1. ScienceCartoonsPlus.com

2. Rod Jackson 2013 evidence-based medicine (EBM)*: what it is & why its necessary * also called evidence-based practice (EBP)

3. evidence-based medicine (EBM)*: what it is? ‘its about how to better inform your clinical decisions with the best up-to- date epidemiological evidence’

4. core components of ‘traditional’ evidence based decision-making *relied on clinical knowledge or ‘mechanistic evidence’ mainly from: anatomy, physiology, pathology, biochemistry, psychology, etc.

5. ‘modern’ EBM explicitly emphasises ‘current’ best clinical epidemiological evidence about outcomes directly relevant to people evidence from direct observation, what happens in practice

6. clinical epidemiological evidence* how accurate are diagnostic tests? how strong are prognostic markers? how effective are interventions? –therapy –Screening –prevention * study of the probability of outcomes in groups of patients

7. Aristotle (384 – 322 BCE): the first evidence based practitioner? None of the arts (i.e sciences) theorise about individual cases. Medicine, for instance, does not theorise about what will help to cure Socrates, but only about what will help to cure any or all of a given class of patients. This alone is our business. Individual cases are so infinitely various that no systematic knowledge of them is possible. Aristotle. Rhetoric. book I, chapter 2: 1356b (clinical epidemiology is the science of investigating the probability of outcomes in ‘groups ‘or classes’ of patients’)

8. evidence-based practice ‘informing decisions more explicitly with the best up-to-date evidence, particularly from epidemiology’ by using this evidence: more efficiently more critically more systematically EBP: informing decisions with the best up-to-date evidence

9. 5,000? per day 2,000 per day 75 per day Articles Per Year why do we need to use evidence efficiently? EBP: informing decisions with the best up-to-date evidence

10. Bastian, Glasziou, Chalmers PLoS 2010 Vol 7 | Issue 9 | e1000326 more efficiently clinical evidence increasing so rapidly we need better skills to keep up-to-date more efficiently than previous generations of clinicians

11. validity: most articles should be ignored EBM Journal Process 140+ journals scanned –60,000 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 to find 1 valid is 20+ Number Needed to Read to find 1 valid & relevant is 200+ using evidence more critically more critically EBP: informing decisions with the best up-to-date evidence

12. but many clinicians cannot tell good from poor quality research BMJ study of 607 reviewers –14 deliberate errors inserted Detection rates –On average <3 of 9 major errors detected –Poor Randomisation (by name or day) - 47% –Not intention-to-treat analysis - 22% –Poor response rate - 41% Schroter S et al, accepted for Clinical Trials more critically EBP: informing decisions with the best up-to-date evidence

13. Egger, M. et al. BMJ 1997;315:1533-1537 Total mortality from trials of β- blockers in 2° prevention after MI. Black square & horizontal line correspond to odds ratio (OR) & 95% confidence interval (CI) for each trial. The size of the black square reflects the weight of each trial. The diamond represents the combined OR & 95 CI, showing a 22% reduction in odds of death using evidence more systematically

14. Egger, M. et al. BMJ 1997;315:1371-1374 Cumulative meta- analysis of total mortality results from trials of oral β-blockers after MI. Size of squares reflect amount of statistical information available at a given point in time using evidence more systematically

15. Gets worse with “duration in practice”

16. what skills will you need to keep up to date with the best evidence? to find the evidence more efficiently to appraise the quality of the evidence more effectively to use good quality evidence more systematically

17. the steps of practicing EBM 1. ask a focused question. 2. access (systematically search for) epidemiological evidence to help answer question. 3. appraise evidence found for its validity, effect size, precision (ideally all the relevant evidence) 4. apply the evidence in practice: a. amalgamate the valid evidence with other relevant information (values & preferences, clinical/health issues, & system issues) and make an evidence-based decision; and b. act (implement) the decision in practice explicitly improving practice with external evidence from literature

18. about 1/2 of ‘valid’ evidence today is out of date in 5 years ScienceCartoonsPlus.com about 1/2 of valid evidence is not implemented

19. the 5 th step of EBP = Quality Improvement 5.audit your practice: compare your actual practice with best (evidence- based) practice i.e. the gap between your evidence-based decisions and your actions explicitly improving practice with internal evidence from your practice

20. GATE: Graphic Approach To Evidence Based Practice - a framework for learning the skills of EBP 1 picture, 2 formulas & 3 acronyms 20