EVIDENCE-BASED MEDICINE Dr. Gerry Gormley Clinical Research Registrar Dept. of General Practice QUB

OBJECTIVES  Define the term EBM  Understand the components involved in EBM  Describe how to develop an ‘answerable question’  List several resources of evidence  List several methods of how to evaluate your performance

How do we make clinical decisions?  Toss coins  Guess  "Do no harm." (Hippocrates)  Ask colleagues  Text books?  Browse journals  Searching bibliographic databases

What is EBM? ‘ The process of systematically finding, appraising and using contemporaneous research findings as a basis for clinical decisions’.

WHY BOTHER? New evidence is being produced every day which could make major changes in the way that we care for our patients. Clinical governance / Revalidation. Without keeping up-to-date our clinical performance may deteriorate. EBM has been shown to keep doctors up to date and ultimately improve health care. GMC regulations. General public have greater access to health care information eg the web, media etc.

How many minutes a week did you spend last week reading around your patients? Medical students PRHOs SHOs SpRs Consultants

How many minutes a week did you spend last week reading around your patients? Medical students 120mins PRHOs SHOs SpRs Consultants

How many minutes a week did you spend last week reading around your patients? Medical students 120mins PRHOs 10mins SHOs SpRs Consultants

How many minutes a week did you spend last week reading around your patients? Medical students 120mins PRHOs 10mins SHOs 30mins SpRs Consultants

How many minutes a week did you spend last week reading around your patients? Medical students 120mins PRHOs 10mins SHOs 30mins SpRs 45mins Consultants

How many minutes a week did you spend last week reading around your patients? Medical students 120mins PRHOs 10mins SHOs 30mins SpRs 45mins Consultants 60mins

WHAT ARE THE IMPORTANT ELEMENTS OF EBM? ‘EBM begins and ends with patients’ 1)Convert patient health care needs into answerable questions. 2) Track down the best evidence. 3) Critically appraise evidence. 4) Apply the results into clinical practice. 5) Evaluate your performance.

ASK CLINICAL QUESTIONS THAT YOU CAN ANSWER ‘Answerable questions are the backbone of practising EBM’ In practice, good questions usually include:- Patient’s clinical needs Intervention(s) comparison intervention clinical outcome(s)

John, a retired 78yr old gentleman is your last patient of the day. He has a long history of AF and asks you ‘my friend has atrial fibrillation and he is on warfarin - should I be on warfarin?’

ELEMENTEXAMPLE PATIENTIn patients with AF and who are >65…. INTERVENTION….would adding warfarin…. COMPARSION….when compared with aspirin …. OUTCOME….lead to lower mortality or morbidity from VTE. Is this enough to be worth the increased risk of bleeding?

EVIDENCE SEARCH General search strategy:- Define searchable question Select evidence resource Design search strategy

EVIDENCE RESOURCES Up-to-date text books Journals Databasesprint electronic Consult experts Department of health bulletins

EVIDENCE RESOURCES Up-to-date text books Journals Databasesprint electronic Consult experts Department of health bulletins

EVIDENCE RESOURCES Up-to-date text books Journals Databasesprint electronic Consult experts Department of health bulletins

EVIDENCE RESOURCES Up-to-date text books Journals Databasesprint electronic Consult experts Department of health bulletins

EVIDENCE RESOURCES Up-to-date text books Journals Databasesprint electronic Consult experts Department of health bulletins

COMPUTER BASED SEARCHES Permit evidence search in real time. Hierarchy of resources: Cochrane collaboration Bandolier web site UK Primary care EB database Medline Lycos, yahoo etc.

CRITICALLY APPRAISE EVIDENCE Hierarchy of study designs:- Systematic review Meta-analysis RCT (DB/SB) Cohort study Case controlled study Cross sectional study Case series

CAN YOU APPLY THIS EVIDENCE INTO CLINICAL PRACTICE? Can the results be extrapolated to your patient? Availability of tests/treatment Affordability of tests/treatment Are there adverse risks? Are there alternatives? What are the patient preferences?

EVALUTE PERFORMANCE Audit Clinical efficacy Cost analysis Patient surveys Prescribing / referral rates Mortality / morbidity rates