1. Life long learning with EBM
Prof Eiad Al-Faris MD, MSc, MRCGP, MMEd, Prof. and Consultant of Family Medicine King Saud University Supervisor -King Saud University chair for medical education

2. Outline Introduction Definition of EBM Steps of EBM Practical search
Conclusion
Closure

3. INFORMATION EXPLOSION
850,000
500,000
100,000
10,000
MEDICAL JOURNALS
1900
1990
2000
2014

5. Rule 31 – Review the World Literature Fortnightly*
8,500
per day
2,142 per day
94 per day

6. Clinical Scenario
Ibrahim is a 30 years old teacher, he is known case of allergic rhinitis. He presented with a flare up of rhinitis symptoms, and he wants to get refills of the antihistamine pills.
You wonder should you prescribe intranasal steroids or refill the antihistamines?!

7. Clinical Scenario
Ibrahim is a 60 years old teacher, he is known to have hypertension. He presented to the ED with severe chest pain for the last two hours.
In addition to history / exam and ECG, you wonder should you request for the timely diagnosis: troponin or creatine kinase- MB or both?

8. When confronted with a clinical question, whom usually you consult?

9. Colleagues- experts A great source of information.
Quick, affordable and accessible.
But potentially very biased:
Variability
Not updated

10. Textbooks Rapidly out-of-date (2-4y).
A good source of background information (pathophysiology),
but a poor source of information for most foreground questions (clinical).

11. Burn your traditional textbooks

12. What is EBM?

13. EBM is
The integration of the current best evidence (from research) with our clinical expertise and patient’s values.

14. Three (Es)- EBM Components

15. Rules of Evidence All evidence is not created equal.
Evidence alone never makes clinical decisions.

16. Hierarchy of Evidence Multi-centric large RCTs
Meta-analysis of RCTs
Multi-centric large RCTs
Single Centre RCT
Observational studies
Patient-important outcomes
Evidence from different sources can be categorized in a hierarchy:
Meta-analysis or systematic reviews are at the top of the hierarchy.
When summaries of the evidence are not available, individual randomized controlled trials provide the next best evidence.
Next are observational studies. We should try to find studies that focus on outcomes important to the patient.
If there are no clinical studies available we may look at basic scientific research, although caution must be used in extrapolating the results to the clinical setting.
Clinical experience is at the bottom of the hierarchy, either your own or that of colleagues or experts.
Clinical experience
Basic research
test tube, animal, human physiology

17. 6 As to practice EBM Assess Ask clinical Acquire the Appraise
your patient
Ask clinical
questions
Alternative to next slide
Acquire the
Evidence(s)
Appraise
the evidence(s)
Apply The
best evidence
to patient
Assess
Yourself

18. Pretest probability of disease
Assess Your Patient
History
Physical examination
Objective data – labs, x-rays
Formulate differential diagnosis
Pretest probability of disease

19. To answer a clinical question effectively
First, turn your scenarios into 'well-built' clinical Q.
Four domains: PICO
1) the patient (problem)
2) the intervention or exposure
3) the comparison (intervention)
4) the clinical outcomes

20. Treponine or creatine kinase-MB
1.Patient population.
2. Intervention.
3. Comparison intervention.
4. Outcomes.
Patients attending the ED with chest pain
Troponine
creatine kinase-MB
Accuracy of diagnosis of IHD
“In Patients attending the ED with chest pain, is troponine as compared to creatine kinase-MB more valid for the diagnosis of ischemic heart disease?

21. For healthy adults is it worthwhile to give aspirin as a prophylaxis to reduce MI and or stroke ?

22. Aspirin and Primary Prevention
1. Patient population.
2. Intervention.
3. Comparison intervention.
4. Outcomes.
Asymptomatic adults with no risk factors
Aspirin
Placebo
Incidence of CV events

23. “In asymptomatic adults no risk factors, would the use of aspirin reduce the incidence of cardiovascular events?

24. Ask Clinical Questions (PICO)
Components of Clinical Questions (PICO)
Patient/
Population
Outcome
Intervention/
Exposure
Comparison
In patients with
acute MI
In post-
menopausal
women
In women with
suspected
coronary disease
does early treat-
ment with a statin
what is the
accuracy of
exercise ECHO
does hormone
replacement
therapy
compared to
placebo
exercise
ECG
compared to No
HRT
decrease cardio-
vascular mortality?
for diagnosing
significant
CAD?
increase the
risk of
breast cancer?

25. 25

26. Types of clinical questions
Therapy and harm: how to select treatments to offer patients that do more good than harm
Diagnostic tests: how to select and interpret diagnostic tests, in order to confirm or exclude a diagnosis
Prognosis: how to estimate the patient's likely clinical course over time

27. Acquire the Best Evidence
Prefiltered Sources:
UpToDate
Clinical Evidence
Dynamed
Physicians Information and Education Resource (PIER)
Clinical Practice Guidelines
Cochrane Library
Ovid
MD Consult
Medscape
Unfiltered Sources
MEDLINE (
Google scholar (
We need to focus and familiarize ourselves with few of them

28. Summaries Synopsis of Syntheses Syntheses Synopsis of Studies Studies
Systems
Summaries
Synopsis of Syntheses
Syntheses
Synopsis of Studies
Studies

29. Summaries Clinical Evidence www.clinicalevidence.com Dynamed
Physicians Information and Education Resource (PIER) pier.acponline.org
UpToDate
Clinical Practice Guidelines
National Guidelines Clearinghouse

30. Synopses of Syntheses ACP Journal Club www.acpjc.org
The database of abstracts of reviews of effects (DARE)
Evidence Based Medicine ebm.bmj.com
Evidence Based mental health ebmh.bmj.com

31. A comparison of answer retrieval. Ahmadi SF Med Teach - 2011
UpToDate
Clinical key
PIER
EssentiEvid +
Rate retriev
86%
69%
49%
45%
The mean time
14.6 min
15.9 min
17.3 min
16.3 min

32. Syntheses ACPJC plus (plus.mcmaster.ca/acpjc)
The Cochrane Library

33. Synopsis of Studies Evidence-Based Abstraction Journals
EvidenceAlerts

34. Studies www.pubmed.gov Clinical queries Mesh search
Special queries: for health services and qualitative research

35. Federated Search Engines
TRIP Turning Research Into Practice
SUMSearch sumsearch.uthsca.edu

40. 40

41. 41

42. EBM can reduce reading need How much is valid AND relevant?
PROCESS
120+ journals scanned
50,000 articles
Is it valid? (<5%)
Intervention: RCT
Prognosis: inception cohort
Etc
Is it relevant?
6-12 GPs & specialists asked: Relevant? Newsworthy?
< 0.5% selected
Number Needed to Read
is 20+
Number Needed to Read
is 200+

43. The “Evidence Transfer Gap”
Controlled
trials
Clinical
Practice
Haynes calls this the “evidence transfer gap”. EBM seeks to close the gap between completed research activity and the practice of medicine.

44. The Challenge – Bridging the gap!
New EBM teaching models
Deals with barriers
EBM Environment
At a recent clinic or family or your own ….
Discuss question with neighbour 44

45. Appraise the Evidence Four Pillars
RV-RA system
Relevance: It focuses on medical problems common to our practice. patient-oriented evidence
Validity: Correctness (likely to be true)- bias-
Results: Clinically important
Magnitude and Precision (MP)
Can we apply the results to our patient? Applicable in and useful for my patients

46. Relevance Consider three questions to determine Relevance
From your practice
Require change of practice
Patient-oriented outcome (POEM)

47. POEM Vs. DOE POEM: Patient-oriented evidence that matter
mortality, morbidity, quality of life
DOE: Disease-oriented evidence
pathophysiology, pharmacology, etiology

48. Comparing DOE and POEM DOE POEM Antihypertensiv therapy
Lowers Blood Pressure
Mortality MI
CVA
Screening for prostate CA
PSA screening detects Prostate CA at an early stage
Unknown whether PSA screening reduces Mortality

49. The cardiac arrhythmia suppression trial. N Engl J Med 1991.
DOE POEM
Clofibrate decreases
cholesterol
Clofibrate decreases CV mortality/
Morbidity
It Increases overall mortality
β –blockers are contraindicated for heart failure patients
β –blockers are indicated for heart failure patients
Antiarrhythmic A decreases PVCs
Antiarrhythmic A decreases symptoms
Antiarrhythmic A increases mortality
The cardiac arrhythmia suppression trial. N Engl J Med 1991.

50. The cardiac arrhythmia suppression trial. N Engl J Med 1991.
DOE POEM
Clofibrate decreases
cholesterol
Clofibrate decreases CV mortality/
Morbidity
It Increases overall mortality
β –blockers are contraindicated for heart failure patients
β –blockers are indicated for heart failure patients
Antiarrhythmic A decreases PVCs
Antiarrhythmic A decreases symptoms
Antiarrhythmic A increases mortality
The cardiac arrhythmia suppression trial. N Engl J Med 1991.

51. The cardiac arrhythmia suppression trial. N Engl J Med 1991.
DOE POEM
Clofibrate decreases
cholesterol
Clofibrate decreases CV mortality/
Morbidity
It Increases overall mortality
β –blockers are contraindicated for heart failure patients
β –blockers are indicated for heart failure patients
Antiarrhythmic A decreases PVCs
Antiarrhythmic A decreases symptoms
Antiarrhythmic A increases mortality
The cardiac arrhythmia suppression trial. N Engl J Med 1991.

52. Five journals with highest concentration of POEMS
JAMA-17%
Annals of Internal Medicine-17%
NEJM-16%
Journal of the American Board of Family Practice-16%
Journal of Family Practice-15%
Ebell MH et al. J Fam Pract :

53. Appraise the Evidence
Relevance: It focuses on medical problems seen in our practice. patient-oriented evidence
Validity: Correctness (likely to be true)
Results: Clinically important
Magnitude and Precision (MP)
Can we apply the results to our patient? Applicable in and useful for my patients

54. Validity
In RCT:
Randomization
Blindness
Drop-out
ITT

55. Appraise the Evidence
Relevance: It focuses on medical problems seen in our practice. patient-oriented evidence
Validity: Correctness (likely to be true)
Results: Clinically important
Magnitude and Precision (MP)
Can we apply the results to our patient? Applicable in and useful for my patients

56. Results Clinical importance can be assessed by its: Magnitude
Precision

57. Results of a hypothetical randomized trial
Total N. of Pts
No. who did not improve
No. who improved
Treatment 40 18 22
Ibuprofen 33 7
Placebo

58. Calculations made from these results
Experimental event rate
Control event rate
Experimental event odds
Control event odds
Odds ratio
Relative risk
Relative risk increase
Absolute risk increase or reduction
NNT

59. Results of a hypothetical randomized trial
Total N. of Pts
No. who did not improve
No. who improved
Treatment 40 18 22
Ibuprofen 33 7
Placebo

60. Relative Risk
A relative risk is the risk in the treatment group compared to the risk in the control group.
A relative risk of (1) means there is no difference between the groups

61. Results of a hypothetical randomized trial
Total N. of Pts
No. who did not improve
No. who improved
Treatment 40 18 22
Ibuprofen 33 7
Placebo

62. Results of a hypothetical randomized trial
Total N. of Pts
No. who did not improve
No. who improved
Treatment 40 18 22
Ibuprofen 33 7
Placebo

63. Experimental event rate:
22/40 =55%
Control event rate:
7/40 = 18%

64. Relative risk:
=0.55/ 0.18= 3.1
Relative risk increase:
=( )/ 0.18 = 2.06
Absolute risk increase or reduction=
= 0.37
NNT = 1/ 0.37 = 2.7

65. Odds
The odds of an event are the probability of it occurring compared to the probability of it not occurring

66. Results of a hypothetical randomized trial
Total N. of Pts
No. who did not improve
No. who improved
Treatment 40 18 22
Ibuprofen 33 7
Placebo

67. What was the ratio of odds?
The odds of an event in the treatment (or exposed) group compared to the odds in the control (or unexposed) group
OR=(A/B)/(C/D)

68. An odds ratio
is the odds of an event in a patient in the experimental group relative to that of a patient in the control group.
Relative risk is the risk of an event in a pt in the experimental group relative to that of a pt in the control group.

69. Results of a hypothetical randomized trial
Total N. of Pts
No. who did not improve
No. who improved
Treatment 40 18 22
Ibuprofen 33 7
Placebo

70. Experimental event odds:
22/18= 1.2
Control event odds:
7/ 33 =0.21
Odds ratio:
1.2/ 0.21= 5.7

71. Applicability
Three arms for the applicability criteria to be looked at (IPP)
Intervention
Patient population
Patient preferences.

72. Information management Principles

73. Applying Research
One size doesn’t fit all

74. Learning about “Just in Time” learning
Keep a logbook of questions
Answer a few important questions
Search and appraise yourself, then
Discuss with colleagues / mentor

75. Learning about learning in teams
(Post graduate “problem-based” learning)
List our important current issues
Vote on importance
Search for evidence for next session
Example Questions
Does ‘bibliotherapy’ help depression?
Should all diabetics take aspirin?
Are antidepressants safe in adolescents?
Is atenolol OK for hypertension?
What is the impact of Tamiflu on flu?
Is diabetic self-monitoring helpful?
“Journal”
Clubs

76. Questions?

77. The Prognosis of Ignorance is Poor

78. Implications for practice
Treatment of Ignorance
Implications for practice
Interactive workshops can improve professional practice. Lectures alone are unlikely to change professional practice

79. If EBM looks impossible then resign it!