This presentation focuses on informed decision making in clinical practice making use of evidence based practice. It addresses the use of PICO to formulate clinical question, searching the evidence/literature, critically appraising the evidence, and application of the evidence to improve the quality of clinical practice

1. INFORMED
DECISION MAKING
IN
CLINICAL MEDICINE
Dr KD DELE .
DEPT OF FAMILY MEDICINE . DNH

3.  To highlight the importance of Evidence-Based Medicine
and how it can act as a crucial tool in decision-making to
empower the quality of medical services for better
patient outcomes.
 To learn the steps in EBM process
 Identify the parts of a well-built clinical question
 Discuss resources for literature search
 Critical appraisal of the evidence
 Apply the evidence to the patient.
THE PURPOSE OF THIS PRESENTATION

4. EVIDENCE-BASED
MEDICINE
EBM.
“Just because we can, doesn’t mean we should”

6. EVIDENCE-BASED MEDICINE
(PRACTICE)
■ Evidence based medicine is the conscientious, explicit, and judicious use
of current best evidence in making decisions about the care of individual
patients
 Sackett DL et al. Evidence based Medicine.
■ It is “integrating individual clinical expertise with the best available
external clinical evidence from systematic research” to achieve the best
possible patient management
 Sackett DL et al. Evidence based Medicine.
■ It is about trying to improve the quality of the information on which
healthcare decisions are based
 Glasziou P et al. Evidence based Practice Work book. 2nd edition.

7. WHAT IS EVIDENCE?
■ “Evidence’’ basically means information.
■ There are may sources of evidence available:
 From scientific research suggesting generally applicable facts about the
world, people, or organizational practices.
 Based on numbers or descriptions or other forms of research.
 From local, organizational or business indicators, or observations of
practice conditions.
 From professional experience – past experiences, trials and errors may
indicate the approach that is likely to be the most successful.
 However, loosely speaking, evidence is used to mean scientific research.

8. INFORMED
DECISION MAKING
■ Effective decision-making
thus depends on…
■ the ability to base ones
practices on THE BEST
AVAILABLE EVIDENCES…
■ … rather than on guts,
assertions, hearsays and
personal opinions.
■ Always pause to ask the
question:
■ “What does the evidence
say?”

9. Principles
Of
EVIDENCE-
BASED
(Informed)
DECISION-
MAKING

10. Some Common Misconceptions Of
Evidence-Based Practice
Misconception 1:
Evidence-based practice
ignores the practitioner’s
professional experience.
Misconception 4:
Each organization is
unique, so the usefulness
of scientific evidence is
limited.
Misconception 5:
Evidence-based practice is
all about numbers and
statistics..
Misconception 3:
Good-quality evidence
gives you the answer to
the problem.
Misconception 6:
Doctors need to make
decisions quickly and
don’t have time for
evidence-based practice.
Misconception 2:
If you do not have
high-quality evidence, you
cannot do anything.

11. In essence,

12. STEPS IN
EVIDENCE-BASED
MEDICINE.

13. The Process of Evidence -Based Medicine
■ This relies on the following SIX SKILLS:
1. Asking: translating a practical issue or problem into an answerable
question
2. Acquiring: systematically searching for and retrieving the evidence
3. Appraising: critically judging the trustworthiness and relevance of the
evidence
4. Aggregating: weighing and pulling together the evidence
5. Applying: incorporating the evidence into the decision-making process
6. Assessing: evaluating the outcome of the decision taken

14. STEP 1. The Patient
■ Start with a clinical problem
arising from the case.

15. STEP 2: The Question – PICO!
■ Construct and formulate the clinical question according to PICO
method
■ PICO is a well-built question developed by the national Library of
Medicine
■ It consists of four main parts
 P: Population or Participants
 I: Intervention or Indicator
 C: Comparator or Control, and
 O: Outcome

16. STEP 2: The Question – PICO!
■ The questions:
 What is the case?
 What intervention, treatment, diagnostic tests, etc.?
 What type of comparison – treatment A versus B, placebo?

17. STEP 3: The Resource – PICO-TS(r)!
■ Recently it has been suggested to add T & S (&R) to PICO (PICO-TS-r)
■ T: refers to the best Type of study and
■ S: refers to the best Setting where it takes place.
■ R: Select the best resource(s) to conduct the research, e.g.
 Systematic review?
 Randomized Clinical Trials (RCTs)?

18. STEP 4: The Evaluation
■ Critically appraise for
 Internal validity
 External validity
 Significance
 Applicability
&
 Impact of intervention.

19. STEP 5: Apply The Evidence
The Patient
Integrate the EBM with the
clinical expertise:
Apply to practice, and
Consider patient’s values
and circumstances.
Self-Evaluation
Evaluate your performance
and assess the outcome
Right question?
Better outcome?
Clinical sense?
Good medical performance is based on quality and quality depends on
the best available EBM.

20. A DECISION-AID
FOR EVIDENCE
BASED
MEDICINE

21. EBM
Evidence-
Based
Medicine
(Practice)

22. FORMULATE A
CLINICAL
QUESTION.

23. Case Scenario 1: The Patient
■ Miss PN is a 30 year old HIV positive married mother of 2 from Newton Park. Her CD4
count is 104 and she is currently on HAART.
She now presents to Dora Nginza Emergency unit with a one day history of a severe
headache, neck stiffness and photophobia.
On examination, BP130/98, P126, T38.7, appears acutely ill with neck stiffness on CNS
examination but no focal neurology.
A lumbar puncture was done which confirmed “cryptococcal meningitis”.
While in the ward, her husband poses the following question to you:
“Was there any way you could have prevented this type of meningitis in my wife?”
~ EBM by a Family Medicine intern in 2018.

24. Case Scenario 1: The Question/PICO
■ Population : HIV positive patients
■ Intervention : use of antifungals (in this case, itraconazole)
■ Comparison : no use of antifungals
■ Outcome : reduction in incidence of cryptococcal meningitis
■ Question formulated:
 Can antifungals be used in the primary prevention of cryptococcal
meningitis in HIV positive patients?
~ EBM by a Family Medicine intern in 2018.

25. Case Scenario 2: The Patient
■ It’s Saturday night, a busy typical casualty call. A man comes running in, his wife is
about to deliver. You don a pair of gloves and accompany the man to a small vehicle
in front of the entrance.
In the back seat is a young female, a newborn baby and a large amount of blood.
You clamp and cut the chord and both mother and baby are taken into casualty
The baby is clinically stable. The placenta is delivered complete, the uterus is
contracted however the mother continues to bleed. You ask the sisters for
oxytocin. After a few minutes, a sister reports back that they can not find Oxytocin
or Ergometrine. The only available drug is Cyclokapron.
~ EBM by a Family Medicine intern in 2018.

26. Case Scenario 2: The Question/PICO
■ Question formulated:
 In Post Partum females will tranexamic acid be as effective in the
prevention of post-partum haemorrhage as compared to
uterotonic agents
■ Population : Post partum Haemorrhage Females
■ Intervention : Tranexamic acid
■ Comparison : Placebo/ Oxytocin/ Ergometrine
■ Outcome : Prevention of Post Partum Haemorrhage

27. Case Scenario 3: PicO
■ In some instances, only the problem and the outcome may be
required to formulate a question.
■ Example
 Mabel a 6wk old ex prem, parents ask you for the chances of their
child developing sensorineural deafness as their friends had a baby
born prematurely who was discovered to have nerve deafness
detected late
 Question: In infants born prematurely, what is the frequency
(incidence) of nerve deafness?
■ Population / problem : Infants born prematurely
■ Outcome : Nerve deafness

28. Case Scenario 4 : The Question/PICO
■ Question formulated:
 What is the effectiveness of non- pharmacological vs
pharmacological management of insomnia?
■ Population : Adults with insomnia
■ Intervention : Cognitive Behavioral Therapy
■ Comparison : Pharmacotherapy
■ Outcome : Improved sleep
~ EBM by a Family Medicine intern in 2018.

29. THE RESOURCE:
SEARCHING
FOR EVIDENCE.

30. Searching for Evidence: Search Engines
■ PubMed – http://www.pubmed.gov
■ The Cochrane library - http://www.cochrane.org
■ Clinical Evidence (BMJ publication) – http://www.clinicalevidence.com
■ EMBASE (subscription only) – http://www.embase.com
■ Others:
■ Google scholar

31. Searching for Evidence: Search Engines
■ Filtered resources are usually used to appraise the quality of search
and to allow practice recommendations.
■ Good sources of systemic reviews and meta-analysis studies: include
 The Cochrane Database
 The Database of Abstracts of Reviews of Effects (DARE)
 PubMed and
 Ovid MEDLINE

32. Example of Literature Search
■ Done by the Intern working on the HIV-antifungal EBM study
■ Search engine : Google
■ Source : Google Scholar, PubMed
■ Key words : cryptococcal meningitis, HIV, antifungals, prevention
■ Limitations : English; studies on humans, systematic reviews, Studies
in past 5years, Africa
■ 27 articles
■ Article chosen:
~ EBM by a Family Medicine intern in 2018.

33. Searching for Evidence
■ Track down the best evidence of outcomes available
■ The best evidence you will find comes from studies where the
researchers used methods that maximise chances of eliminating bias.
■ Systematic reviews have the highest level of evidence – it is a collation
of primary research

34. LEVEL
OF
EVIDENCE

35. Primary
&
Secondary
SOURCES OF
EVIDENCE

36. Study
Design
Vs
Level Of
Evidence

37. Levels Of Evidence
1. Systematic reviews, meta analysis, EBM guidelines
2. Randomised controlled trials with definitive results
3. Cohort Studies
4. Case controlled studies
5. Cross sectional surveys
6. Case reports

38. CRITICALLY
APPRAISE
THE EVIDENCE.

39. Why Do We Have To Critically Appraise
Evidence?
■ Evidence is never perfect and can be misleading in many different ways.
■ Evidence-based practice is about using the best available evidence, and
critical appraisal plays an essential role in discerning and identifying such
evidence.
■ Ask the relevant questions regarding your evidence:
 How were these figures calculated?
 Are they accurate?
 Are they reliable?
 How were the data collected?
 How was the outcome measured?
 To what extent are alternative explanations for the outcome found possible?
 To what extent is the evidence generalisable to our context?

40. Some Components of Clinical Appraisal
■ What is the PICO of the study?
■ How well was the study done? – Internal validity
■ What do the results mean?
■ Could they have been due to chance?
■ Can the findings of the study be applicable in your setting? – External
validity

41. What Is The PICO Of The Study?
■ Is the study question the same as yours?
■ Is the outcome measured the same as the outcome you are
investigating?

42. HOW WELL WAS
THE STUDY DONE?
(INTERNAL
VALIDITY)

43. Methodology
 Check the methodology
 How were the subjects recruited? Are they a true representation
of the study population?
 Is it a large enough sample?
 Was it random selection or consecutive patients selected in a
clinic?
 How were they allocated to the study groups? Was it a blinded
process? Did they make adjustments for confounding factors?
 Were the groups managed equally except for the intervention?
 How was the outcome measured? Was it devoid of bias on the
side of the assessors?

44. Recruitment
■ What were the inclusion and exclusion criteria?
 How well were these defined?
 If not defined clearly, target population may not be clear, and
introduces recruitment bias – poor internal validity.

45. Allocation
■ Allocation of subjects
 The control and intervention groups should be comparable at the
start of the trial
 If not comparable, the differences in outcome could be said to be
due to one of the non matched characteristics rather than due to
the intervention
 This process is best done randomly and researcher must be
careful to avoid bias
 If allocation is not random, it is important that the researcher
corrects for confounding factors with statistical adjustments

46. Maintenance
■ Maintenance of the groups
 Equal management throughout the trial except for the factor
being tested
 Unequal management of the groups renders the results non valid
 Measurement of outcomes for both groups must be done in the
same manner to avoid observer bias
 It is important to follow up for long enough

47. Measurements
■ Measurement of outcomes
 It is always best to blind observers and subjects in studies where
the outcome measured is subjective.
 Objective measurements are easier to read as these are based on
e.g. lab readings, weight checks, etc.

48. What do the results mean?
■ Are the results real or are they due to chance?
 2 statistical tests used to test this
 P values (hypothesis testing)
 Confidence intervals (estimation)
■ Other definitions:
 NNT (number needed to treat)
 NNH (number needed to harm)
 OR (odds ratio)
 RR (relative risk) etc

49. EXTERNAL
VALIDITY
(APPLICABILITY/GENERALIZABILITY)

50. External Validity
■ Are the results generalisable?
■ Is the treatment or test feasible in my setting?
■ What alternatives are available?
■ Are my patients similar to the target population in the study?
■ Will the potential benefits of treatment outweigh the potential
harms?
■ What does my patient think about it?

51. STEP 5: Apply The Evidence
The Patient
Integrate the EBM with the
clinical expertise:
Apply to practice, and
Consider patient’s values
and circumstances.
Self-Evaluation
Evaluate your performance
and assess the outcome
Right question?
Better outcome?
Clinical sense?
Good medical performance is based on quality and quality depends on
the best available EBM.

52. OUTLINE.

53. Outline.
■ For the purpose of upcoming presentations
1. Answerable question (PICO, etc)
2. Search strategy
3. Best study found in answer to the question
4. Statistical definitions
5. Methodology
6. Results
7. Internal validity
Important to note: P value, Confidence interval etc
8. External validity / Generalisability of the results to this context
9. Apply the evidence to practice.

55. REFERENCES
■ Mohsen MO, Malki AM, Aziz HA, 2015. Evidence-based medicine; climbing a
mountain for a better decision-making. Integr Mol Med, 2015 doi:
10.15761/IMM.1000132. Available from: https://www.oatext.com/pdf/IMM-2-132.pdf
■ Barends E, Rousseau dm & Briner RB, (2014). Evidence-Based Management: The
Basic Principles. Amsterdam: Center for Evidence-Based Management
Acknowledgement
■ Many thanks to Dr F Ajudua.

56. EXAMPLES.