Welcome to Inspire! Michael Fleming, MD, FAAFP Senior Medical Editor Antidote Education Company

2 Inspire! Inspirein-'spI(-&)r Etymology: Middle English, from Anglo-French & Latin; Anglo-French inspirer, from Latin inspirare, from in- + spirare to breathe transitive verb 1 a : to influence, move, or guide by divine or supernatural inspiration b : to exert an animating, enlivening, or exalting influence on c : to spur on: IMPEL, MOTIVATE d : AFFECT

3 Audience Response Question: My degree is: 1. MD 2. DO 3. NP / FNP 4. PA / PA-C 5. Other

4 My specialty is: 1. Family Medicine 2. General Practice 3. Internal Medicine 4. Critical Care / Emergency Medicine 5. Other Audience Response Question:

5 Audience Response Question Inspired When I leave here today, I will be Inspired!! 1.Yes 2.No

6 Audience Response Question Evidence-based medicine is the integration of current best research evidence with clinical expertise and patient values. Evidence-based medicine is of value in making decisions about the care of families and communities. 1.Strongly Agree 2.Agree 3.Neutral 4.Disagree 5.Strongly Disagree

Evidence Based Medicine An idea whose time has come… Michael Fleming, MD, FAAFP

8 Importance of Evidence-Based Medicine “Evidence-based medicine is the integration of current best research evidence with clinical expertise and patient values. Evidence-based medicine is of value in making decisions about the care of families and communities.” Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman J, Ewigman B, Bowman M. Strength of Recommendation Taxonomy (SORT): A patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:

13 Importance of Evidence-Based Medicine “A patient on your team has just had a Q-wave myocardial infarction that resulted in moderate congestive heart failure. The senior resident on Cardiology wants to administer a beta-blocker. A professor with 40 years experience in the Division of Cardiology advises against this, stating that instituting such medication will further decrease cardiac function.“ Adapted from Evidence-Based Medicine: A Framework for Clinical Practice Edited by Daniel J. Friedland, MD

14 Importance of Evidence-Based Medicine The traditional medical paradigm comprises four assumptions: Individual clinical experience provides the foundation for diagnosis, treatment, and prognosis. The measure of authority is proportional to the weight of individual experience. Pathophysiology provides the foundation for clinical practice.

15 Importance of Evidence-Based Medicine Traditional medical training and common sense are sufficient to enable a physician to evaluate new tests and treatments. Clinical experience and expertise in a given subject area are a sufficient foundation to enable the physician to develop clinical practice guidelines. Quoted from Evidence-Based Medicine: A Framework for Clinical Practice Edited by Daniel J. Friedland, MD

16 Importance of Evidence-Based Medicine The new evidence-based medicine paradigm comprises a different set of assumptions: When possible, clinicians use information derived from systematic, reproducible, and unbiased studies to increase their confidence in the true prognosis, efficacy of therapy, and usefulness of diagnostic tests.

17 Importance of Evidence-Based Medicine An understanding of pathophysiology is necessary but insufficient for the practice of clinical medicine.

18 Importance of Evidence-Based Medicine An understanding of certain rules of evidence is necessary to evaluate and apply the medical literature effectively. Quoted from Evidence-Based Medicine: A Framework for Clinical Practice Edited by Daniel J. Friedland, MD

19 What is Evidence Based Medicine Evidence-based medicine is the practice of making medical decisions through the judicious identification, evaluation, and application of the most relevant information. Quoted from Evidence-Based Medicine: A Framework for Clinical Practice Edited by Daniel J. Friedland, MD

20 The Three Steps of EBM Medical Decision-Making Techniques: helps frame the clinical scenario and apply the relevant information to the care of the patient. Accessing Medical Information: optimally retrieves the most rigorously designed studies or evidence-based integrative literature. Assessing the Validity of Medical Information: critically appraises the validity of findings in individual studies or integrative literature. Quoted from Evidence-Based Medicine: A Framework for Clinical Practice Edited by Daniel J. Friedland, MD

21 Evidence Based Medicine Frame the question What treatment or medicine are we looking at What is the comparator treatment or medicine What outcome are we looking at

22 Evidence Based Medicine Frame the question: Must be relevant to patients you see. What treatment or medicine are we looking at?: What is the comparator treatment or medicine?: Should be the current gold standard. What outcome are we looking at?: Should be something that really matters.

23 Levels of Evidence A.Randomized controlled trials. Rich body of data. Definition: Evidence is from endpoints of well- designed randomized controlled trials that provide a consistent pattern of findings in the population for which the recommendation is made. Category A requires substantial numbers of studies involving substantial numbers of participants.

24 Levels of Evidence B. Randomized controlled trials. Limited data. Definition: Evidence is from endpoints of intervention studies that include only a limited number of patients, post hoc or subgroup analysis of randomized controlled trials, or meta-analysis of randomized controlled trials. In general, Category B pertains when few randomized trials exist, they are small in size, they were undertaken in a population that differs from the target population of the recommendation, or the results are somewhat inconsistent.

25 Levels of Evidence C. Nonrandomized trials. Observational studies. Definition: Evidence is from outcomes of uncontrolled or nonrandomized trials or from observational studies.

26 Levels of Evidence D. Panel consensus judgment. Definition: This category is used only in cases where the provision of some guidance was deemed valuable but the clinical literature addressing the subject was insufficient to justify placement in one of the other categories. The Panel Consensus is based on clinical experience or knowledge that does not meet the above-listed criteria.

27 American Family Physician Strength-of-Recommendation Grades Strength of recommendation A B C Basis for recommendation Consistent, good-quality patient-oriented evidence* Inconsistent or limited-quality patient-oriented evidence* Consensus, usual practice, opinion, disease-oriented evidence,* or case series for studies of diagnosis, treatment, prevention, or screening Ebell MH, Siwek J, Weiss BD, Woolf SH, Susman J, Ewigman B, Bowman M. Strength of Recommendation Taxonomy (SORT): A patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:

28 The End