This document discusses evidence-based medicine (EBM) and its key steps. EBM involves integrating the best available research evidence with clinical expertise and patient values. The rise of EBM was driven by various factors. The five steps of EBM are: 1) formulating a question, 2) finding evidence, 3) critically appraising the evidence, 4) applying findings to practice, and 5) evaluating performance. A case study example of a patient with acute pulmonary edema is provided to demonstrate applying EBM in practice.

1. EVIDENCE BASED
MEDICINE (EBM)
Nandinii Ramasenderan
080100332

2. OVERVIEW
Definition
History
Factors driving EBM
Steps in EBM
Case discussion

3. WHAT IS EBM?
A systematic approach to
clinical problem solving
which allows the integration
of the best available
research evidence with
clinical expertise and
patient values
-Da ve Sa c ke tt-
Patient
Concerns
Best research
evidence
EBM
Clinical
Expertise

4. INTEGRATED WITH CLINICAL
EXPERTISE

5. RISE OF EVIDENCE BASED
MEDICINE

7. LIFE LONG LEARNING
The hardest conviction to get into the
mind of a beginner is that the education
upon which he is engaged is not … a
medical course, but a life course, for
which the work of a few years under
teachers is but a preparation.
Sir Willia m O s le r (1 8 49 -1 9 1 9 ), fro m : The Stud e nt
o f M d ic ine
e

8. STEPS IN PRACTISING EBM

9. STEP 1 : FORMULATE
QUESTION
Background Question
-Ask for general knowledge about a condition or thing
-Have 2 essential components:
a)A question root (who, what, where, when how, why) and a verb
b)A disorder, test, tx, or other aspect of health care.
Eg: -how does heart failure cause ascites?
-what causes SARS?

10. STEP 1 : FORMULATE QUESTION
Foreground Question
-Ask for specific knowledge to inform clinical decision / actions
-4 essential components:
a)Patient and /or problem
b)Intervention (or exposure)
c)Comparison, if relevant
d)Outcome (clinical), including time if relevant
Eg: “ In adults with he a rt fa ilure who are in sinus rhythm, would a d d ing wa rfa rin to
standard therapy re d uc e m o rbid ity o r m o rta lity fro m thro m bo e m bo lis m enough over
3-5 years to be worth warfarin’s harmful effects and inconveniences.”

11. STEP 1 : Formulate Question
The nature of the question asked is
critically experience dependent.
FOREGROUND
TYPE OF
QUESTION
BACKGROUND
CLINICAL EXPERIENCE

12. STEP 2: USE BEST EVIDENCE TO
ANSWER QUESTION
Computerized decision support system (CDSS)
Evidence-based journal abstracts
Cochrane reviews
Original published articles in journals

13. STEP 2: USE BEST EVIDENCE TO
ANSWER QUESTION
System
Synopses
-Evidence based clinical information,
researches
-A brief summary/ review of individual
studies
-Electronic based
-Provide only information to support a
clinical action
BMJ Clinical Evidence (
http://www.clinicalevidence.com)
UpToDate
(http://www.uptodate.com)
PIER: The Physician’s Information
and Education Resource
(http://pier.acponline.org/index.html).
ACP [American College of
Physicians] Journal
Club(http://www.acpjc.org
EBM (http://ebm.bmj.com).

14. STEP 2: USE BEST EVIDENCE TO
ANSWER QUESTION
Syntheses
Studies
-summaries of articles/ reviews
-original research journal
The Cochrane Library Web site
(http://www3.interscience.wiley.com/
cgibin/mrwhome/106568753/HOME)
Medline/ PubMed Clinical
Queries (www.pubmed.com)
DARE(www.york.ac.uk/inst/crd/welcome
.htm)
EMBASE (OVID)
(www.ovid.com)

15. HIERARCHY OF
EVIDENCE PYRAMID

16. LEVEL OF EVIDENCE
Level type of investigation
Ia Evidence obtained from meta analysis of
randomized controlled trials
Ib Evidence obtained from at least one randomized
controlled trial
IIa Evidence obtained from at least one well designed
controlled study without randomization
IIb Evidence obtained from at least one other type of
well designed quasi experimental study
III Evidence obtained from well designed non
experimental studies, such as comparative studies,
correlational studies, and case studies
IV Evidence obtained from expert committee reports or
opinions

17. STEP 3: CRITICALLY
APPRAISE EVIDENCE
To understand the methods and results of research and to assess the quality of the research
THREE MAIN ASPECTS TO BE APPRAISED:
1.
VIA
VALIDITY :
VALID (CLOSENESS TO THE TRUTH) → IN THE METHODOLOGY SECTION
2.
IMPORTANCE :
IMPORTANT (USEFULNESS) → IN THE RESULTS SECTION
3.
APPLICABILITY :
APPLICABLE (CAN BE APPLIED IN CLINICAL PRACTICE) → IN THE DISCUSSION SECTION

18. STEP 4: INTEGRATE FINDINGS
INTO PRACTISE
Making a concise decision based on research finding & information found.
Discuss with patient regarding our findings & risk-benefit assessment

19. CASE DISCUSSION

20. 68 years old Malay Female
Hx of Congestive Heart Failure & Hypertension
Surgical Hx: CABG 10 years ago
On medication: Digoxin, Lasix, Isosorbide nitrate
Mild increase of dysnea on exertion past 4 days
Having acute Shortness of breath 1hour prior to admission

21. On examination:
BP: 188/104 mmHg
Pulse rate:122 bpm
Respiratory rate: 30
Temp: 37.5 Celsius
SpO2: 90% (On Non-rebreather mask)
Lung auscultation: Crackles to ½ bilateral
Jugular vein distended, S3 gallop
Pretibial edema bilaterally

22. PLAN & INVESTIGATION
IV, O2, & vital sign Monitoring
Chest Xray, ECG, Cardiac markers, Digoxin level
ECG: Sinus tachycardia, old inferior myocardial infarction, no st-elevation
changes
CXR: acute pulmonary edema (pulmonary venous congestion, small
bilateral effusion)
Treatment
 GTN
 Lasix
 Morphine

23. QUESTION—GENERAL
STATEMENT
What about using ACE inhibitors for acute pulmonary
edema?

24. BACKGROUND
•Describe pathophysiology of CHF and acute pulmonary edema
•Discuss causes of decompensation of CHF
•Discuss Differential Diagnosis of acute pulmonary edema
•Relate pathophysiology of CHF to treatment, especially role of ACE-I in CHF
•Describe treatment goals
•Describe standard treatment of CHF

25. EBM QUESTION
Patients: Acute Pulmonary Edema
Intervention: ACE Inhibitor
Comparison: Placebo
Outcome:
 Mortality
 Intubation
 Hemodynamic parameters
 ICU/CCU admission

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