Evidence Based

Medicine
Victor Babes University of Medicine and Pharmacy Timisoara
Evidence Based
Medicine
Victor Babes University of Medicine and Pharmacy Timisoara
What Evidence Based Medicine is:
 What Evidence Based Medicine is:

EBM is a conscientious and judicious use of

current best research evidence in combination
with clinical expertise and patient values applied
to the management of individual patients.

Sackett, et al 2001
What Evidence Based Medicine is:

Patient
Values

Best
Clinical
Research
Expertise
Evidence
What Evidence Based Medicine is:

Patient
Values

Best
Clinical
Research
Expertise
Evidence
What Evidence Based Medicine is:

Patient
Values

Best
Clinical
Research
Expertise
Evidence
What Evidence Based Medicine is:

Patient
Values

Best
Clinical
Research
Expertise
Evidence
Without clinical expertise, practice
risks becoming tyrannized by external
evidence, for even excelent external
evidence may be inapplicable to or
innapropriate for an individual patient.
Without current best external evidence,
practice risks becoming rapidly out of
date, to the detriment of patients
Learning Surgery. The Surgery Clerkship Manual; Stephen F. Lowry. Springer. SPIN 10941119
EBM Philosophy
 EBM Philosophy

Translating sound evidence into good

clinical decisions ensures safe and
effective patient management
 EBM Philosophy

Translating sound evidence into good

clinical decisions ensures safe and
effective patient management
EBM provides a systematic framework
to facilitate medical practice
EBM and clinical judgement
EBM and clinical judgement

EBM does not ignore clinical practice

EBM and clinical judgement

EBM does not ignore clinical practice

EBM does not promote a cookbook
approach to medicine or healthcare
EBM and clinical judgement

EBM does not ignore clinical practice

EBM does not promote a cookbook
approach to medicine or healthcare
no evidence available to guide more
than 70% of clinical decisions
EBM and clinical judgement

EBM does not ignore clinical practice

EBM does not promote a cookbook
approach to medicine or healthcare
no evidence available to guide more
than 70% of clinical decisions
oportunities to employ judgement:
applications of trial to individual patients
do benefits of intervention outweigh risks?
 JASPA*
(Journal associated score of personal angst)

* Modified from: BMJ 1995;311:1666-1668

 JASPA*
(Journal associated score of personal angst)

J: Are you ambivalent about renewing your

JOURNAL subscriptions?

* Modified from: BMJ 1995;311:1666-1668

 JASPA*
(Journal associated score of personal angst)

J: Are you ambivalent about renewing your

JOURNAL subscriptions?
A: Do you feel ANGER towards prolific authors?

* Modified from: BMJ 1995;311:1666-1668

 JASPA*
(Journal associated score of personal angst)

J: Are you ambivalent about renewing your

JOURNAL subscriptions?
A: Do you feel ANGER towards prolific authors?
S: Do you ever use journals to help you SLEEP?

* Modified from: BMJ 1995;311:1666-1668

 JASPA*
(Journal associated score of personal angst)

J: Are you ambivalent about renewing your

JOURNAL subscriptions?
A: Do you feel ANGER towards prolific authors?
S: Do you ever use journals to help you SLEEP?
P: Are you surrounded by PILES of PERIODICALS?

* Modified from: BMJ 1995;311:1666-1668

 JASPA*
(Journal associated score of personal angst)

J: Are you ambivalent about renewing your

JOURNAL subscriptions?
A: Do you feel ANGER towards prolific authors?
S: Do you ever use journals to help you SLEEP?
P: Are you surrounded by PILES of PERIODICALS?
A: Do you feel ANXIOUS when journals arrive?

* Modified from: BMJ 1995;311:1666-1668

 JASPA*
(Journal associated score of personal angst)

J: Are you ambivalent about renewing your

JOURNAL subscriptions?
A: Do you feel ANGER towards prolific authors?
S: Do you ever use journals to help you SLEEP?
P: Are you surrounded by PILES of PERIODICALS?
A: Do you feel ANXIOUS when journals arrive?
Score:
0 (ignorant or lier?)
1-3 (normal range)
>3(sick; at risk for polythenia gravis and related conditions)

* Modified from: BMJ 1995;311:1666-1668

Background information/ Experts opinion
 Case controlled studies/ Case reports

Background information/ Experts opinion

 Cohort studies

Case controlled studies/ Case reports

Background information/ Experts opinion

 Randomized control trials (RCT)

Cohort studies

Case controlled studies/ Case reports

Background information/ Experts opinion

 Critically-appraised individual articles
(Article Synopses)

Randomized control trials (RCT)

Cohort studies

Case controlled studies/ Case reports

Background information/ Experts opinion

 Critically-Appraised
Topics (Evidence Syntheses)

Critically-appraised individual articles

(Article Synopses)

Randomized control trials (RCT)

Cohort studies

Case controlled studies/ Case reports

Background information/ Experts opinion

 Systematic
Reviews

Critically-Appraised
Topics (Evidence Syntheses)

Critically-appraised individual articles

(Article Synopses)

Randomized control trials (RCT)

Cohort studies

Case controlled studies/ Case reports

Background information/ Experts opinion

Rule 31- Review the World Literature
Fortnightly*
 Rule 31- Review the World Literature
Fortnightly*

* Kill as Few Patients as Possible - Oscar London

Rule 31- Review the World Literature
Fortnightly*

5000/ day
2.000.000 articles/ year

1400/ day

55/ day

Trials MedLine Biomedical

EBM Approach to Therapy Article
EBM Approach to Therapy Article

Randomization
EBM Approach to Therapy Article

Randomization
Concealed allocation
EBM Approach to Therapy Article

Randomization
Concealed allocation
Double-blinding
EBM Approach to Therapy Article

Randomization
Concealed allocation
Double-blinding
Intention-to-treat analysis
EBM Approach to Therapy Article

Randomization
Concealed allocation
Double-blinding
Intention-to-treat analysis
Complete follow-up of patients
 Managing Information
Push and Pull Methods

Do I need it? www.evidence-basedmedicine.com

 Managing Information
Push and Pull Methods

Push - Just in case learning

Do I need it? www.evidence-basedmedicine.com

 Managing Information
Push and Pull Methods

Push - Just in case learning

Alerts you to new information - Use
only for important, new, valid
research

Do I need it? www.evidence-basedmedicine.com

 Managing Information
Push and Pull Methods
 Managing Information
Push and Pull Methods

The failure of common sense

 Managing Information
Push and Pull Methods

The failure of common sense

I shake a tree, an apple falls out. Now I can eat.

 Managing Information
Push and Pull Methods

The failure of common sense

I shake a tree, an apple falls out. Now I can eat.

I give antibiotics for sinusitis, the patient gets
better, Im doing a good job as a doctor.
 Managing Information
Push and Pull Methods

The failure of common sense

I shake a tree, an apple falls out. Now I can eat.

I give antibiotics for sinusitis, the patient gets
better, Im doing a good job as a doctor.
I just saw a patient with a tumor lysis
syndrome, I will start looking more and maybe
Ill find it more
 Managing Information
Push and Pull Methods

Pull - When you need learning

Formulate an answerable question
Track down the best evidence
Critically apprise the evidence
Integrate with clinical expertise and
patient values
The First Steps
 The First Steps

Patient
Intervention
Comparison
Outcome
 The First Steps

Patient
Intervention
Comparison
Outcome
 The First Steps

Patient
Intervention
Comparison
Outcome
 The First Steps

Patient
Intervention
Comparison
Outcome
 The First Steps

Patient
Intervention
Comparison
Outcome
 The First Steps

Clinical scenario
Child with acute diarrhea and lower respiratory infection, You know the Zinc
supplementation will improve diarrhea, but will it help the respiratory infection as
well? Or is there something else that you can add that might work with the zinc?

Patient
Intervention
Comparison
Outcome
 The First Steps

Clinical scenario
Child with acute diarrhea and lower respiratory infection, You know the Zinc
supplementation will improve diarrhea, but will it help the respiratory infection as
well? Or is there something else that you can add that might work with the zinc?

Patient Child with diarrhea and respiratory infection

Intervention
Comparison
Outcome
 The First Steps

Clinical scenario
Child with acute diarrhea and lower respiratory infection, You know the Zinc
supplementation will improve diarrhea, but will it help the respiratory infection as
well? Or is there something else that you can add that might work with the zinc?

Patient Child with diarrhea and respiratory infection

Intervention Zinc supplementation

Comparison
Outcome
 The First Steps

Clinical scenario
Child with acute diarrhea and lower respiratory infection, You know the Zinc
supplementation will improve diarrhea, but will it help the respiratory infection as
well? Or is there something else that you can add that might work with the zinc?

Patient Child with diarrhea and respiratory infection

Intervention Zinc supplementation

Comparison Zinc supplementation plus something else

Outcome
 The First Steps

Clinical scenario
Child with acute diarrhea and lower respiratory infection, You know the Zinc
supplementation will improve diarrhea, but will it help the respiratory infection as
well? Or is there something else that you can add that might work with the zinc?

Patient Child with diarrhea and respiratory infection

Intervention Zinc supplementation

Comparison Zinc supplementation plus something else

Outcome Improvement in diarrhea and respiratory infection

 Levels of Evidences

(I) A well done systematic review of 2 or more RCTs

(II) A RCT
(III)A Cohort study
(IV)A case-control study
(V) A dramatic uncontrolled experiment
(VI)Respected authorities, expert comities, etc...
(VII)...someone once told me...
The Essence of EBM
 The Essence of EBM

Two roads diverged in a yellow wood,

And sorry I could not travel both . . . .
Robert Frost
 The Essence of EBM

Two roads diverged in a yellow wood,

And sorry I could not travel both . . . .
Robert Frost
 The Essence of EBM

Two roads diverged in a yellow wood,

And sorry I could not travel both . . . .
Robert Frost

Does convincing information leads to

optimal decision making?
 The Essence of EBM

Two roads diverged in a yellow wood,

And sorry I could not travel both . . . .
Robert Frost

Does convincing information leads to

optimal decision making?
Do most healthcare professionals base their
decision on the best evidence?
Thank You!