Practicing Evidence Based Medicine

The Ways Medicine Goes forwards What is EBM

Continuum of clinical Practice B: Continuous improvement: Reduce variation improve global performance (e.g. evidence base guidelines A: Quality Assurance: Prevent or eliminate substandard practice (e.g. effective credentialing, peer review C: Clinical Innovation: More leading edge of practice forwards (e.g. new research technology Strategies for improving health care: There are three major elements for improving health care practice. Best Performance Worst Performance Continuum of clinical Practice

What is Evidence-Based Medicine? "...the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." (Sackett 1997)

Limitations of Current Clinical Practice There Is Good Evidence That The Quality Of Care We Give To Our Patients Could Be Better: Clinical Examples: In Which Lack Of Good Evidence Has Led To Harm For Our Patients Common Patterns Of Thinking That Introduce Bias The Wide Variation In Current Clinical Practice The Difficulty Of Managing Medical Information Our Knowledge Declines Over Time: Unfortunately, there is good evidence that the quality of care we give our patients could be better. Such evidence comes from: clinical examples, in which lack of good evidence has led to harm for our patients common patterns of thinking that introduce bias ("heuristics") the wide variation in current clinical practice among physicians the difficulty of managing medical information, when results conflict and thousands of articles are published every month our knowledge declines over time, as we get further from medical school, and unfortunately traditional CME doesn't work

Objectives of EBM Using The Best Evidence EBM - Improving On "Common Sense" Reducing Variation In Practice Managing Medical Information Reversing The Decline In Medical Knowledge

Steroids in prematurity In 1973, a small study demonstrated that steroids Reduces the likelihood of Death In Premature Infants. In the next 10 years Six further studies had mixed results.   In 1983 a meta-analysis (analysis of the combined studies) showed that the combined trials supported a beneficial effect of steroids.  However, it took another decade and seven more studies before these results were accepted and began to change practice.  In 1973, a small study demonstrated that steroids given to women expected to deliver prematurely reduced the likelihood of death in their infants.  Six further studies in the next 10 years had mixed results, primarily because they were all quite small.  In 1983 a meta-analysis (analysis of the combined studies) showed that the overall results of all the trials combined supported a beneficial effect of steroids.  However, it took another decade and seven more studies before these results were accepted and began to change practice.  Had a systematic review of the literature been performed in 1983, it might have changed practice much sooner and saved thousands of lives. 

The Bars Represent The CI Of The OR Of Infant Death, And The Vertical Line Is An OR Of 1.0.  Thus, Lines Completely To The Left Of The Vertical Bar Represent: - Statistically Significant Benefit Of Steroids In Preventing Death. The results of the first seven studies of steroids in prematurity are memo- rialized in the logo of the Cochrane Collaboration

The Argument For Evidence-based Medicine Stay Up To Date With The Current Literature. Communicate Effectively With Consultants. Make The Best Use Of Other Sources Of Information. Make The Best Use Of Information From The History, Physical Examination, And Diagnostic Testing. Avoid Common Pitfalls Of Clinical Decision-making. Taking an evidence-based approach to practice, teaching, and research can help you address some of the limitations of current medical practice.   It can help you: stay up to date with the current literature communicate effectively with consultants make the best use of other sources of information, such as pharmaceutical representatives and colleagues make the best use of information from the history, physical examination, and diagnostic testing avoid common pitfalls of clinical decision-making

Steps in Practicing Evidence-Based Medicine Step 1:Construct well-built and answerable clinical questions Step 3:Critically appraise your findings questions Step 2: Locate the best evidence to answer these Step 4: integrate findings with clinical expertise and patient needs Steps in Practicing Evidence-Based Medicine Sackett et al. has streamlined the practice of evidence-based medicine into 5 steps. Step 1: Start with the patient. Convert the need for information (e.g., about diagnosis, treatment, or prevention) into an answerable question. Step 2: Track down the best evidence with which to answer that question. Step 3: Critically appraise that evidence for its validity, impact, and applicability. Step 4: Integrate the critical appraisal with our clinical expertise and with our patient’s concerns, preferences, expectations and circumstances. Step 5: Evaluate our effectiveness and efficiency in executing Steps 1-4 and seek ways to improve. This step emphasizes the need for lifelong learning through the self-evaluation process. Step 5: Evaluate your performance of these steps and seek ways to improve Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000.

Step 1: Construct Well-Built Clinical Questions • “Background” questions – Ask for general knowledge about a disorder • “Foreground” questions – Ask for specific knowledge about managing patients with a disorder Step 1: Construct Well-Built Clinical Questions The practice of evidence-based medicine is usually initiated by a patient encounter that generates questions about the effects of therapy, the utility of diagnostic tests, the prognosis of diseases, or the etiology of disorders. The first step is to convert the need for information into a well-built and answerable question. The inability to ask a focused and specific question can be a major impediment to the practice of evidence-based medicine. Clinical questions may include both background and foreground knowledge questions. Background knowledge questions are general questions about conditions, illnesses, syndromes, or pathophysiology. Foreground questions are more often about issues of care. The answers to these questions provide specialized and distinct knowledge needed for specific and relevant clinical decision-making. As clinicians, we all have needs for both background and foreground knowledge, in proportions that vary over time depending primarily on our clinical experience. Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000.

Step 2: Locate the Best Evidence • Sources of information and evidence may include: – Colleagues – Textbooks – Journals (e.g., evidence-based) – Systematic reviews – Guidelines – Electronic databases • Where to start searching may depend on: – Available time – Available databases – Foreground versus background knowledge required Step 2: Locate the Best Evidence The next step is to locate the best evidence to answer these questions. There are many sources of information that can support clinical decisions. Textbooks may become rapidly out of date and thus may not be the best source for establishing the cause, diagnosis, prognosis, prevention, or treatment of a disease. A growing number of periodicals summarize the best evidence found in traditional journals (e.g., ACP Journal Club). Because systematic reviews summarize and combine the results of several studies, they may be ideal sources of evidence for busy clinicians. Good guidelines come from the practice of evidence-based medicine. Evidence-based guidelines describe the strength of the evidence and try to separate opinion from evidence. Current best evidence from specific studies of clinical problems can be found in an increasing number of electronic databases, some with explicit evidence processing (e.g., Cochrane Library, Evidence-based Medicine Reviews). Where to start searching depends on the amount of time you have, the databases you have available to you, and the type of question you are asking. Instead of routinely reviewing the contents of dozens of journals for interesting articles, evidence-based medicine suggests that you target your reading to issues related to specific patient problems. Developing clinical questions and then searching current databases may be a more productive way of staying current with the literature. Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000. .

Selected Electronic Health Information Resources Internet Address ACP Journal Club www.acpjc.org Cochrane Library www.update-software.com UpToDate www.uptodate.com PubMED www.ncbi.nlm.nih.gov/PubMed eMedicine www.emedicine.com Clinical practice guidelines www.guidelines.gov MD Consult www.mdconsult.com EBMR1 Reviews (OVID) www.ovid.com/site/catalog Selected Electronic Health Information Resources Adapted from: Hunt DL et al. JAMA April 12, 2000 283(14): 1875-1879 1 Evidence-based Medicine Reviews

Expert opinion based on clinical experience Level of Evidence Type of Study 1a Systematic reviews of RCT 1b Individual RCTs 2a Systematic reviews of cohort studies 2b Individual cohort studies and low-quality RCTs 3a Systematic reviews of case-controlled studies 3b Individual case-controlled studies Levels of Evidence To help clinicians critically review the external evidence they locate, Sackett et al. developed a hierarchical model to categorize most studies. It is important to note that these levels of evidence are not a rigid set of rules, but serve only as a set of guidelines for the critical appraisal of the literature. According to Sackett (BMJ 1996;312:71-2), the randomized trial (especially the systematic review of randomized trials) has become the “gold standard” for judging whether or not a particular treatment is beneficial. The practice of evidence-based medicine is not restricted to randomized trials. Studies from other levels may be better meet you needs for information or may be better in terms of quality. For example, although the cohort study design ranked lower than that of the randomized controlled trial, it may be the highest level of evidence (excluding systematic reviews) for other aspects of patient care (e.g., validity of diagnostic tests, assessing prognosis) or when randomized controlled clinical trials cannot be performed due to ethical concerns (e.g., study of harmful interventions or exposures). 4 Case series and poor-quality cohort and case-control studies 5 Expert opinion based on clinical experience

Step 3: Critically Appraise the Evidence Attribute Question Validity Can I trust this information? e.g., Are the study methods sound? Clinical importance Are the valid results of the study important? e.g., What is the magnitude of the treatment effect? Applicability Can the results be applied to my patient? e.g., Is my patient so different from those in the study that its results cannot apply? Step 3: Critically Appraise the Evidence The third step in the process of evidence-based medicine practice is to critically appraise the evidence. Adapted from: Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000.

Step 4: Integrate Findings With Clinical Expertise and Patient Needs Critical Appraisal Patient Clinical Decision Preferences Concerns Expectations Step 4: Integrate Findings With Clinical Expertise and Patient Needs According to Sackett et al., the fourth step in practicing evidence-based medicine requires the integration of the findings from the critical appraisal with clinical expertise and patient needs. Evidence-based medicine is the integration of clinical expertise, patient values, and the best evidence into the decision-making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education, and clinical skills. By patient values we mean the unique preferences, concerns, and expectations each patient brings to a clinical encounter which must be integrated into clinical decisions if they are to serve the patient. The best evidence is usually found in clinically-relevant research that has been conducted using sound methodology. The evidence, by itself, does not make a decision for you, but it can help support the patient care process. The full integration of these three components into clinical decisions enhances the opportunity for optimal clinical outcomes. Clinical Expertise Adapted from: Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000.

Step 5: Evaluate Performance and Seek Ways to Improve Examples of Self-Evaluation Questions: Am I asking well-formulated clinical questions? Am I searching at all? Do I know the best sources of current external evidence? Am I critically appraising external evidence? Am I integrating my critical appraisal into my practice? Step 5: Evaluate Performance and Seek Ways to Improve The fifth step in practicing evidence-based medicine is often overlooked. Self-evaluation allows physicians to identify areas that need improvement and reinforces strengths. Asking the right questions, tracking down solid evidence, ensuring that evidence is applicable to a particular patient, and doing this on an everyday basis will serve to help the physician provide patients with the highest quality of care.

Definition of 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. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” –David Sackett, MD Definition of Evidence-Based Medicine One of the most frequently cited definitions of evidence-based medicine comes from Dr. David Sackett of McMaster University. Evidence-based medicine is “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” Evidence-based medicine represents a paradigm shift in the way clinicians learn and practice medicine. It is an attitude switch from authority to evidence, from anecdote to outcomes. Evidence-based medicine cannot be considered “cookbook” medicine. Because it requires an approach that integrates the best evidence with individual clinical expertise and patient choice, it cannot result in cookbook approaches to individual patient care. External evidence can complement, but can never replace, individual clinical expertise. It is this expertise that decides whether the evidence can be applied to your individual patient, and if so, how it should be integrated into a clinical decision. Sackett DL et al. BMJ. 1996;312:71–72.