Introduction to

Evidence-Based Medicine
Bill Cayley Jr MD MDiv
UW Health Augusta Family Medicine
Objectives
1. Describe the use of evidence in making
medical decisions
2. Demonstrate searching for an evidence-
based answer to a medical question
What is
evidence-based
medicine?
Two fundamental questions
What is the purpose of medicine?
How do I decide what to do?



You have to know where youre going before
deciding how to get there

What is the purpose of medicine?
Patient care
Public health
Research


Improving the quality of
patients lives
What is evidence-based medicine?
Evidence based medicine is the conscientious,
explicit, and

judicious use of current best
evidence in making decisions about

the care of
individual patients.

Sackett, et al. BMJ 1996;312:71-72
What is EBM NOT?
What we have always
done
Cookbook medicine
Only a cost-cutting trick
Only randomized trials







Evidence based medicine IS
Tracking down the best
external

evidence with which
to answer our clinical
questions

EBM a short history
JAMA 1992
EBM: a new approach
JAMA 1993 2000
Users' Guides to the
Medical Literature
1990s 3 trends
Systematic reviews
Search engines
Knowledge distillation
and push services




Classification of evidence
How do I decide what to do?
How do I make decisions?
Dogma: Natural is best
Tradition: Weve always done it that way
Convention: Everyone does it this way
Evidence-Based: Evidence supports this way

How do I decide what to do?
The answer from EBM
use of current best
evidence

Evidence: systematic observation

Meta-Analysis
Randomized Controlled Trial
Uncontrolled Trial
Case Series
Anecdote

Meta-Analysis
Randomized Controlled Trial
Uncontrolled Trial
Case Series
Anecdote

More systematic observation better evidence




Integrating evidence & practice
What type of outcome measures?
Surrogate markers of disease:
Hb A1c, cholesterol, blood pressure
Stage or extent of disease:
Diabetic ulcers, angiographic CAD, stroke
Patient-oriented outcomes:
Mobility, suffering, longevity
Morbidity and mortality
Patient or disease oriented?
Disease-Oriented Outcomes.
Intermediate, histopathologic, physiologic, or surrogate
results
Examples: blood sugar, blood pressure, flow rate, coronary
plaque thickness
May or may not reflect improvement in patient outcomes.
Patient-Oriented Outcomes.
Outcomes that matter to patients and help them live
longer or better lives
Examples: including reduced morbidity, reduced mortality,
symptom improvement, improved quality of life, or lower
cost
Which outcomes????
Topical antibiotics for bacterial conjunctivitis may improve
early and late resolution rates, but nearly all cases ultimately
have complete remission.
Br J Gen Pract. 55: 962-4.
Digoxin for symptomatic heart failure provides no significant
difference in mortality but is associated with lower rates of
hospitalization and of clinical deterioration.
J Card Fail. 10:155-64.
Long-acting beta-2 agonists for asthma are effective in
reducing symptoms but may increase mortality or
exacerbations.
Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006363.
SORT
When guidelines conflict
Questions of evidence
Were the clinical questions
different?
Were different studies
considered?
Were the results analyzed
differently?
Was the quality of evidence
assessed differently?

Questions of outcomes
Did the effect estimates for
important outcomes differ?
Did judgments about
evidence quality differ?
Were health consequences
weighed differently?
Were economic
consequences considered
differently?
Systems applications
Clinical Questions
Background - What is it?
General information on a condition or disease
Foreground What do I do for this patient?
Patient
Intervention/Investigation
Comparison Intervention/Investigation
Outcome (Patient-Oriented)

Clinical Questions - PICO
Example:
In a 5 year old child with conjunctivitis (patient) will
topical antibiotics (intervention) compared to no
treatment (comparison) lead to quicker symptom relief
(outcome)?
In a 5 year old child with conjunctivitis (patient) will
topical antibiotics (intervention) compared to no
treatment (comparison) lead to improved cure rates
(outcome)?
Trip Database (http://www.tripdatabase.com/)
Database of Abstracts of Reviews of Effectiveness
(http://www.crd.york.ac.uk/crdweb/)
DynaMed (http://www.dynamicmedical.com/)
*Subscription required.
Essential Evidence Plus (http://www.essentialevidenceplus.com/)
*Subscription required.
Cochrane Library (http://www.cochrane.org/)
*Subscription for full access, abstracts free.
FPIN (http://www.fpin.org/)
*Subscription required.
Clinical Evidence (www.clinicalevidence.com/)
*Subscription required.
Finding Evidence-based Answers
Woolever DR. The art and science of clinical decision making. Fam Pract
Manag. 2008 May;15(5):31-6. PMID: 18546805
(http://www.aafp.org/fpm/20080500/31thea.html)
Krumholz H, Lee T. Redefining Quality -- Implications of Recent Clinical
Trials. N Engl J Med 2008 358: 2537-2539
(http://content.nejm.org/cgi/content/full/358/24/2537)
Ebell MH. How to find answers to clinical questions. Am Fam Physician.
2009 Feb 15;79(4):293-6. PubMed PMID: 19235495.
(http://www.aafp.org/afp/2009/0215/p293.html)
For further reading
In short
EBM is the conscientious,
explicit, and

judicious use of
current best evidence in
making decisions about

the
care of individual patients.


Evidence
Systematic observation =
high-quality evidence



Patient-oriented evidence
preferable to
Stage of disease
preferable to
Surrogate markers