Evidence-based Medicine Journal Club Khalid Bin Abdulrahman Director of Medical Education Center King Saud University

A brief overview of EBM Tips on how to conduct EBM Journal Club

Practicing Medicine " the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." David Sackett

Steps in the EBM process 1. Start with the patient and a need for information 2. Formulate a relevant, answerable question 3. Select the resource and conduct a search 4. Appraise the evidence for its validity and applicability 5. Return to the patient -- integrate the evidence

1. Start with the Patient You Already have seen 6 kids under the age of 2 years with Otitis Media at your family practice. Your experience from Pediatric clinical rotations and your memory of Pediatric textbooks indicates that Amoxicillin for 10 days is the accepted treatment for this problem. But you are also acutely aware of the consequences of over-prescribing antibiotics and the possible adverse effects of the drug. You wonder if it is really necessary to treat every occurrence of Otitis Media with Amoxicillin, especially in this age group.

2. Formulate the question Patient Intervention Comparison Outcome Type of Question Study Design Richardson,W.S., Wilson M. ACP Journal Club 123:A12 Nov-Dec 1995

study design

Formulate the question PatientOtitis Media, 2 yrs old InterventionAmoxicillin Comparisonno meds, placebo Outcomereduce fever, pain, long term benefit Questiontherapy Study Designrandomized, controlled clinical trial

The well built clinical question is: In children under the age of 2 years presenting with Otitis Media, does Amoxicillin significantly reduce fever and pain faster with better long term results than no medication? It’s a therapy question and the best evidence would be an RCT.

3. Select the resource Ideal information resource: Valid –contains high quality data Relevant –clinical applicable Comprehensive – has data on all benefits/harms User-friendly – quick, easy to access and use see EBM Resource List

Conduct the Search MEDLINE TRIP Database Cochrane POEMS ACP Journal Club

MEDLINE

Cochrane Library

TRIP Database Search on otitis media

the evidence

4. Evaluate the evidence Validity Results Applicability to the patient

Validity issues: Randomization Follow-up complete (80% or better) Blinding (concealed allocation) Baseline similarities Groups treated equally

Results of the evidence: Persistent symptoms at day 4 were present in 59% of the children in the Amoxicillin group and 72% in the placebo group. There was a high rate of treatment failure in both groups after therapy was completed: 64% in the treated group and 70% in the placebo group. Journal of Family Practice May 2000

Applicability of the evidence Same diagnosis Same age groups General practice population Study done in Netherlands

5. Return to the patient: Between 7 and 8 children aged younger than 2 years have to be treated with an antibiotic for 1 of them to receive a symptomatic benefit at 4 days compared with placebo. However, only a small percentage (30% to 36%) will be completely symptom free 11 days after presentation, regardless of antibiotic treatment. Since antibiotic treatment is not completely benign and its benefits are minimal. Most children between the ages of 6 months and 2 years need not be treated with antibiotics.