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EVIDENCE-BASED MEDICINE

Zwasta Pribadi M

Discuss this question with your A quick question to help you grow neighbour

X is a sexually transmitted disease With prevalence of 0.2% Fatal in 1 in 8 people Treatment prevents death End 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 Sensitivity of a test to detect X is 99% Specificity of a test to detect X is 99% 1 in 25 people diagnosed with X commit suicide Will screening prevent more deaths than it causes?

A dilemma

You are very ill

Which doctor do you want?

William Osler, 1900

Smart young doctor

Which doctor do you want?

Wise & experienced smart young doctor

What is evidence-based medicine?

Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values
Patient Concerns EBM Best research Clinical Expertise evidence

What is EBM ?

By best research evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. New evidence from clinical research both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer

What is EBM ?

By clinical expertise we mean the ability to use our clinical skills and past experience to rapidly identify each patients unique health state and diagnosis, their individual risks and benefits of potential interventions, and their personal values and expectations

What is EBM ?

by patient values we mean the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient

Why the sudden interest in EBM?

our daily need for valid information about diagnosis, prognosis, therapy and prevention (up to 5 times per in-patient and twice for every 3 out-patients). the inadequacy of traditional sources for this information because they are out-of-date (textbooks), frequently wrong (experts), ineffective (didactic continuing medical education) or too overwhelming in their volume and too variable in their validity for practical clinical use (medical journals). the disparity between our diagnostic skills and clinical judgement, which increase with experience, and our up-to-date knowledge and clinical performance, which decline. our inability to afford more than a few seconds per patient for finding and assimilating this evidence, or to set aside more than half an hour per week for general reading and study

Rule 31 Review the World Literature Fortnightly*


*"Kill as Few Patients as Possible" - Oscar London

2500000

Articles Medical YearYear Per per Articles Medical

5,000? per day

2000000 1500000 1000000 500000 0

1,500 per day 95 per day


Biomedical MEDLINE Trials Diagnostic?

The Need for EBM


In the years after you graduate, two things will happen: 1. Your memory of what you learned in medical school will lose its freshness. 2. New treatment methods will be found that they never taught you about in school because they didn't exist.

The Need for EBM

If you are to remain a good doctor, or become a better one, you need to stay on top of new developments as they occur. Evidence Based Medicine provides you with the tools you need to find important new medical research quickly and easily, and to work out its implications for your practice.

Is keeping up to date Mission Impossible?

Bluegreenblog 2006

How do we actually practice EBM?

Step 1Converting the need for information (about prevention, diagnosis, prognosis, therapy, causation, etc) into an answerable question. Step 2 Tracking down the best evidence with which to answer that question. Step 3 Critically appraising that evidence for its validity (closeness to the truth), impact (size of the effect), and applicability (usefulness in our clinical practice). Step 4 Integrating the critical appraisal with our clinical expertise and with our patient's unique biology, values and circumstances. Step 5 Evaluating our effectiveness and efficiency in executing Steps 1-4 & seeking ways to improve them both for next time

EBM practice requires:


Asking Acquiring Appraising Applying Assessing

Process of EBP

Patient dilemma
Ask Act & Assess

Acquire

Principles of evidence-based practice

Appraise Hierarchy of evidence

Apply

Evidence alone does not decide combine with other knowledge and values

The five As of the Evidence Cycle


ASSESS: Clinical Evaluation The clinician must ASSESS the patient and the problem to determine the pertinent issues, which may include a differential diagnosis, treatment decisions, or prognosis

The five As of the Evidence Cycle


ASK: Clinical Question Development The clinician must draw from this evaluation and ASK a clear, answerable question to be pursued.

The five As of the Evidence Cycle


ACQUIRE: Searching for the Evidence The next step is to efficiently ACQUIRE the evidence from an appropriate source. Potential sources include original research studies, systematic reviews, evidence-based journal abstracts, textbooks and computerized decision support systems

The five As of the Evidence Cycle


APPRAISE: Critical Appraisal of the Evidence With a potential source in hand, the clinician must APPRAISE the evidence to further examine its worth and reliability

The five As of the Evidence Cycle


APPLY: Applying Evidence to the Patient Finally, the process must conclude by returning to the individual patient, as the clinician has to decide whether it is appropriate to APPLY the evidence to the particular patient and their unique values and circumstances.

What are your clinical questions?

A 35 year old man says his brother recently died of a ruptured cerebral aneurysm. He is worried about whether he might have one and what the chances are that it would rupture.

-> PIC Table

Types of question: stroke


Risk Factors
Cohort Study

Frequency

Prognosis

Survey Inception Cohort Study

CT Scan Treatments

Treatment Effect

Cause(s) Past

Symptoms Signs, Tests current

Randomised Trial

Cross Sectional Study

future

Background/Foreground Questions

Where you look for information is determined by what kind of question you are asking. One way of classifying your question is to ask whether you are seeking background information or foreground information.

Background information

is sought when a learner has general clinical questions regarding a topic such as what is the disorder; what causes it; how does it present; what are some treatment options. These questions can be answered by using "background" resources such as textbooks (both in print and electronic) and narrative reviews in journals which give a general overview of the topic.

Foreground information

answers specific questions a clinician has regarding a specific patient. Foreground resources can be divided into primary sources such as original research articles published in journals; and secondary sources such as systematic reviews of the topic, and synopses and reviews of individual studies.

The Benefits of EBM

The total amount of knowledge out there is far greater and often more reliable than the clinical experience of one physician or even a group of experts. You no longer need to read through masses of journals in order to take advantage of it. It is no longer your job to know everything, even in your chosen specialty. It IS your job to be able to find the information as and when you and your patients need it.

The Benefits of EBM

A detailed and exact knowledge of the outcomes of different interventions, derived from the research, can often save lives.

Thank you for joining in


Questions or comments ? Send to zwasta_pm@yahoo.com

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