EVIDENCE-BASED MEDICINE

1
EVIDENCE-BASED MEDICINE

• Dr. Gerry Gormley
• Clinical Research Registrar
• Dept. of General Practice
• QUB

2
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

3
How do we make clinical decisions?

• Toss coins
• Guess
• "Do no harm." (Hippocrates)
• Ask colleagues
• Text books?
• Browse journals
• Searching bibliographic databases

4
What is EBM?

• The process of systematically finding,
  appraising and using contemporaneous research
  findings as a basis for clinical decisions.

5
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.

6
How many minutes a week did you spend last week
reading around your patients?

• Medical students
• PRHOs
• SHOs
• SpRs
• Consultants

7
How many minutes a week did you spend last week
reading around your patients?

• Medical students 120mins
• PRHOs
• SHOs
• SpRs
• Consultants

8
How many minutes a week did you spend last week
reading around your patients?

• Medical students 120mins
• PRHOs 10mins
• SHOs
• SpRs
• Consultants

9
How many minutes a week did you spend last week
reading around your patients?

• Medical students 120mins
• PRHOs 10mins
• SHOs 30mins
• SpRs
• Consultants

10
How many minutes a week did you spend last week
reading around your patients?

• Medical students 120mins
• PRHOs 10mins
• SHOs 30mins
• SpRs 45mins
• Consultants

11
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

12
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.

13
ASK CLINICAL QUESTIONS THAT YOU CAN ANSWER

• Answerable questions are the backbone of
  practising EBM
• In practice, good questions usually include-
• Patients clinical needs
• Intervention(s)
• comparison intervention
• clinical outcome(s)

14

• 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?

15
ELEMENT EXAMPLE

• PATIENT In patients with
• AF and who are gt65.
• 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?

16
EVIDENCE SEARCH

• General search strategy-
• Define searchable question
• Select evidence resource
• Design search strategy

17
EVIDENCE RESOURCES

• Up-to-date text books
• Journals
• Databases print
• electronic
• Consult experts
• Department of health bulletins

18
EVIDENCE RESOURCES

• Up-to-date text books
• Journals
• Databases print
• electronic
• Consult experts
• Department of health bulletins

19
EVIDENCE RESOURCES

• Up-to-date text books
• Journals
• Databases print
• electronic
• Consult experts
• Department of health bulletins

20
EVIDENCE RESOURCES

• Up-to-date text books
• Journals
• Databases print
• electronic
• Consult experts
• Department of health bulletins

21
EVIDENCE RESOURCES

• Up-to-date text books
• Journals
• Databases print
• electronic
• Consult experts
• Department of health bulletins

22
COMPUTER BASED SEARCHES

• Permit evidence search in real time.
• Hierarchy of resources
• Cochrane collaboration
• Bandolier web site
• UK Primary care EB database
• Medline
• Lycos, yahoo etc.

23
CRITICALLY APPRAISE EVIDENCE

• Hierarchy of study designs-
• Systematic review
• Meta-analysis
• RCT (DB/SB)
• Cohort study
• Case controlled study
• Cross sectional study
• Case series

24
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?

25
EVALUTE PERFORMANCE

• Audit
• Clinical efficacy
• Cost analysis
• Patient surveys
• Prescribing / referral rates
• Mortality / morbidity rates