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  • 1. EBM OVERVIEW Dr. Faisal Al Haddad Consultant of Family Medicine & Occupational Health PSMMC
  • 2. Outline of Talk  Definition of EBM  History of EBM  Obstacles of EBM  How to practice EBM ( The Five A’s )
  • 3. What is EBM?  Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients while considering patient values.  The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.
  • 4. How did it start?  Late 1970’s clinical epidemiologists at McMaster University wrote a series of articles on how to read clinical journals called critical appraisal that were published in 1981 in Canadian Medical Association Journal.  This team started teaching the practice at the University and the term changed to EBM in a document for resident applicants in 1990.  In 1991 the term EBM appeared in ACP JC.
  • 5. Why EBM?  Daily need for valid information.  Inadequacy of traditional textbooks – out of date, ineffective, overwhelming.  Disparity between our diagnostic skills and clinical judgment – and up to date knowledge and clinical performance.  The EBM process aims to make it easier to apply current quality evidence from research in clinical and healthcare decisions.
  • 6. Obstacles to EBM  Shortage of coherent consistent scientific evidence.  Difficulty applying to my patient population.  Developing skills for searching and appraising.  Time  Limited number of studies that show “EBM” works.
  • 7. EBM - How to practice:  The 5 A’s  Ask – formulated clinical question  Acquire – best evidence to answer a question  Appraise – evidence for validity, impact and applicability  Apply – to our patient  Assess – effectiveness
  • 8. Ask  Formulate the Question :  A clinical question related to the diagnosis, treatment, prognosis, or etiology of a patient’s illness.  Include the patient’s problem or diagnosis; the intervention of interest, as well as any comparison intervention; and the outcome of interest.  Needs to be focused and searchable.
  • 9. PICO QUESTION  Patient population and problem of interest  Intervention of interest or exposure  Comparison of interest  Outcome of interest
  • 10. EXAMPLE A 55-year old Type II diabetic woman came to your clinic for regular follow up and result inquiring. You notice that she has microalbuminuria. You decide to start her on ACEI to prevent progression to nephropathy. Sit-in intern asks you if ACEI is more effective than ARB in term of prevention of nephropathy?
  • 11. PICO QUESTION  Patients: Type II diabetic patients with microalbuminuria.  Intervention: ACEI  Comparison: ARB  Outcomes: Diabetic nephropathy
  • 12. Aisha, a former nurse, brings her 18 months-old boy in for a minor problem which is easily sorted out. However, you noted that her child didn't have the MMR vaccine till now. When you ask Aisha 'why not' she says that she does not want to give her son the MMR because it is probably not safe and many boys have developed autism after being immunized with the MMR. How would you formulate clinical question?
  • 13. Acquire  Search for Answers  Having formulated the question, the next step is to try to find an answer.  This step involves both an assessment of the type of evidence that would be most appropriate to answer the question, as well as the actual search for the evidence.
  • 14. Best study design Diagnosis Controlled Trial, Cross-sectional analytical study Harm Cohort, population based-case control Prognosis Cohort Studies, Case Control, Case Series Treatment Double blind RCT or systematic review of RCTs
  • 15.  Best Evidence  Cochrane Library  Internet Database of Evidence-Based Abstracts and Articles (IDEA)  MEDLINE via PubMed  Clinical Evidence  Up To Date  Bandolier
  • 16. Appraise  Appraise the Evidence  Once an article is located, it is necessary to appraise its validity and importance before applying the results.  The specific analysis of the paper, regarding validity and importance etc, depend on the type of study design and the nature of the question.
  • 17. Apply  Apply the Results to Your Patient  Is the evidence valid, important, applicable to your patient, and feasible in your setting?  Would your patient fit inclusion and not exclusion criteria?  Were all clinically important outcomes considered?  Are costs and risks acceptable?  Are patients values/expectations considered?
  • 18. Assess  Assess the Outcome  The final step includes an evaluation of your performance in searching the literature, as well as an assessment of the patient’s response.  Perform self evaluations to improve your skills in using EBM.
  • 19. Self Evaluation  Are my questions well formulated?  Am I effectively/efficiently searching?  How am I doing with critical appraisal?  Am I integrating what I have learned into clinical practice?  Are patients benefiting?
  • 20. EBM conclusion  The use of current best available evidence in making decisions about patient care while considering patient values.  Requires skills for critical appraisal as well as skills for applying evidence appropriately to individual patients.  Lifelong process of learning enhanced by selfevaluation.
  • 21. Any Question?
  • 22. Thank you