Evidence-based medicine (EBM) or evidence-based practice (EBP) aims to apply the best available evidence gained from the scientific method to clinical decision making. It seeks to assess the strength of evidence of the risks and benefits of treatments (including lack of treatment) and diagnostic tests. Evidence quality can range from meta-analyses and systematic reviews of double-blind, placebo-controlled clinical trials at the top end, down to conventional wisdom at the bottom.

1. Journals, Papers & the Research Question Frederick Mars Untalan MD http://entmdclinic.webs.com/

2. Show me the evidence. What does the literature say? Frederick Mars Untalan MD http://entmdclinic.webs.com/

3. Case presentations Clinical problem solving Journal Club appraisal CATs & EBM Frederick Mars Untalan MD http://entmdclinic.webs.com/

4. objectives Research question PICO format Levels of evidence Pubmed Frederick Mars Untalan MD http://entmdclinic.webs.com/

5. What is a research? R and D Analysis Experimentation Exploration fact-finding inquiry Investigation probe Frederick Mars Untalan MD http://entmdclinic.webs.com/

6. Research question What is a research? the search for knowledge, or as any systematic investigation, with an open mind, to establish novel facts, usually using a scientific method. Scientific research relies on the application of the scientific method, a harnessing of curiosity. provides scientific information and theories for the explanation of the nature and the properties of the world around us. Frederick Mars Untalan MD http://entmdclinic.webs.com/

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9. PICO format Frederick Mars Untalan MD http://entmdclinic.webs.com/ There are five steps to providing Evidence-Based Care (EBC):

10. PICO format The Well-Built Clinical Question: Model “PICO” Frederick Mars Untalan MD http://entmdclinic.webs.com/ ( P •_____) among Patient / Population / Problem ( I •_____) does Intervention / Exposure ( C •______) versus Comparison ( O_______) affect Outcome

11. Example: For persons entering a health care facility, is hand rubbing with a waterless, alcohol based solution, as effective as standard hand for reducing hand washing with antiseptic soap contamination? Frederick Mars Untalan MD http://entmdclinic.webs.com/ The Well-Built Clinical Question: Model “PICO”

12. PICO format Frederick Mars Untalan MD http://entmdclinic.webs.com/ • P Patient/ Population of Interest Who are the patients of interest? • Is there a particular age group, gender or population? • What is the health concern? Example: For persons entering a health care…

13. PICO format Frederick Mars Untalan MD http://entmdclinic.webs.com/ PICO format I = Intervention or Exposure What therapeutic, diagnostic, preventive or other health care interventions are you interested in knowing more about? What health care management strategies are you interested in comparing? • Example: For persons entering a health care is hand rubbing with a waterless, alcohol- facility, based solution

14. PICO format Frederick Mars Untalan MD http://entmdclinic.webs.com/ PICO format C= Comparison of Interest Is there a comparison to be evaluated against the intervention? • Only used if more than one intervention or if no intervention is a factor. Is there a comparison to be evaluated against the intervention? • Only used if more than one intervention or if no intervention is a factor Example: For persons entering a health care facility, is hand rubbing with a waterless, alcohol as effective as standard hand based solution, washing with antiseptic soap

15. PICO format Frederick Mars Untalan MD http://entmdclinic.webs.com/ PICO format O=Outcome of Interest What is the desired outcome to be evaluated? • How will the patient or population be affected, or not affected, by the intervention? Example: For persons entering a health care facility, is hand rubbing with a waterless, alcohol based solution, as effective as standard hand for reducing hand washing with antiseptic soap contamination?

16. In addition to the PICO elements of your clinical question, it’s important to know: Frederick Mars Untalan MD http://entmdclinic.webs.com/ – What TYPE of question are you asking? – What is the best STUDY DESIGN to search for to find evidence to answer your clinical question?

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18. What type of question are you asking and what will the evidence support? Therapy/Treatment questions: evidence supports how to select treatments to offer your patients that do more good than harm and that are worth the efforts and costs of using them. Prognosis questions supports how to estimate your patient’s likely clinical course over time and anticipate likely complications of the disorder. Frederick Mars Untalan MD http://entmdclinic.webs.com/

19. What type of question are you asking and what will the evidence support? Diagnosis questions: supports how to select and interpret diagnostic tests, in order to confirm or exclude a diagnosis, based on considering their precision, accuracy, acceptability, expense, safety, etc. evidence Harm/Etiology questions: evidence supports how to identify causes for disease (including its iatrogenic forms) Frederick Mars Untalan MD http://entmdclinic.webs.com/

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21. Frederick Mars Untalan MD http://entmdclinic.webs.com/ Clinical Scenario Traditionally, clinicians have used a conservative approach to the diagnostic evaluation of head-injured infants, arguing that infants are at increased risk of intracranial injury (ICI) and that symptoms or signs of brain injury may not be reliably present in those with ICI. A number of previous studies have reported that a significant fraction of ICIs in a normal neurological status infants occur in patients with and with no signs or symptoms of brain injury. You want to see how well clinical features predict ICI in infants.

22. Frederick Mars Untalan MD http://entmdclinic.webs.com/ Answerable Clinical Question PICO: • P – Among children with minor head injury • I – does the use of CT scan • C – versus other clinical findings • O – affect identification and diagnosis of intracranial hemorrhage? Type of Study/Methodology: Systematic Review/Meta Analysis of Controlled Studies, Controlled Studies Type of Question: DIAGNOSIS

23. Strength of Study Design: The Evidence Pyramid Frederick Mars Untalan MD http://entmdclinic.webs.com/ Find the highest strength of evidence available to answer your clinical question.

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25. Case presentations Clinical problem solving Journal Club appraisal CATs & EBM Frederick Mars Untalan MD http://entmdclinic.webs.com/

26. Show me the evidence. What does the literature say? Frederick Mars Untalan MD http://entmdclinic.webs.com/

27. Journals, Papers & the Research Question Frederick Mars Untalan MD http://entmdclinic.webs.com/