Evidence based med


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Evidence Based Medicine
Dr Marwa Refaat


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  • PRESENTATION ONE 19/03/12 Introduction to Evidence-Based Practice
  • PRESENTATION ONE 19/03/12 Introduction to Evidence-Based Practice
  • PRESENTATION ONE 19/03/12 Introduction to Evidence-Based Practice
  • The National Health Service: A Service with Ambitions. www.archive.officialdocuments. co.uk/document/doh/ambition/ambition.htm (last accessed 27 April 2009)
  • PRESENTATION ONE 19/03/12 Introduction to Evidence-Based Practice
  • Source. Adapted from Trzepacz PT, Wise MG: "Neuropsychiatric Aspects of Delirium," in The American Psychiatric Press Textbook of Neuropsychiatry, Third Edition. Edited by Yudofsky SC, Hales RE. Washington, DC, American Psychiatric Press, 1997, pp. 447–470.
  • Don’t necessarily need source
  • The National Association of Mental Health Planning and Advisory Councils The National Association of Mental Health Planning and Advisory Councils The National Association of Mental Health Planning and Advisory Councils The National Association of Mental Health Planning and Advisory Councils
  • Evidence based med

    1. 1. E v id e n c e - B a s e d M e d ic in e Dr. Marwa Refaat
    2. 2. EBMIntroductionHistoryDefinition & ClassificationElements of EBMSteps of EBMApplying concepts of EBM tomanagement of some psychiatricdisorders
    3. 3. A dilemmaYou are very ill …
    4. 4. Which doctor do you want?William Osler, 1900 Smart young doctor
    5. 5. Rule 31 – Review the World Literature Fortnightly* *"Kill as Few Patients as Possible" - Oscar London 5,000? 2500000 per dayMedical Articles Per YearMedical Articles per Year 2000000 1500000 1,500 1000000 per day 95 per 500000 day 0 Biomedical MEDLINE Trials Diagnostic?
    6. 6. Evidence-based medicine Evidence-based medicine (EBM) is theconscientious, explicit, and judicious use ofcurrent best evidence (about therapy,prevention, etiology, harm, prognosis, diagnosisand economic analysis) in making decision aboutthe care of individual patients (Timmermans andMauck, 2005) and it seeks to assess the qualityof evidence of the risks and benefits oftreatments (Elstein, 2004).
    7. 7. The practice of evidence-based medicineis a systematic approach to clinicalproblem solving, which allows theintegration of the best available researchevidence with clinical expertise
    8. 8. A Cross-Cutting Principle:Science to Services/Evidence-Based Practices How do we translate research into practice? How do we connect services to science?
    9. 9. The history of EBM Although the formal assessment of medicalinterventions using controlled trials wasalready becoming established in the 1940s,it was not until 1972 that Professor ArchieCochrane, director of the Medical ResearchCouncil Epidemiology Research Unit inCardiff, expressed what later came to beknown as evidence-based medicine (EBM) inhis book Effectiveness and Efficiency: RandomReflections on Health Services.
    10. 10. In 1992, the UK government funded the establishment of the Cochrane Centre in Oxford under Iain Chalmers, with the objective to facilitate the preparation of systematic reviews of randomized controlled trials of healthcare. The following year it expanded into an international collaboration of centers, of which there are now thirteen, whose role is to co-ordinate the activities of 11,500 researchers.The National Health Service: AService with Ambitions. www.archive.officialdocuments.co.uk/document/doh/ambition/ambition.htm (last accessed 27 April 2009)
    11. 11. Skills of Evidence-based Medicine Critical thinking of theKnowledge applied to patients care content of medical literature Knowledge Critical Translation Appraisal KT CA Information Mastery IM Skills searching the medical literature
    12. 12. Elements of Evidence Based
    13. 13. Five essential steps of EBMpractice:Step 1- converting information needs into an an- swerable questionStep 2- finding the best evidence to answer the questionStep 3- critically appraising the evidence for its validity and usefulnessStep 4- applying the results of the appraisal into clinical practiceStep 5- evaluating clinical performance
    14. 14. Five essential steps of EBM practice
    15. 15. Step 1 of EBM practice: formulating an answerable clinical questionGood clinical question must be clear, directly focused on the problem, and answerable by searching the medical literature. 1- PICO format P Patient or problem, I Intervention, C Comparison, O Outcome 2- Type of clinical question The most common types of clinical questions is about intervention, etiology ,risk factors, rate, diagnosis, prognosis , cost-effectiveness, and question about phenomena (Glasziou P, 2003).
    16. 16. PICO format
    17. 17. CLASSIFICATION OF EBM:1. Evidence-based Health Care, also called as the evidence-based guidelines, is the practice of evidence based medicine at the organizational or institutional level. This includes the production of guidelines, policy and regulations (Gray, 1997).2. Evidence-based Individual Decision Making, is the practice of evidence based medicine by the individual health care provider (Eddy, 2005).
    18. 18. Step 2 of evidence-based medicine practice: findingthe evidence search for relevant evidence that will provide the answer to the question. Some research designs are more powerful than others in their ability to answer research questions.
    19. 19. Levels of evidence and grade of recommendation for ranking thevalidity of studies about therapy,prevention,etiology and harm,Oxford Centre for EBM
    20. 20. The “best” evidence depends on the type of questionLevel Treatment Prognosis DiagnosisI Systemic Systemic Systemic Review of … Review of … Review of …II Randomised Inception Cross trial Cohort sectionalIII
    21. 21. Level of Evidence
    22. 22. Evidence-based databases The Cochrane Library (through the Cochrane Collaboration, http://www.cochrane.org The DARE: includes systematic reviews that have been published outside of the Cochrane collaboration, all quality-assesses and with structured summarieshttp://www.crd.york.ac.uk/crdweb
    23. 23. The Cochrane Controlled Trials Register(CEN-TRAL):PubMed Clinical Queries (http://www.ncbi.nlm.nih.gov/entrez/query/static)SUMSearch(http://sumsearch.uthscsa.edu/): a meta-searching service
    24. 24. Step 3 of evidence-based medicine practice: appraisingthe evidence There are several tools for appraising a research article. One of them was developed by the Critical Appraisal Skills Programme (CASP), Oxford, UK. CASP aims to help individuals to develop the skills to find and make sense of research evidence, helping them to put knowledge into the practice.
    25. 25. Step 4 of evidence-based medicine model: applying theevidence The evidence should be fully discussed with the patient. The decision also should take into account the potential side effects of the drug (does side effect outweigh its potential benefits in a particular patient), the cost and availability of that particular treatment in the hospital or practice. The questions that we should ask before the decision to apply the results of the study are
    26. 26. Factors affecting decision in applying EBM:1- pt. profile2- Availability of treatment3- Alternative modalities4- Side effects profile5- Appropiate outcomes
    27. 27. Step 5 of evidence-based medicine model: evaluatingclinical performancewe need to ask whether we formulate answerable questions, find best evidence quickly, effectively appraise the evidence, and integrate clinical expertise and patient preferences and values with the evidence in a way that leads to a rational, acceptable management strategy.We need to evaluate our approach at frequent intervals and decide whether we need to improve any of the four steps discussed above.
    28. 28. Evidence Based Psychiatry
    29. 29. Applying concepts of EBM tomanagement of Psychiatric Disorders
    30. 30. Panic Disorder
    31. 31. Panic Disorder, With or Without AgoraphobiaPanic disorder is a chronic and recurrentillness associated with significantfunctional impairment. The estimated lifetime prevalence ofpanic attacks is 15%,with a 1-yearprevalence of 7.3%About one-third to one-half of patients withPD also have symptoms of agoraphobia
    32. 32. DSM-IV-TR of Panic Attack
    33. 33. Treatment of PD
    34. 34. I- Approach to Psychological ManagementCBT is the most consistently efficaciouspsychological treatment for PD, accordingto metaanalyses (Level 1) (Austeralian & NewZeland GL, 2003. – Glum GA, metaanalysis 1993)Various CBT approaches to the treatmentof panic attacks have been developedover the years (Landon et al 2004)
    35. 35. Common components of CBT for PD
    36. 36. Treatment Recommendations
    37. 37. II- Approach toPharmacologic Management
    38. 38. Strength of evidence ofpharmacological treatment of PD.cont.
    39. 39. III- Combined Psychological and Pharmacologic TreatmentCombined treatment had someadvantages during the acute and follow-upphases, but, when the medication wasdiscontinued after the follow-up phase,there was a considerably lower relapserate inthe CBT and CBT-with-placebo groups(18%), compared with the CBT-plus-imipramine group (48%) and imipramine-alone group (40%) (Barlow et al. 2000 )
    40. 40. Diagnosis & Assessment of Delirium
    41. 41. Diagnosis & Assessment of DeliriumDelirium characterized by :- Disturbed level of consciousness A change of cognition not better explained by a pre-existing dementia Disturbance develops over a short period of time Evidence from the history, physical, examination, or lab. Investigation that disturbance due to medications, medical condition ,or substance use.
    42. 42. Assessment of Delirium
    43. 43. 3- Basic laboratory testsBlood chemistries: electrolytes, glucose,calcium, albumin, blood urea nitrogen (BUN),creatinine, SGOT, SGPT, bilirubin, alkalinephosphatase, magnesium, phosphorusComplete blood count (CBC)Electrocardiogram (ECG)Chest X-rayArterial blood gases or oxygen saturationUrinalysis
    44. 44. 4- Additional laboratory testsUrine culture and sensitivityUrine drug screenBlood tests (e.g., VDRL, heavy metal screen, B12 and folate levels,antinuclear antibody [ANA], urinary porphyrins, ammonia level,human immunodeficiency virus [HIV], erythrocyte sedimentation rate[ESR])Blood culturesSerum levels of medications (e.g., digoxin, theophylline,phenobarbital, cyclosporine)Lumbar puncture(CT) or (MRI)(EEG)
    45. 45. Risk factors in recurrence of major Depressive Disorder
    46. 46. APA Guidelines for risk factors in recurrence of major depressive DisorderPrior history of multiple episodesSeverity of episodesEarlier age at onsetPresence of an additional non affective psychiatric diagnosisPresence of a chronic general medical disorderFamily history of psychiatric illness, particularly mood disorderOngoing psychosocial stressors or impairmentNegative cognitive stylePersistent sleep disturbances
    47. 47. Key components of effectiveScreening & careassessment “CollaborativePatient education Care” IAPTand activation program- NICE guidelinesTreatmentCaremanagementMental health
    48. 48. Integrating Ten Rules for Quality Mental Health Services1. Informed Choice2. Recovery Focus3. Person Centered4. Do No Harm5. Free Access To Records6. A System Based on Trust7. A Focus On Cultural Values8. Knowledge-Based9. Partnership Between Consumer & Provider10. Access to Services Regardless Of Ability To PayInfusing recovery-based principles into mental health services: A white paper by people who are New York state consumers, survivors, patients and ex- patients. September, 2004. New York State Office of Mental Health.
    49. 49. SummaryEBM is a great advance over informal, non-quantitative approaches to clinicaldecisions.EBM should result in more effective, moreuniform, and more efficient medical care.EBM is an adjunct, not a substitute forphysicians who can diagnose accurately,access evidence efficiently, and thinkanalytically.The integration of EBM with cost-benefitanalysis poses a major challenge forhealth policy.
    50. 50. k a n h o uT Y