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Ebm misconception myths facts

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  • 1. Prof. Aboubakr Elnashar Benha university, Egypt Email: elnashar53@hotmail.com
  • 2.  Benefits of EBM  Misconceptions  Myths  Conclusion
  • 3. Yes
  • 4. EBM: Way of critical thinking Appropriate tool for sound clinical decisions Problem solving approach Life-long self-directed learning
  • 5. Use: more effective intervention proven therapies and diagnostic tests only Result in: Better management of patients Better patient outcomes. Less harm or side-effects Better communication with patients about the rationale behind the management decisions.
  • 6. More efficient use of resources Improve resource utilization Reduced cost per patient.
  • 7. Using the best available evidence : Appropriate funding decisions. More effective and efficient care
  • 8. Upgrade knowledge routinely. Up-to-date, Keeping up knowledge explosion &med literature based on valid evidence. Improve clinicians’ understanding of research methods & make them more critical in using data. Improves confidence in management decisions. Relieve anxiety about uncertainty Improves reading habits.
  • 9. Gives team a framework for group problem solving & for teaching Enables juniors to contribute fully to the team. VI. The graduates: EBM curricula Self-directed Problem-based
  • 10. •There is a significant gap between EBM & application of this to clinical practices
  • 11. Clinical Practice Research Haynes calls this the “evidence transfer gap”. EBM seeks to close the gap between completed research activity and the practice of medicine. The “Evidence Transfer Gap” EBM
  • 12. •A mistaken thought, idea, or notion; a misunderstanding. •Can happen anywhere, in any situation: not understanding a topic; not knowing the full story; hearing the wrong story… there’s many reasons how one can misunderstand something.
  • 13. The clinically-important knowledge of physicians deteriorates rapidly after we complete our training.
  • 14. 2. Expert opinion is the best evidence. •Experience: “I always did it this way”  Clinical experience is crucial.  Clinical guideline should be based on critical appraisal of medical literature
  • 15. Traditional CME is completely ineffective in changing our behavior. A great deal of research reported in journals is poorly done, poorly analyzed: not valid & irrelevant to our patients and practices. Only 20% of health care is EB (Kerr White, 2002)
  • 16. 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%
  • 17. Decision based on pathophysiologic principles may be incorrect
  • 18. Certain rules of evidence are necessary. Systematic unbiased observation increases the confidence of the physician knowledge.
  • 19. CAT = Critical appraisal of topic is necessary Critical appraisal: assessment of evidence by systematically reviewing its relevance, validity, results and applicability (RVRA)
  • 20. 1. Relevance: Common to our practice & patient-oriented outcome (POEM) not DOE 2. Validity: Free from bias (Truth)  Randomization.  Follow up complete.  Intention to treat.  Blindness.  Similar groups at start.  Both groups treated equally. 3. Results: Clinically important (magnitude and precession) 4. Applicability: Applicable at my setting & useful for my patients
  • 21. •Derived from the Greek word mythos, which means "word of mouth." •Something that is widely thought to be false •Holy story
  • 22. EBM focus on: patient preference clinical judgment of the practitioner best available evidence to produce the best patient outcomes EBM takes into account the circumstances of the patient
  • 23. Three (Es) - EBM Components
  • 24. EBP is a patient-centered approach & is highly individualized Begin & end with the patient in mind Any practice that fails to take into account of the individual patient is not EBP Clinical evidence can never replace individual clinical expertise because this expertise decides whether the external evidence applies to the patient (Sackett, 1998)
  • 25. The traditional medical paradigm is based on authority. EBM is dependent on the use of RCT, systematic reviews & meta-analysis, although it is not restricted to these.  RCT is  the epitome of all research designs because its design provides the strongest validity  It provides the best assurance that the result was due to the intervention
  • 26. 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
  • 27. Randomized Controlled study
  • 28.  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  Meta-Analysis The use of statistical techniques in a SR to integrate the results of included studies.
  • 29. Why SR on the top: Rigorous methodology Peer reviewed Relatively large sample size Ensures the highest quality evidence
  • 30. There are now many advocates of a more inclusive approach to evidence: Qualitative research is as valid a form of evidence as quantitative research There are now methodologies to systematic review both numerical and textual findings of research  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.
  • 31. It is not disputed that practice should be grounded in theory, however it should be predicated on the best available evidence This is addressed by systematic reviews
  • 32. Disease-Oriented Evidence DOE (intermediate outcomes) ▪ Pathophysiology, pharmacology, etiology, test result ▪ using drug x decreases the level of serum Lipid Patient-Oriented Evidence that Matters to the Patient POEM (final outcomes)  Mortality Morbidity quality of life  using drug x decreases morbidity & mortality
  • 33. This indicates a fundamental misunderstanding of the financial consequences Physicians identify & implement the most efficacious treatments to maximize the outcomes for patients, this may increase costs EBP does not reduce the need for treatments, it attempts to ensure that each patient gets the best treatment appropriate for his/her condition.
  • 34. EBP incorporates the more extensive processes of SECONDARY & TERTIARY RESEARCH searching, appraisal, synthesis and incorporation of the best available evidence into practice
  • 35. Refuted by audits from within clinical care where at least some inpatient clinical teams have provided EB care to patients Busy clinicians who can devote their scarce time can practice EBM
  • 36. EBP critically examines all clinical procedures, critically evaluating their appropriateness for the specific situation. Text books: Fail to recommend Rx up to 10 ys after it’s been shown to be efficacious. Continue to recommend therapy up to 10 ys after it’s been shown to be useless.
  • 37. The use of evidence is only one piece of the clinical decision-making process. Patient situations, preferences & values are a key component in the process.
  • 38. It 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.  Lag time from time of “knowing” to time of implementation: 13 ys for thrombolytic therapy. 10 ys for corticosteroids to enhance fetal lung maturity.
  • 39. Do not need skills in biomathematics or statistics Physicians can gain skills to make independence decisions & can evaluate expert opinions. EBP does not mean continous running to the library, but that clinicians should remember to search for evidence to support or refute their practice methods. EBM reduces reading by quality filters
  • 40. Search Cascade
  • 41. EBM approach depends on high-quality literature, which is lacking in many areas of medicine There are more RCT each year There are many other types of evidence to make good decisions.
  • 42.  Many myths & misconceptions exist in health care practice  Myths & misconceptions must be overcome to implement EBM  EBM:
  • 43. Life is short & the evidence is too hard to find??? Thank you Questions?