Health Services Research 2005
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Patient / Problem / Population
InterventionComparison
Outcome
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Youre a community midwife running and
antenatal group.
Following the recent appearance on television
and newspapers about celebrities smokingduring pregnancy , one of the women asks for
advice on using nicotine patches to help her
give up smoking for the rest of the pregnancy.
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P: Pregnant smokers
I: nicotine replacement
C: N/AO: cessation
Is nicotine replacement therapy an effectiveand safe smoking cessation treatment inpregnant women?
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P P I OPregnant
Pregnancy
maternal
Smoking
Smoker
Nicotinereplacement
Nicotine patch
Nicotine gum
Cessation
Stop
Quit
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Its peer-reviewed, therefore it must be OK?
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What do the resultsmean on average?
What do they mean
for this individual?
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Participants
Exposure Group Comparison Group
OutcomesTime
P
E C
O
T
All epidemiological studies can be hung on the GATE frame
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1. Participants (patient(s) you want to treat)
2. Exposure (an intervention if about therapy)
3. Comparison (there is always an alternative! -another therapy, nothing
4. Outcome (usually a disease or condition you wantto prevent or manage)
5. Time frame (over which you expect a result)
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1. Determine best practice (EBP Steps 1-4)
2. Assess current practice: survey
3. Compare with best practice - is there a gap?
4. Consider reasons for gap, identify processes to
reduce gap & implement
5. Re-survey: is there any improvement?
= quality improvement / audit
The evolution of information resources for
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Systems
Summaries
Synopses
Syntheses
Studies
Examples
Computerized decision
support
Evidence-based
textbooks
Evidence-based journal
abstracts
Systematic reviews
Original journal articles
The evolution of information resources forevidence-based decisions
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Can the new incretin therapies (eg,exenatide, pramlintide or sitagliptin)
help?
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Harrisons Textbook nothing
Books@Ovid nothing
Kelleys Textbook - nothing
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TRIP
SUMSEARCH
CLINICAL QUERIES
A CAT documents the steps for a specific question
Download from www.epiq.co.nz
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Groups of 2 3
Discuss >1 question
from recent work Write it down
Be ready to report to
group Return in 2 minutes
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In woman immediately postpartum, notlactating, when should she begincontraception
50 yr old pt with htn, how effective is ASA inreducing CV risk
When can a 55 yr old nurse with RA return towork
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In pt with cough, chills, fever, does ct scan comparedwith x-ray confirm the dx
In pt with cough, chills, fever, does multidisiplinaryconsultation improve outcome compared withprimary care clinician
In a pt with cough, chills, fever will ct scan changerisk of death
In pt with cough, chills, fever do 3 antibiotics speedrecovery compared with single therapy
In 1st yr residents, does teaching EBM improvelearning and practice compared with traditionallearning
In pts with pneumonia is outcome better with 3 vs 1physicians
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Consider:
What is illness?
What is role? What are
learning needs?
What areavailableresources?
Of these, select:
Most urgent
Most interesting Most feasible to
answer
Most likely torecur
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1. Work through the first step of EBP.
2. Allocate sources of evidence to participants.
3. Give them 10 minutes to find the evidence.
4. Compare experiences.
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Teaching EBM wikihttp://tebm-libs.wikispaces.com/
Wetpaint EBM Librarian wikihttp://ebmlibrarian.wetpaint.com
Teaching on the Run series by Medical Journal of
Australiahttp://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/
Create your own EBM sitehttp://www.ebmpyramid.org/home.php
Exploring the evidence basehttp://clinicallibrarian.wordpress.com/2008/08/ Evidence-based nursing resources useful for all
disciplineshttp://:muhc.ebn.mcgill.ca/EBN_tools.htm
CEBM : centre for evidence based medicine
http://tebm-libs.wikispaces.com/http://ebmlibrarian.wetpaint.com/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://www.ebmpyramid.org/home.phphttp://clinicallibrarian.wordpress.com/2008/08/http://muhc.ebn.mcgill.ca/EBN_tools.htmhttp://muhc.ebn.mcgill.ca/EBN_tools.htmhttp://clinicallibrarian.wordpress.com/2008/08/http://clinicallibrarian.wordpress.com/2008/08/http://clinicallibrarian.wordpress.com/2008/08/http://clinicallibrarian.wordpress.com/2008/08/http://clinicallibrarian.wordpress.com/2008/08/http://www.ebmpyramid.org/home.phphttp://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://annietv600.wordpress.com/2006/04/17/teaching-on-the-run-tips-a-series-from-the-medical-journal-of-australia/http://ebmlibrarian.wetpaint.com/http://tebm-libs.wikispaces.com/http://tebm-libs.wikispaces.com/http://tebm-libs.wikispaces.com/7/28/2019 EBM evidence based medicine,
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