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EBM Questions Anyone?
EBM Questions Anyone?
EBM Questions Anyone?
EBM Questions Anyone?
EBM Questions Anyone?
EBM Questions Anyone?
EBM Questions Anyone?
EBM Questions Anyone?
EBM Questions Anyone?
EBM Questions Anyone?
EBM Questions Anyone?
EBM Questions Anyone?
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EBM Questions Anyone?

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  • 1. EBMEBM QUESTIONSQUESTIONS ANYONE ?ANYONE ? Todd D. Tillmanns, MD, FACOGTodd D. Tillmanns, MD, FACOG Assistant ProfessorAssistant Professor Division of Gynecologic OncologyDivision of Gynecologic Oncology West ClinicWest Clinic && University of Tennessee Health ScienceUniversity of Tennessee Health Science CenterCenter
  • 2. What is Evidence BasedWhat is Evidence Based Medicine (EBM)Medicine (EBM)  Evidence-based medicine is the care ofEvidence-based medicine is the care of patients using the best available evidencepatients using the best available evidence from the results of research to guide clinicalfrom the results of research to guide clinical decision making [1-3]decision making [1-3] 1. Sackett, DL, Straus, SE, Richardson, WS, et al. Evidence-based medicine. How to practice and teach EBM, 2nd edition, Churchill Livingstone, Edinburgh 2000. 2. 2. Sackett, DL, Rosenberg, WM, Gray, JA, et al. Evidence-based medicine. What it is and what it isn't. BMJ 1996; 312:71. 3. 3. Geyman, JP, Deyo, RA, Ramsey, SD. Evidence-Based Clinical Practice, Butterworth-Heinemann, Woburn, MA 1999.
  • 3. What EBM is not!What EBM is not!  EminenceEminence  VehemenceVehemence  EloquenceEloquence  Confidence of the sourceConfidence of the source  Practicing defensive medicinePracticing defensive medicine  The way we do it, you could…..The way we do it, you could….. Isaacs, D, Fitzgerald, D. Seven alternatives to evidence based medicine. BMJ 1999; 319:1618.
  • 4. Don’t put the cart before theDon’t put the cart before the horsehorse  The question must be definedThe question must be defined before the answer to the questionbefore the answer to the question can be elucidated through a carefulcan be elucidated through a careful searchsearch
  • 5. Good Evidence Based QuestionsGood Evidence Based Questions  Is the finding abnormal?Is the finding abnormal?  What is the diagnosis?What is the diagnosis?  How often does it occur?How often does it occur?  What are the risk factors for the disease?What are the risk factors for the disease?  What is the pathogenesis?What is the pathogenesis?  What is the natural history?What is the natural history?  How effective (harmful) is the treatment?How effective (harmful) is the treatment?  How effective or (harmful) are preventativeHow effective or (harmful) are preventative interventions?interventions?
  • 6. Putting EBM into practicePutting EBM into practice  What is the incidence and prevalence?What is the incidence and prevalence?  What are the signs and symptoms?What are the signs and symptoms?  What are the best diagnostic tests with the best clinicalWhat are the best diagnostic tests with the best clinical findings that confirm the suspected diagnosis?findings that confirm the suspected diagnosis?  What is the best treatment of the disease process?What is the best treatment of the disease process?  Once treated what is the best way to maintain health forOnce treated what is the best way to maintain health for discharge from your care?discharge from your care?  How would you prevent the disease process?How would you prevent the disease process?
  • 7. Where do you find the answers?Where do you find the answers?  You must invest your time to become proficient searching theseYou must invest your time to become proficient searching these sites and otherssites and others  full text journals (OVID, Medline, Pubmed)full text journals (OVID, Medline, Pubmed)  Cochran Data BaseCochran Data Base  OrganizationsOrganizations  American College of PhysiciansAmerican College of Physicians  American Society of Internal MedicineAmerican Society of Internal Medicine  APGO, ACOGAPGO, ACOG  Infectious Disease Society of AmericaInfectious Disease Society of America  governmental organizations:governmental organizations:  National Institutes of HealthNational Institutes of Health  Centers for Disease Control and PreventionCenters for Disease Control and Prevention  National Guideline Clearinghouse:National Guideline Clearinghouse: www.guideline.govwww.guideline.gov
  • 8. Summary of Good Sources forSummary of Good Sources for Quick EBM ReviewQuick EBM Review  UpToDateUpToDate editors and authors revise the program continually. New information is highlighted in each new edition of theeditors and authors revise the program continually. New information is highlighted in each new edition of the CD-ROM and internet versions, and the date when the topic was last updated is noted at the beginning of each topic review.CD-ROM and internet versions, and the date when the topic was last updated is noted at the beginning of each topic review. Other textbooks are finding ways to update regularly, but readers should be aware of how often each part of the information baseOther textbooks are finding ways to update regularly, but readers should be aware of how often each part of the information base is updated and when the last update of each section they are depending on was done.is updated and when the last update of each section they are depending on was done.  ACP Journal ClubACP Journal Club is published every two months by the American College of Physicians/American Society of Internalis published every two months by the American College of Physicians/American Society of Internal Medicine. It reviews the world's English-language medical journals in internal medicine, selects scientifically strong articles byMedicine. It reviews the world's English-language medical journals in internal medicine, selects scientifically strong articles by explicit criteria, and summarizes those meeting these criteria as structured abstracts with commentary by an expert, one article perexplicit criteria, and summarizes those meeting these criteria as structured abstracts with commentary by an expert, one article per page. (ACP Journal Club, ACP-ASIM, 190 North Independence Mall West, Philadelphia, PA 19106-1572, USA; 800-523-1546)page. (ACP Journal Club, ACP-ASIM, 190 North Independence Mall West, Philadelphia, PA 19106-1572, USA; 800-523-1546)  The Medical LetterThe Medical Letter, a four-page, biweekly, evidence-based review of drugs, including effectiveness, mechanism of, a four-page, biweekly, evidence-based review of drugs, including effectiveness, mechanism of action, side effects and interactions, and cost – for new drugs in relation to older alternatives. (The Medical Letter, Inc., 1000 Mainaction, side effects and interactions, and cost – for new drugs in relation to older alternatives. (The Medical Letter, Inc., 1000 Main Street, New Rochelle, NY 10801; 800-211-2769).Street, New Rochelle, NY 10801; 800-211-2769).  Evidence-Based MedicineEvidence-Based Medicine is similar to ACP Journal Club but with a wider scope, including articles of interest tois similar to ACP Journal Club but with a wider scope, including articles of interest to family medicine, pediatrics, obstetrics and gynecology, surgery, and psychiatry. (Evidence-Based Medicine, ACP-ASIM, 190 N.family medicine, pediatrics, obstetrics and gynecology, surgery, and psychiatry. (Evidence-Based Medicine, ACP-ASIM, 190 N. Independence Mall West, Philadelphia, PA 19106-1572; 800-523-1546)Independence Mall West, Philadelphia, PA 19106-1572; 800-523-1546)  The Family Practice NewsletterThe Family Practice Newsletter is a four-page, "biweekly update and commentary on new and practicalis a four-page, "biweekly update and commentary on new and practical clinical information for the primary care practitioner," written by a family physician with public health and law degrees. (Primaryclinical information for the primary care practitioner," written by a family physician with public health and law degrees. (Primary Care Press, 5423 Monocracy Drive, Bethlehem, PA 18017; 888-399-7442; fax 631-474-5390; cpkerr@nni.com).Care Press, 5423 Monocracy Drive, Bethlehem, PA 18017; 888-399-7442; fax 631-474-5390; cpkerr@nni.com).  Evidence-Based PracticeEvidence-Based Practice, "patient-oriented evidence that matters," from the publishers of The Journal of Family, "patient-oriented evidence that matters," from the publishers of The Journal of Family Practice. (Dowden Health Media, 110 Summitt Ave., Montvale, NJ 07645-9894; 800-707-7040; ebp@dowdenhealth.com)Practice. (Dowden Health Media, 110 Summitt Ave., Montvale, NJ 07645-9894; 800-707-7040; ebp@dowdenhealth.com)  Journal WatchJournal Watch is a monthly publication of the Massachusetts Medical Society that summarizes recent articles withis a monthly publication of the Massachusetts Medical Society that summarizes recent articles with commentary. (Massachusetts Medical Society. 860 Winter St. Waltham, MA 02451.1411. 781-893-4610).commentary. (Massachusetts Medical Society. 860 Winter St. Waltham, MA 02451.1411. 781-893-4610).
  • 9. Credibility of ResourcesCredibility of Resources  Internal validityInternal validity: Are the results of clinical: Are the results of clinical research correct for the patients in the study?research correct for the patients in the study? (threatened by two processes: bias and chance)(threatened by two processes: bias and chance)  GeneralizabilityGeneralizability: Do the results of the study: Do the results of the study apply to my patientsapply to my patients  Classification of levels of evidence andClassification of levels of evidence and recommendationsrecommendations
  • 10. Level of Evidence Type of EvidenceType of Evidence IaIa Evidence obtained from meta-analysis of randomized controlled trialsEvidence obtained from meta-analysis of randomized controlled trials IbIb Evidence obtained from at least one randomized controlled trialEvidence obtained from at least one randomized controlled trial IIaIIa Evidence obtained from at least one well designed controlled study withoutEvidence obtained from at least one well designed controlled study without randomization.randomization. IIbIIb Evidence obtained from at least one other type of well designed quasi-Evidence obtained from at least one other type of well designed quasi- experimental studyexperimental study IIIIII Evidence obtained from a well designed non-experimental descriptiveEvidence obtained from a well designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies.studies, such as comparative studies, correlation studies, and case studies. IVIV Evidence obtained from expert committee reports or opinions or clinicalEvidence obtained from expert committee reports or opinions or clinical experiences of respected authoritiesexperiences of respected authorities Grade (Levels)Grade (Levels) RecommendationRecommendation A (Ia, Ib)A (Ia, Ib) Requires at least one randomized control trial, adressing a specificRequires at least one randomized control trial, adressing a specific recommendationrecommendation B (IIa, IIb, III)B (IIa, IIb, III) Requires availability of well conducted clinical trialsRequires availability of well conducted clinical trials C (IV)C (IV) Indicates absence of directly applicable clinical studies of good qualityIndicates absence of directly applicable clinical studies of good quality GPP (Good PracticeGPP (Good Practice Points)Points) Recommended best practice based on the clinical experience of theRecommended best practice based on the clinical experience of the guideline development groupguideline development group
  • 11. Guidelines for practicing EBMGuidelines for practicing EBM  Worksheet for EBM presentations by residentsWorksheet for EBM presentations by residents  Clinical questionClinical question  Reference research articles by level of evidenceReference research articles by level of evidence  Identify the incidence and prevalence of disease or disorderIdentify the incidence and prevalence of disease or disorder  Give backgroundGive background  Signs and symptoms ( M/C symptom most reliable)Signs and symptoms ( M/C symptom most reliable)  Laboratory, studies, findings that confirm diagnosis (and exclude others)Laboratory, studies, findings that confirm diagnosis (and exclude others)  Treatment (Best, most economical and options for second line)Treatment (Best, most economical and options for second line)  Discharge measures and follow up evaluationDischarge measures and follow up evaluation  Preventative measuresPreventative measures  EBM GuidelinesEBM Guidelines  Guidelines for proposing good EBM questions (Sackett)Guidelines for proposing good EBM questions (Sackett)
  • 12. THANK YOU!THANK YOU! QUESTIONS?QUESTIONS? Even my family hasEven my family has stopped listeningstopped listening to me!to me! Love isLove is unconditional withunconditional with NoraNora

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