This document discusses evidence-based medicine (EBM) and addresses some common misconceptions. It outlines the benefits of EBM, including that it is a rigorous, problem-solving approach that leads to better patient outcomes when the best available evidence is incorporated into clinical decision making. Some myths are addressed, such as the idea that experience is better evidence than clinical trials, or that EBM is too time consuming. The document emphasizes that EBM helps improve quality of care when combined with clinical expertise and patient preferences.
4. EBM:
๏ผWay of critical thinking
๏ผAppropriate tool for sound clinical decisions
๏ผProblem solving approach
๏ผLife-long self-directed learning
5.
6. ๏ผUse:
more effective intervention
proven therapies and diagnostic tests
only
๏ผResult in:
Better management of patients
Better patient outcomes.
Less harm or side-effects
Better communication with patients about the
rationale behind the management decisions.
7. ๏ผMore efficient use of resources
๏ผImprove resource utilization
๏ผReduced cost per patient.
8. ๏ผUsing the best available evidence :
Appropriate funding decisions.
More effective and efficient care
9. ๏ผUpgrade knowledge routinely.
๏ผUp-to-date, Keeping up knowledge
explosion &med literature based on valid
evidence.
๏ผImprove cliniciansโ understanding of research
methods & make them more critical in using
data.
๏ผImproves confidence in management
decisions. Relieve anxiety about uncertainty
๏ผImproves reading habits.
10. ๏ผGives team a framework for group
problem solving & for teaching
๏ผEnables juniors to contribute fully to
the team.
VI. The graduates:
EBM curricula
Self-directed
Problem-based
11. โขThere is a significant gap between
EBM & application of this to clinical
practices
12. Clinical
Practice
Research
Haynes calls this the โevidence transfer gapโ. EBM seeks to close the gap
between completed research activity and the practice of medicine.
The โEvidence Transfer Gapโ
EBM
13. โขA mistaken thought, idea, or notion; a misunderstanding.
โขCan happen anywhere, in any situation: not understanding a
topic; not knowing the full story; hearing the wrong storyโฆ thereโs
many reasons how one can misunderstand something.
15. 2. Expert opinion is the best evidence.
โขExperience: โI always did it this wayโ
๏ผ Clinical experience is crucial.
๏ผ Clinical guideline should be based on
critical appraisal of medical literature
16. ๏ผTraditional CME is completely ineffective in
changing our behavior.
๏ผA great deal of research reported in journals
is poorly done, poorly analyzed: not valid &
irrelevant to our patients and practices.
๏ผOnly 20% of health care is EB (Kerr White, 2002)
17. Setting Type I Type II No Evid.
Cancer center (USA) 24% 21% 55%
Tertiary surgical center (USA) 14% 64% 22%
Primary care centers (Spain) 38% 4% 58%
General medicine hospital (UK) 53% 29% 18%
General psychiatric ward (UK) 65% 35%
Anesthesia (Australia) 32% 65% 3%
19. ๏ผCertain rules of evidence are
necessary.
๏ผSystematic unbiased observation
increases the confidence of the
physician knowledge.
20. ๏ผCAT = Critical appraisal of topic is
necessary
Critical appraisal: assessment of evidence
by systematically reviewing its relevance,
validity, results and applicability (RVRA)
21. 1. Relevance:
Common to our practice &
patient-oriented outcome (POEM) not DOE
2. Validity: Free from bias (Truth)
๏ถ Randomization.
๏ถ Follow up complete.
๏ถ Intention to treat.
๏ถ Blindness.
๏ถ Similar groups at start.
๏ถ Both groups treated equally.
3. Results:
Clinically important (magnitude and precession)
4. Applicability:
Applicable at my setting &
useful for my patients
22. โขDerived from the Greek word mythos, which means "word of mouth."
โขSomething that is widely thought to be false
โขHoly story
23. ๏ผEBM focus on:
patient preference
clinical judgment of the
practitioner
best available evidence to
produce the best patient
outcomes
๏ผEBM takes into account the
circumstances of the patient
25. ๏ผEBP is a patient-centered approach &
is highly individualized
๏ผBegin & end with the patient in mind
๏ผAny practice that fails to take into
account of the individual patient is not
EBP
๏ผClinical evidence can never replace
individual clinical expertise because this
expertise decides whether the external
evidence applies to the patient (Sackett,
1998)
26. ๏ผThe traditional medical paradigm is based on
authority.
๏ผEBM is dependent on the use of RCT, systematic
reviews & meta-analysis, although it is not restricted
to these.
๏ผ RCT is
๏ผ the epitome of all research designs because its
design provides the strongest validity
๏ผ It provides the best assurance that the result was
due to the intervention
27. RCT:
a group of patients is randomised into
study group & control group. These
groups are followed up for the
variables/outcomes of interest.
If the sample size is large enough, this
study design avoids problems of bias
and confounding variables
29. ๏ง SR
A review of a clearly formulated question that
uses systematic & explicit methods to
1. identify, select and critically appraise relevant
research
2. collect & analyse data from the studies that are
included in the review
๏ง Meta-Analysis
The use of statistical techniques in a SR to
integrate the results of included studies.
30.
31. Why SR on the top:
Rigorous methodology
Peer reviewed
Relatively large sample size
Ensures the highest quality evidence
32. ๏ผThere are now many advocates of a more
inclusive approach to evidence:
Qualitative research is as valid a form of
evidence as quantitative research
๏ผThere are now methodologies to systematic
review both numerical and textual findings of
research
๏ผ EBP insists that each client is treated with
the best available evidence, that practitioners
make a genuine effort to find the best solution
given their resources.
33. ๏ผIt is not disputed that practice should be
grounded in theory, however it should be
predicated on the best available evidence
๏ผThis is addressed by systematic reviews
35. ๏ผThis indicates a fundamental
misunderstanding of the financial
consequences
๏ผPhysicians identify & implement the
most efficacious treatments to maximize
the outcomes for patients, this may
increase costs
๏ผEBP does not reduce the need for
treatments, it attempts to ensure that
each patient gets the best treatment
appropriate for his/her condition.
36. ๏ผEBP incorporates the more
extensive processes of
SECONDARY & TERTIARY
RESEARCH
searching,
appraisal,
synthesis and
incorporation of the best available
evidence into practice
37.
38. ๏ผRefuted by audits from
within clinical care where at
least some inpatient clinical
teams have provided EB
care to patients
๏ผBusy clinicians who can
devote their scarce time can
practice EBM
39. ๏ผEBP critically examines all
clinical procedures, critically
evaluating their appropriateness
for the specific situation.
๏ผText books: Fail to recommend
Rx up to 10 ys after itโs been
shown to be efficacious.
Continue to recommend therapy
up to 10 ys after itโs been shown to
be useless.
40. ๏ผThe use of evidence is only one piece of
the clinical decision-making process.
๏ผPatient situations, preferences & values
are a key component in the process.
41. ๏ผIt is impossible for any practitioner
to keep up with the entire health care
literature {2 million articles published
annually, 6000 articles published
daily].
To keep up to date, physician should
read 19 articles/d.
๏ผ Lag time from time of โknowingโ to
time of implementation:
13 ys for thrombolytic therapy.
10 ys for corticosteroids to enhance
fetal lung maturity.
42. ๏ผDo not need skills in biomathematics or
statistics
๏ผPhysicians can gain skills to make
independence decisions & can evaluate
expert opinions.
๏ผEBP does not mean continous running to
the library, but that clinicians should
remember to search for evidence to support or
refute their practice methods.
๏ผEBM reduces reading by quality filters
45. ๏ผEBM approach depends on high-quality
literature, which is lacking in many areas of
medicine
๏ผThere are more RCT each year
๏ผThere are many other types of evidence to
make good decisions.
46. ๏ง Many myths & misconceptions exist in
health care practice
๏ง Myths & misconceptions must be overcome
to implement EBM
๏ง EBM:
47.
48. Life is short &
the evidence is too
hard to find???
Thank you
Questions?