The document provides an introduction to evidence-based medicine (EBM). It defines EBM as an approach to clinical decision-making that integrates the best available research evidence, patient values and clinical expertise. The document outlines the key steps of EBM, including asking clinical questions, acquiring evidence from reliable sources, appraising the quality of the evidence, and applying it to individual patients. EBM aims to improve healthcare quality by minimizing ineffective, unsafe practices and promoting interventions that are supported by scientific evidence.
4. Pierre Louis (1787-1872)
Inventor of the “numeric method” and the “method
of observation”
Found that,
on average,
patients who
were bled did
worse than those
who were not.
6. William Osler (1849 -1919)
First “attending physician” at Johns Hopkins
Hugely influential
textbook author,
believed that most
drugs in his day were
useless, but still
advocated blood-letting
in some cases.
8. Patient: Mr. A
Mr. A is a 60 year old presenting with
1 hour of retrosternal chest pain.
ECG shows lateral ST-elevation consistent
with acute MI.
QUESTION: In patients with acute MI,
does treatment with aspirin reduce mortality?
What is the best evidence?
9. Evidence: 1988
Reduction
of mortality in acute myocardial
infarction with streptokinase and aspirin
therapy. Results of ISIS-2.
–
Patients with acute MI treated with ASA vs.
placebo had a significant 23% relative risk
reduction in five-week cardiovascular mortality,
with an absolute risk reduction of 11.8% to 9.4%.
–
The combination of SK and ASA resulted in a 42%
relative risk reduction in cardiovascular mortality
after five weeks compared with the placebo.
10. Application: 1997
How
many patients receive ASA
following acute myocardial infarction?
463 patients with a definitive
diagnosis of acute MI
–
Aspirin was not given to 55%!!!
–
78% of patients who did receive aspirin
received it more than 30 minutes after
arrival to the emergency department.
Annals of Intern Medicine. Jul 1997;127(2):126
11. EBM Misconceptions
FALLACY
FACT
EBM is useless when
there is no good
evidence
EBM means
appropriately using the
best available evidence
to care for patients
EBM is algorithms that
ignore clinical
judgment/expertise
Clinical judgment must be
used in deciding how to
apply the evidence
EBM is just numbers
and statistics
EBM is not numbers in a
vacuum – the evidence
must be individualized to
each patient
12. EBM - What is it?
Clinical
Expertise
Research
Evidence
Patient
Preferences
13. Why EBM?
Caring
for patients creates the need for
clinically important information
– Diagnosis….Therapy….Prognosis
Knowledge deteriorates with time:
Practitioners practice what they learned
during residency training
–
EBM: goal of life-long self-directed
learning
14. Why EBM?
New
evidence often changes clinical
practice
Prospective
learning from reading
journals and going to conferences is
important, but not sufficient
–
Impossible to prospectively acquire all
information necessary to treat all future
patients
15. Evidence is not Black and White
Use it to inform Clinical Practice
16. Besieged with Information
More
than 3800 biomedical journals
in MEDLINE
More than 7300 citations added
weekly
Lag period
–
–
Publication of research findings
Implementation in clinical practice
21. Ask Clinical Questions
Components of Clinical Questions
Patient/
Population
Intervention/
Exposure
Comparison
Outcome
In patients with
acute MI
does early treatment with a statin
compared to
placebo
decrease cardiovascular mortality?
In women with
suspected
coronary disease
what is the
accuracy of
exercise ECHO
compared to
exercise
ECG
for diagnosing
significant
CAD?
In postmenopausal
women
does hormone
replacement
therapy
compared to no
HRT
increase the
risk of
breast cancer?
22. Transforming Clinical Question into
Searchable Question
PICO(T) Question
Patient
In adult patients following spinal
tap procedures
I
Question
P
Intervention
or Issue of
Interest
Does Bedrest
C
O
Comparison
Outcome
of Interest
Compared to No Bedrest
T
Time
In first 4-8 hours post procedure
Result in Decreased Incidence and
Severity of Headaches
23. Transforming Clinical Question into
Searchable Question
PICO(T) Question
Question
P
I
Patient
Intervention
or Issue of
Interest
In older adults with a risk for falls
C
O
Comparison
Outcome
of Interest
Compared to No hip protectors
T
Time
Occurring with Accidental Falls
Does the use of hip protectors
Result in Decreased Incidence of
Hip Fractures
24. Transforming Clinical Question into
Searchable Question
PICO(T) Question
Question
P
I
Population
Intervention
or Issue of
Interest
For Adult Children
C
Comparison
In Placing a Parent in a Nursing
Home
O
Outcome
of Interest
T
Time
Stressors Associated with Decision
Making
25. Acquire the Best Evidence
Where
do you find high-quality evidence?
–
Textbook (print or online)
–
Medline or PubMed search: find and review
articles
–
Pre-appraised evidence
Best
Evidence
Clinical
Evidence (Therapy only)
Cochrane
Collaboration (Therapy only)
UpToDate
Which
source enables you to find answers
most quickly?
27. Appraise the Evidence
Determine
if evidence is unbiased
or flawed
–
–
Critically appraise articles yourself
Used a source that appraises trials for you
Best
Evidence
Clinical Evidence
Cochrane Library
UpToDate
28. Apply the Evidence
Evidence
must be applied to each
individual patient
Is your patient similar enough to
those studied?
– Do benefits outweigh harms?
– Cost
– What are your patient’s values and
preferences?
–
29. Rules of Evidence
All
evidence is not created
equal.
Evidence
alone never makes
clinical decisions.
Values
always influence
decisions.
30. Learning through play
Try
all “buttons”
Make lots of “mistakes”
Have fun
Survey your ‘information
environment’; try to
influence choices of new
resources
33. The bridge to address all of these improvement
mandates and to cross the “quality chasm” is
evidence-based practice brought alive at the
microsystem level
Editor's Notes
Postprandial somnolence
Guide to knowing when to nap
“Explicit, judicious, and conscientious use of current best evidence from medical care research to make decisions about the medical care of individuals”
Clinical expertise IS important!
Why?
Experience with patients:
improves efficiency of diagnosis and treatment
Improves ability to determine applicability of research data to your patients
Allows consideration of patient preferences
EBM is the process of systematically finding the most recent applicable research,
appraising its validity, and
using it as the basis for clinical decisions.
Clinical Expertise
improves efficiency of Dx and Rx
considers patient preferences
Overestimates usefulness of therapy
-placebo effect
- loss to follow-up
“Have not all concerned physicians been doing this (EBM) for ages... ? The steps and recommendations of the EBM acolytes reek of obfuscations and platitudes.”
WKC Morgan, London, Ontario Lancet, October 28, 1995
1) Our up-to-date knowledge and clinical performance that we all possessed upon completing our residency program definitely deteriorate with time.
Sure, we certainly gain experience and some knowledge with practicing medicine, but we tend to lose more than we gain.
2) New types of evidence are generated daily which should create major changes in the way we care for our patients.
Also, modern evaluation tools allow dissection, understanding, and objectification of the diagnostic reasoning skills of expert clinicians. In other words we can sort out how skilled doctors think and apply these rigorous systems to training doctors.
3) Although we need to use the new research information being generated daily, we usually fail to use it.
4) Listserv example of variation in care delivery (PE diagnosis, pneumovax)
What’s the evidence that we need it?
If we look at the delivery of healthcare, we don’t see a well-ordered, knowledge-based system.
When health insurers and employers, the people paying for health insurance in America, they don’t see a well-ordered, knowledge-based system.
We and they see chaos!
Now, am I being excessively alarmist or critical?
A story in a past Sunday New York Times Magazine has likened unexplained variation to three jumbo jets crashing every two days.
Highlight the number of patients killed every year because of missed diagnoses, medication mishaps, and other preventable errors.
The balance, and even tension, between evidence and clinical expertise is summarized by Sackett:
The lag period between publication of research findings demonstrating clinical effectiveness and the subsequent implementation in clinical practice is well recognized.
Practitioners continue to base clinical decisions on outdated training and on experience with individual patients.