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evidence based medical practice


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evidence based medical practice

  1. 1. Evidence-based Medicine Journal Club dr shabeel pn
  2. 2. <ul><li>A brief overview of EBM </li></ul><ul><li>Tips on how to conduct EBM Journal Club </li></ul>
  3. 3. Practicing Medicine <ul><li>&quot; the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.&quot; </li></ul><ul><li>David Sackett </li></ul>
  4. 4. Steps in the EBM process <ul><li>1. Start with the patient and a need for information </li></ul><ul><li>2. Formulate a relevant, answerable question </li></ul><ul><li>3. Select the resource and conduct a search </li></ul><ul><li>4. Appraise the evidence for its validity and applicability </li></ul><ul><li>5. Return to the patient -- integrate the evidence </li></ul>
  5. 5. 1. Start with the Patient <ul><li>You Already have seen 6 kids under the age of 2 years with Otitis Media at your family practice. Your experience from Pediatric clinical rotations and your memory of Pediatric textbooks indicates that Amoxicillin for 10 days is the accepted treatment for this problem. But you are also acutely aware of the consequences of over-prescribing antibiotics and the possible adverse effects of the drug. You wonder if it is really necessary to treat every occurrence of Otitis Media with Amoxicillin, especially in this age group. </li></ul>
  6. 6. 2. Formulate the question <ul><li>P atient </li></ul><ul><li>I ntervention </li></ul><ul><li>C omparison </li></ul><ul><li>O utcome </li></ul><ul><li>Type of Question </li></ul><ul><li>Study Design </li></ul><ul><li>Richardson,W.S., Wilson M. </li></ul><ul><li>ACP Journal Club 123:A12 </li></ul><ul><li>Nov-Dec 1995 </li></ul>
  7. 7. study design
  8. 8. Formulate the question <ul><li>P atient Otitis Media, 2 yrs old </li></ul><ul><li>I ntervention Amoxicillin </li></ul><ul><li>C omparison no meds, placebo </li></ul><ul><li>O utcome reduce fever, pain, long term benefit </li></ul><ul><li>Question therapy </li></ul><ul><li>Study Design randomized, controlled clinical trial </li></ul>
  9. 9. <ul><li>The well built clinical question is: </li></ul><ul><li>In children under the age of 2 years presenting with Otitis Media, does Amoxicillin significantly reduce fever and pain faster with better long term results than no medication? </li></ul><ul><li>It’s a therapy question and the best evidence would be an RCT. </li></ul>
  10. 10. 3. Select the resource <ul><li>Ideal information resource: </li></ul><ul><ul><li>Valid –contains high quality data </li></ul></ul><ul><ul><li>Relevant –clinical applicable </li></ul></ul><ul><ul><li>Comprehensive – has data on all benefits/harms </li></ul></ul><ul><ul><li>User-friendly – quick, easy to access and use </li></ul></ul><ul><li>see EBM Resource List </li></ul>
  11. 11. Conduct the Search <ul><li>MEDLINE </li></ul><ul><li>TRIP Database </li></ul><ul><ul><li>Cochrane </li></ul></ul><ul><ul><li>POEMS </li></ul></ul><ul><ul><li>ACP Journal Club </li></ul></ul>
  12. 12. MEDLINE
  13. 13. Cochrane Library
  14. 14. TRIP Database Search on otitis media
  15. 15. the evidence
  16. 16. 4. Evaluate the evidence <ul><li>Validity </li></ul><ul><li>Results </li></ul><ul><li>Applicability to the patient </li></ul>
  17. 17. Validity issues: <ul><li>Randomization </li></ul><ul><li>Follow-up complete (80% or better) </li></ul><ul><li>Blinding (concealed allocation) </li></ul><ul><li>Baseline similarities </li></ul><ul><li>Groups treated equally </li></ul>
  18. 18. Results of the evidence: <ul><li>Persistent symptoms at day 4 were present in 59% of the children in the Amoxicillin group and 72% in the placebo group. There was a high rate of treatment failure in both groups after therapy was completed: 64% in the treated group and 70% in the placebo group. </li></ul><ul><li>Journal of Family Practice </li></ul><ul><li>May 2000 </li></ul>
  19. 19. Applicability of the evidence <ul><li>Same diagnosis </li></ul><ul><li>Same age groups </li></ul><ul><li>General practice population </li></ul><ul><li>Study done in Netherlands </li></ul>
  20. 20. 5. Return to the patient: <ul><li>Between 7 and 8 children aged younger than 2 years have to be treated with an antibiotic for 1 of them to receive a symptomatic benefit at 4 days compared with placebo. However, only a small </li></ul><ul><li>percentage (30% to 36%) will be completely symptom free 11 days after presentation, regardless of antibiotic treatment. Since antibiotic treatment is not completely benign and its benefits are minimal. Most children between the ages of 6 months and 2 years need not be treated with antibiotics. </li></ul>