evidence based medicine IN THE 21ST CENTURY Bosede B Afolabi, FRCOG (UK), FWACS, FMCOG, DM Associate Professor & Consultant Obstetrician and Gynaecologist, CMUL/LUTH Consultant Obstetrician & Gynaecologist, Paelon Memorial Clinic, VI

Outline What is evidence based medicine Role in clinical effectiveness Five steps in evidence based practice Quality issues and way forward

EBM - Definition Practising health care based on real evidence “The integration of individual clinical expertise (and experience) with the best available clinical evidence from systematic research.” David L Sackett, W Scott Richardson, William Rosenberg, R Brian Haynes Evidence Based Medicine-- How to Practice and Teach EBM, 1996

PURPOSE OF EBM Primarily to assist in clinical decisions EBM sounds strange as medicine practice should typically be based on evidence Not been the case in the past

Evidence based practice. Hoffman et al, 2010.

Hoffman et al

The essence of evidence based practice All evidence is sought and examined systematically Evidence is wherever possible quantified Evidence is considered in All decisions in healthcare Evidence doesn’t make decisions: human beings do

Origin of EBM McMaster University in Canada in 1970s 3 yr curriculum Students had to be given skills to carry out their own learning instead of didactic teaching

EBM – precisely… Evidence from systematic reviews Randomised controlled trials Meta-analysis

Randomised controlled trial All participants are RANDOMLY allocated to groups Have equal chances of being in either group No bias in outcome assessment Participants are not lost to follow up Control group or placebo being compared

Systematic Review (–not just another review) ‘review of a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant research and to collect and analyse data from the studies that are included in the review. Statistical methods (meta-analysis) may or may not be used to analyse and summarise the results of the included studies’ Clark M and Oxman AD 2003. Cochrane Reviewers’ Handbook 4.2.0 Oxford: The Cochrane Library 2

Levels of evidence I: At least one properly designed randomized controlled trial. II: Well-designed controlled trials without randomization. III: Well-designed cohort or case–control analytic studies, preferably from more than one center or research group. IV: Opinions of respected authorities, based on clinical experience, descriptive studies, case reports or reports of expert committees V: Expert opinion

Five steps to EBM process 1.Formulate an answerable clinical question 2.Find the best evidence to answer it 3.Critically appraise the evidence for its validity, impact and applicability 4.Integrate the evidence with clinical expertise, patient values and context 5.Evaluate the efficiency & effectiveness of the above and find ways to improve perfomance

Answerable question PICO Patient – type of disorder or disease Intervention – diagnostic tool, treatment Comparison – pre-existing treatment or placebo Outcome – what is expected

Example A 9 year old girl has abdominal pain and diarrhoea and appendicitis is suspected. What is the best method of making the diagnosis? CT or Ultrasound?

EBM Evidence not always available When unavailable, use next best evidence Least evidence is the one from experts

Role in clinical effectiveness Why should we practice EBM Best possible effect Least side effects may be more than others eg misoprostol versus foley catheter for induction of labour

Role in cost effectiveness The use of the most effective drug available will ensure saving money as it will be used in a shorter time than less effective ones e.g. Non-steroidal anti-inflammatory drugs for dysmenorrhoea instead of buscopan

Quality Efficacy of diagnosis, treatment – surgical and medical Efficiency of prescription and management Cost effectiveness

Drawbacks Huge amount of information – no time or skills Where to look – Good IT access essential Evidence must be backed by experience Experts are afraid of not knowing

Way forward Diagnose current situation and set goals Where are we now, where do we want to be Develop strategy and action plan Determine method to use and ACT Evaluate and monitor

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References Evidence-Based Medicine: Tools, Techniques, Results, Harold P. Lehmann, MD PhD, Cindy Sheffield, MLS Evidence based practice (not medicine): perspectives of an editor. Richard Wright, former editor, BMJ