Evidence based medicine involves integrating clinical expertise with the best available research evidence and patient values. It aims to apply the most appropriate interventions for individual patients based on scientific evidence. The key steps involve formulating an answerable clinical question using the PICO framework, searching for and critically appraising the relevant evidence, and applying the findings to clinical practice. While evidence based medicine improves clinical decision making, it also faces criticisms such as being time-consuming and potentially reducing clinical reasoning.

1. Evidence based
medicine
Dr. Shrey Bhatia
Junior Resident
Department of Pharmacology
GMC Patiala

2. Overview
Introduction
History
Need
Steps
Discussion

3. What is Evidence Based Medicine?
“Evidence-based medicine is the integration of best research evidence with clinical
expertise and patient values”
- Dave Sackett

4. Best research evidence
clinically relevant research
patient centered
 of accuracy and precision of diagnostic
tests , the power of prognostic markers,
and the efficacy and safety of
therapeutic, rehabilitative, and
preventive regimens.
INTRODUCTION

5. Clinical expertise
ability to use our clinical skills and past
experience
rapidly identify each patient’s unique health
status and diagnosis,
individual risks and benefits of potential
interventions,
their personal values and expectations
INTRODUCTION

6. Patient values
unique preferences, concerns and
expectations of each patient
must be integrated into clinical decisions
if they are to serve the patient.
INTRODUCTION

7. History of EBM

8. HISTORY
TRANSITIONAL ERA MODERN ERA
Historical
and
anecdotal
accounts
Biblical
reference
Bloodletting
James Lind
Van
Helmont,
John Clark,
Alexander
Hamilton Jules
Gavarret
1000s 1816 184018011753 1890 1970
Ernest
Amory
Codman
RCT
1972
Cochrane
Collaboration
1993
David
Sackett
ANCIENT ERA RENAISSANCE ERA
Archie
Cochrane
Gordon H
Guyatt
1991
Computer
database
software
Centres of
evidence
based
practice
around the
world
1996 2007-2011
ICMR
Centre for
EBM

9. HISTORY

10. Need of EBM

11. Growing medical knowledge
NEED
Armchair phenomenon
Question arose 3.2 times /10 patients
Low quality sources
Not the best
Medical myths

12. Delay of "bench-to-bedside" research:
Secondary Research
Routine Clinical Practice
Primary Literature
Years-to-Decades
NEED
Thrombolytic Drugs for acute MI:
6 years delay
(Antman, Lau, et al. JAMA 1992)
Aspirin after acute MI:
Not recommended by expert opinion until 6
years after the first systematic review.
(Antman, Lau, et al. JAMA 1992)

13. Aims to practice EBM
to develop decision-making by emphasizing the use of evidence from well
designed and conducted research
relating patient’s clinical signs and doctor’s clinical experience with the best
scientific evidences obtained by clinical research
applicable to medicine, nursing, physiotherapy, occupational therapy and
all other fields of healthcare Evidence based health care (EBHC)
NEED

14. Steps

15. STEPS
Ask
Acquire

16. The Clinical question
clarify one or two key issues
a clear, patient-oriented, relevant, answerable question
structured in the PICO format.
STEPS
1

17. PATIENT
• Characteristics of
the patient or
population
• Age, gender,
disease
INTERVENTION
• medication,
procedure,
diagnostic/scree
ning test,
surgery,
• exposure
CONTROL
• main alternative
treatment
• placebo,
standard therapy,
no treatment,
the gold standard
OUTCOME
• trying to
accomplish
• reduced
mortality or
morbidity,
improved
memory,
accurate
diagnosis,
decreased
infections
STEPS
1

18. Searching the best evidence
valid (contains high quality data),
 relevant (clinically applicable)
comprehensive (has data on all benefits and
harms of all possible interventions),
user-friendly (is quick and easy to access and
use).
Current (most recent)
Patient focused
STEPS
2

19. Some of the leading EBM resources
JOURNALS
STEPS
Evidence
summaries
InfoRetriever
SUMsearch
The York Database of
Abstracts of Reviews
of Effects (DARE)
Clinical guidelines
dailyPOEMS
2

20. Classify the clinical
question in to
various domains
such as diagnosis,
therapy, prognosis
and harm or
casualty and find
out which study
design fits it best
STEPS
2

21. Critical appraisal of the evidence
STEPS
3
Purpose?
Credentials
?
Sample population?
• Appropriate
• Selection
• control
Information?
• Accuracy
• truth
results?
• Believable?
• Degree of confidence?
Comprehensiveness?
• Large enough?
• Complete enough?
• Long enough?

22. Critical appraisal of the evidence
STEPS
3
Study
design? Reproducible ?
bias?
consistency
among
researchers ?

23. Critical appraisal of the evidence
STEPS
3
address the
questions
raised?
study patients are
comparable to
your patient ?
study
professionals
comparable to
you?

24. Critical appraisal of the evidence
STEPS
3
Is the information
clinically relevant?

25. Evidence based
medicine pyramid
weigh different levels of
evidence
based on the relative
strengths and weaknesses of
each study design
as we ascend, results are
accurate, have less chance of
statistical error, and minimize
bias from
confounding variables
STEPS
3
Systemic
analysis
RCT
Cohort study
Case control study
Case series
Case reports
Expert experience
Meta-analysis

26. Grades of Recommendation Assessment,
Development, and Evaluation (GRADE)
a new approach to rating evidence quality and the grading
strength of recommendations,
limitations of existing evidence hierarchies,
 importance of processed evidence
potential for practice guidelines to improve practice and
outcomes
STEPS
3

27. STEPS
3

28. Applying evidence to the patient
particular patient and their unique
values and circumstances
needs, choices, preferences, values,
socio-economic concerns of the
patient
STEPS
4

29. Efficacy evaluation of EBM application on
a patient
whether certain evidence which is applied
to the patient, caused changes to better
and that to the extent that is confirmed by
research
If the data differ significantly- investigate
why.
STEPS
5

30. ICMR initiatives
funding an Advanced Center for EBM (2007-
2011) that hosted the South Asian Cochrane
Network & Centre (SACNC) at the Christian
Medical College, Vellore
2007, ICMR procured a national subscription to
The Cochrane Library
Advance Center for Evidence-Based Child Health
(CAR EBCH) at the Post Graduate Institute,
Chandigarh since 2011

31. Discussion

32. Advantages
• Clinicians update knowledge base routinely
• Improved understanding of research methods
• Increased confidence in management decisions
• Increased computer literacy, data search technology
• Better reading habits
• Provides framework for group problem solving, team generated
practice
• Can be learned by non-clinicians and other health care workers
DISCUSSION

33. disadvantages
• Time consuming
• Information overload
• Requires financial sources to establish resource infrastructure – library, office,
computers, peripherals
• Internet costs ,Programs, software information, CD-ROMS, Subscription costs
– online and paper resources
• May increase cost of care
• Online references made to unavailable journals or references
• Exposes gaps in the evidence (but provides ideas for researchers!)
• Requires computer skills (but can be done with minimal computer literacy
and skill)
• May expose your current practice as obsolete or dangerous (loss of authority
and respect)
DISCUSSION

34. Criticism
• strict adherence to the evidence hierarchy pyramid
encourages formulaic “cookbook medicine”, discouraging deliberation
and clinical reasoning and leading to automatic decision making
promotes rule-based reasoning instead of intuitive and experiential
thinking, which characterise expert judgment
no high quality evidence that its application has improved patient care.
DISCUSSION

35. References
Sackett DL. Evidence-based medicine. InSeminars in perinatology 1997 Feb 1 (Vol. 21,
No. 1, pp. 3-5). WB Saunders.
Sackett DL, Rosenberg WM, Gray JM, Haynes RB, Richardson WS. Evidence based
medicine: what it is and what it isn’t.
Sinha A, Shah D, Tharyan P. Building capacity of Indian scientists to conduct systematic
reviews in child health: an ICMR initiative. Indian pediatrics. 2015 Mar 1;52(3):195-8
Claridge JA, Fabian TC. History and development of evidence-based medicine. World
journal of surgery. 2005 May 1;29(5):547-53.
Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-
based medicine. Plastic and reconstructive surgery. 2011 Jul;128(1):305.