The evolution of EBM: Where Cochrane fits in <ul><li>brief history of EBM </li></ul><ul><li>Cochrane’s contribution to dat...
 
1990 McMaster University internal medicine residency <ul><li>different practice of medicine </li></ul><ul><ul><li>less tru...
First principle:  Hierarchy of Evidence Randomized Trials Observational studies patient-important outcomes Basic research ...
 
Model of evidence based clinical decisions <ul><li>clinical circumstances </li></ul><ul><li>patient preference   research ...
 
21 5 10 1 1 2 8 7 8 12 4 3 1 1 2 8 7 2 1 1 1 2 8 1 5 15 6 Not Mentioned Routine Experimental Rare/Never Specific M M M M M...
Prophylactic Lidocaine in MI 1970  2  304 1974  9 1451 1976 11 1686 1978 12 1986 1985 14 8412 1988 15 8745 9 1  1 8 0  2 5...
Additional principle of EBM <ul><li>systematic summaries of best evidence should inform clinical decisions </li></ul><ul><...
Limitations of Cochrane Reviews <ul><li>for clinicians  </li></ul><ul><ul><li>long, complex, confusing, inaccessible </li>...
 
GRADE <ul><li>system for rating quality of evidence and grades of recommendations </li></ul><ul><li>system for developing ...
Rating quality of evidence <ul><li>categories of quality </li></ul><ul><ul><li>high, moderate, low, very low </li></ul></u...
 
Role of Cochrane within EBM <ul><li>systematic summaries of best evidence should guide clinical decision-making </li></ul>...
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The evolution of evidence-based medicine: where Cochrane fits in

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Gordon Guyatt speaking at plenary session 1 at the XV Cochrane Colloquium in Sao Paulo, Brasil

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  • The evolution of evidence-based medicine: where Cochrane fits in

    1. 1. The evolution of EBM: Where Cochrane fits in <ul><li>brief history of EBM </li></ul><ul><li>Cochrane’s contribution to date </li></ul><ul><li>Cochrane’s contribution in future </li></ul>
    2. 3. 1990 McMaster University internal medicine residency <ul><li>different practice of medicine </li></ul><ul><ul><li>less trust of personal observations </li></ul></ul><ul><ul><li>less trust of physiological reasoning </li></ul></ul><ul><ul><li>less trust of experts </li></ul></ul><ul><ul><li>more emphasis on controlled clinical observations </li></ul></ul><ul><ul><ul><li>strategies to reduce bias </li></ul></ul></ul><ul><ul><ul><li>reliance on critical use of published literature </li></ul></ul></ul><ul><ul><ul><li>demand of experts/teachers: what is the evidence? </li></ul></ul></ul><ul><li>what to call it? </li></ul><ul><ul><li>scientific medicine </li></ul></ul><ul><ul><li>evidence-based medicine </li></ul></ul>
    3. 4. First principle: Hierarchy of Evidence Randomized Trials Observational studies patient-important outcomes Basic research test tube, animal, human physiology Clinical experience
    4. 6. Model of evidence based clinical decisions <ul><li>clinical circumstances </li></ul><ul><li>patient preference research evidence </li></ul>Clinical expertise
    5. 8. 21 5 10 1 1 2 8 7 8 12 4 3 1 1 2 8 7 2 1 1 1 2 8 1 5 15 6 Not Mentioned Routine Experimental Rare/Never Specific M M M M M M Textbook/Review Recommendations Odds Ratio (Log Scale) 0.5 1.0 2.0 Favours Treatment Favours Control RCTs Pts 1 23 2 65 3 149 4 316 7 1793 10 2544 11 2651 15 3311 17 3929 22 5452 P<.01 23 5767 27 6125 30 6346 33 6571 43 21 059 54 22 051 67 47 531 65 47 185 70 48 154 P<.001 P<.00001 Cumulative Year 1960 1965 1970 1980 1985 1990 Thrombolytic Therapy
    6. 9. Prophylactic Lidocaine in MI 1970 2 304 1974 9 1451 1976 11 1686 1978 12 1986 1985 14 8412 1988 15 8745 9 1 1 8 0 2 5 0 2 8 0 3 14 4 6 4 2 1 1989 - 1st meta-analysis published Recommendations Yes No Not mentioned Favors treatment Favors placebo Outcome = death Relative risk (CI) 0.5 1 1.5 2 Cumulative Year # RCTs Subjects
    7. 10. Additional principle of EBM <ul><li>systematic summaries of best evidence should inform clinical decisions </li></ul><ul><li>need for systematic reviews </li></ul><ul><li>need for practice guidelines </li></ul>
    8. 11. Limitations of Cochrane Reviews <ul><li>for clinicians </li></ul><ul><ul><li>long, complex, confusing, inaccessible </li></ul></ul><ul><li>for guideline developers </li></ul><ul><ul><li>best estimate of effect of alternatives on all patient-important outcomes </li></ul></ul><ul><ul><li>often don’t include all outcomes </li></ul></ul><ul><ul><li>when they do, difficult to efficiently access evidence summaries </li></ul></ul>
    9. 13. GRADE <ul><li>system for rating quality of evidence and grades of recommendations </li></ul><ul><li>system for developing recommendations </li></ul><ul><li>system to guide interpretation of systematic reviews to inform clinical guidelines and clinical decisions </li></ul>
    10. 14. Rating quality of evidence <ul><li>categories of quality </li></ul><ul><ul><li>high, moderate, low, very low </li></ul></ul><ul><li>RCTs start high </li></ul><ul><li>5 factors can lower quality? </li></ul><ul><ul><li>detailed design and execution </li></ul></ul><ul><ul><li>inconsistency </li></ul></ul><ul><ul><li>indirectness </li></ul></ul><ul><ul><li>imprecision </li></ul></ul><ul><ul><li>reporting bias </li></ul></ul>
    11. 16. Role of Cochrane within EBM <ul><li>systematic summaries of best evidence should guide clinical decision-making </li></ul><ul><li>Cochrane central to EBM </li></ul><ul><ul><li>enormous impact and contribution </li></ul></ul><ul><ul><li>but hasn’t met full potential </li></ul></ul><ul><li>full potential may soon be met </li></ul>

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