1. If you teach him how to fish, If you teach him how to fish, he will eat today …  If you give someone a fish, he will eat every day…

2. Evidence –Based Medicine Journal Club Prof. EIAD AL-FARIS Chairman, Department of Family and Community Medicine College of Medicine,King Saud University College of Medicine,King Saud University

3. Contents 1. Aims and Objectives 2. Introduction 3. Definition of EBM. 4. Steps For EBM Practice. 5. Well Built Clinical Questions. 6. Identifying The Evidence 7. Search Strategy. 8. Conclusion

4. Aims and Objectives

6. What is EBM ? Integration of best research evidence with clinical experience & patient values. Integration of best research evidence with clinical experience & patient values.

7. Which database you are prescribed to? Pubmed Pubmed Cochrane Library Cochrane Library Clinical Evidence Clinical Evidence Best Evidence Best Evidence Bandolier Bandolier Therapeutic Initiative Therapeutic Initiative Trip database Trip database Google Google

8. WHAT IS EBM ? The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. DAVID SACKETT

9. Five steps process ?  Asking the right question.  Searching for information.  Evaluating the evidence for validity and usefulness. validity and usefulness.  Implement useful findings in clinical practice clinical practice  Evaluate the whole process

10. « Step I. Converting the need for information into a answerable question. Converting the need for information into a answerable question.

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

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

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

14. Information management Principles

15. Clinical Scenario Ibrahim is a 30 years old teacher, he is known case of allergic rhinitis. He presented to your clinic for follow up, he is having a flare up of rhinitis symptoms, and he wants to get refills of the antihistamine pills that he used to get from his physician. Ibrahim is a 30 years old teacher, he is known case of allergic rhinitis. He presented to your clinic for follow up, he is having a flare up of rhinitis symptoms, and he wants to get refills of the antihistamine pills that he used to get from his physician. You wonder should you prescribe intranasal steroids or refill the antihistamines?! You wonder should you prescribe intranasal steroids or refill the antihistamines?!

16. Step 1 Formulating an answerable question

17. Formulating clinical questions Patient/ Population : Patients with Allergic Rhinitis Patient/ Population : Patients with Allergic Rhinitis Intervention : Intranasal steroids Intervention : Intranasal steroids Comparison : Antihistamines Comparison : Antihistamines Outcome : Control of symptoms Outcome : Control of symptoms

18. Formulating clinical questions In patients with Allergic Rhinitis, is Intranasal steroids more effective than antihistamines in the management of Allergic Rhinitis symptoms? In patients with Allergic Rhinitis, is Intranasal steroids more effective than antihistamines in the management of Allergic Rhinitis symptoms?

19. Step II. Searching best evidence to answer the question. Searching best evidence to answer the question.

77. Identifying The Evidence Primary Sources Secondary Sources Medline Embase Systematic Reviews Clinical Guidelines

78. Where to Find the Best Evidence ? Invest in evidence databases Invest in evidence databases Using Prefiltered sources Using Unfiltered sources

79. Search strategy

80. Disease and intervention well understood & fully evaluated Textbook Disease and intervention well understood & fully evaluated Textbook Common problem Clinical evidence ACP Journal Club Common problem Clinical evidence ACP Journal Club New intervention Medline PubMed clinical queries. New intervention Medline PubMed clinical queries. Broad questions System review articles e.g Cochrane library Broad questions System review articles e.g Cochrane library Internet google Internet google

81. « Q1. For healthy adults is it worthwhile to give aspirin as prophylaxis to reduce MI and or stroke. Scenario and Questions (Cont’d)

82. PRIMARY SOURCES « Primary Sources of evidence MEDLINEEMBASE

83. Other Search Engines EMBASE EMBASE CANCERLIT CANCERLIT CINAHL CINAHL HealthSTAR HealthSTAR

84. Secondary sources of Evidence

85. SECONDARY SOURCES A Unique Source… Its contents are driven by questions rather than by the availability of research evidence. Its contents are driven by questions rather than by the availability of research evidence. It is updated every 6 months. It is updated every 6 months.

86. Clinical Evidence Produced by the BMJ Publishing Group Produced by the BMJ Publishing Group Updated every six months Updated every six months www.clinicalevidence.org www.clinicalevidence.org

87. Aspirin and Primary Prevention 1. Patient population. 2. Intervention. 3. Comparison 4. Outcomes. Asymptomatic adults with no risk factors Aspirin Placebo Incidence of CV events “In asymptomatic adults no risk factors, would the use of aspirin reduce the incidence of cardiovascular events?

88. Aspirin and Primary Prevention Benefit CER=4.8% CER=4.8% EER=4.2% EER=4.2% ARR=4.8-4.2=0.6% ARR=4.8-4.2=0.6% NNT=167 NNT=167Harms IC bleeds: NS EC bleeds: ARI=0.8-0.5=0.3% ARI=0.8-0.5=0.3% NNH=333 NNH=333

89. The Cochrane Library

90. http://www.thecochranelibrary.com

91. Clinical Scenario Khalid is a 40 years old smoker, would like to quit smoking, he tried to do that, by himself, several times over the last two years, but he could not tolerate the withdrawal symptoms. Recently he read an article in the newspaper reporting that anti-depression medications can be used to help smoker to quit, he would like your advise about this issue! Khalid is a 40 years old smoker, would like to quit smoking, he tried to do that, by himself, several times over the last two years, but he could not tolerate the withdrawal symptoms. Recently he read an article in the newspaper reporting that anti-depression medications can be used to help smoker to quit, he would like your advise about this issue! You wonder what is the role of antidepressants in smoking cessation?! You wonder what is the role of antidepressants in smoking cessation?!

92. Formulating clinical questions Patient/ Population : Smoking Cessation Patient/ Population : Smoking Cessation Intervention : Antidepressants therapy Intervention : Antidepressants therapy Comparison : Placebo Comparison : Placebo Outcome : Rate of smoking Cessation Outcome : Rate of smoking Cessation

93. The Cochrane Database of Systematic Reviews Live Demonstration

117. “It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomised controlled trials.” Archie Cochrane

118. The Cochrane Database of Systematic Reviews (CDSR) Include more than 50 review groups. Include more than 50 review groups. Contains over 3541 completed reviews and review protocols. Contains over 3541 completed reviews and review protocols. The CDSR abstracts are free The CDSR abstracts are free The CDSR impact factor is 4.654 ranking number 14 The CDSR impact factor is 4.654 ranking number 14 The collection is updated quarterly. The collection is updated quarterly. Reviews are updated every 2 years. Reviews are updated every 2 years.

119. Review Groups Acute respiratory infections Acute respiratory infections Airways Airways Anaesthesia Anaesthesia Back Back Breast cancer Breast cancer Colorectal cancer Colorectal cancer Consumers and communication Consumers and communication Cystic fibrosis and genetic disorders Cystic fibrosis and genetic disorders Dementia & cognitive improvement Dementia & cognitive improvement Depression, anxiety & neurosis Depression, anxiety & neurosis Developmental, psychosocial and learning problems Developmental, psychosocial and learning problems Drugs and alcohol Drugs and alcohol Ear, nose and throat disorders Ear, nose and throat disorders Effective practice and organisation of care Effective practice and organisation of care Epilepsy Epilepsy Eyes and vision Eyes and vision Fertility regulation Fertility regulation Gynaecological cancer Gynaecological cancer Heart Heart Hepato-biliary Hepato-biliary

120. Database Of Abstracts Of Reviews Of Effectiveness (DARE) DARE is a collection of abstracts of well-conducted and quality-assessed research reviews about the effectiveness of health care interventions. DARE is a collection of abstracts of well-conducted and quality-assessed research reviews about the effectiveness of health care interventions. http://nhscrd.york.ac.uk/darehp.htm http://nhscrd.york.ac.uk/darehp.htm

131. ACP Journal Club Selects articles from the literature that are original commented on by clinical experts. Selects articles from the literature that are original commented on by clinical experts. More than 2000 reviews currently available. More than 2000 reviews currently available. http://www.acpjc.org/ http://www.acpjc.org/

132. ACP Journal Club Selects articles from the literature that are original commented on by clinical experts. Selects articles from the literature that are original commented on by clinical experts. More than 2000 reviews currently available. More than 2000 reviews currently available. http://www.acpjc.org/ http://www.acpjc.org/

133. « Q2. One of my healthy patients asked whether to take folic asked whether to take folic acid or not ? acid or not ? Scenario and Questions (cont’d)

134. Bandolier Search for systematic reviews and abstract them Search for systematic reviews and abstract them Include NNT tables Include NNT tables http://www.jr2.ox.ac.uk/Bandolier/ http://www.jr2.ox.ac.uk/Bandolier/

135. « Bandolier is an Oxford based appraisal site with lots of good material. http://www.jr2.ox.ac.uk/bandolier/bformHJ.ht ml SECONDARY SOURCES

136. « Q3. One of your residents asked you should we stop prescribing traditional NSAID, and shift to the selective C0X2 inhibitors? Scenario and Questions (cont’d)

137. SECONDARY SOURCES « Evidence Based Therapeutics Initiative from UBC, Canada http://www.ti.ubc.ca/index.html http://www.ti.ubc.ca/index.html

138. Q4. A. For type I diabetic patient with microalbuminurea, which is the best ACEI or ARB that will protect the kidney? B. In diabetic and HTN patients, which is more effective in preventing stroke, captopril or enalapril? Scenario and Questions (Cont’d)

139. TRIP Database The TRIP Database searches 70 sites of high- quality medical information. The TRIP Database searches 70 sites of high- quality medical information. The site is updated monthly. The site is updated monthly. http://www.tripdatabase.com/ http://www.tripdatabase.com/

145. Step (3): Critical Appraisal of the Evidence Is the evidence from this article valid? METHOD Is the evidence from this article valid? METHOD If valid, are the RESULTS important? If valid, are the RESULTS important? If valid and important, can you apply the evidence in the caring for the patients in the local contexts? If valid and important, can you apply the evidence in the caring for the patients in the local contexts?

146. Conclusion

147. Five steps process ?  Asking the right question.  Searching for information.  Evaluating the evidence for validity and usefulness. validity and usefulness.  Implement useful findings in clinical practice clinical practice  Evaluate the whole process

148. Conclusion Cont. The main thing is to The main thing is to keep asking questions. keep asking questions.

150. Thank You eiad@ksu.edu.sa

151. King Saud Khazindar Free Journals http://www.alkhazindar.com.sa/onlinejourna ls/first.asp http://www.alkhazindar.com.sa/onlinejourna ls/first.asp http://www.alkhazindar.com.sa/onlinejourna ls/first.asp

152. Literature Review

153. Training Medical Students in Evidence-based Medicine: A Community Campus Approach. Family Med 1999, 31 (10): 703-8.  Michigan State University (MSU)  A nine-session 20 hours curriculum  Third year medical students  It compared this group with the AAMC graduates and the 1994 class who were not taught this course

154. AAMC Comparison of Literature Analysis Skills

155. AAMC Comparison of Research Technique Skills

156. CONCLUSION CONCLUSION

157. If you teach him how to fish, If you teach him how to fish, he will eat today …  If you give someone a fish, he will eat every day…

158.  Be open to questions; never avoid or ignore a question.  Show interest in the patient’s story; never act bored.

159.  Do not give the patient false reassurance.

160. 19001990 2000 10,000 100,000 ? 250,000 INFORMATION EXPLOSION MEDICAL JOURNALS

161. DOE POEM  Disease Oriented Evidence (DOE)  Patient Oriented Evidence that Matters (POEM)  the outcomes that matter most to our patients.

162.  POEMs  Decreased symptoms, mortality, morbidity, cost  Increased QOL.  Doe  pathophysiological point of view point of view

163. RELEVANCE X VALIDITY WORK Shaughnessy et. al. JFP 1994. Shaughnessy et. al. JFP 1994. USEFULNESS OF INFORMATION =

164. Relevance  Applicability to practice.  DOE VS POEMs  Frequency of the Problem

165. DOE makes sense  Can we apply it to our patients before POEM?

166.  EBM encourages a healthy skepticism  Example from the history  Antiarrhytharic ??  β -blockers

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

168. Five steps process ?  Asking the right question.  Searching for information.  Evaluating the evidence for validity and usefulness. validity and usefulness.  Implement useful findings in clinical practice clinical practice  Evaluate the whole process

169. Step 1 Formulating an answerable question

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

172. Clinical Scenario Ibrahim is a 30 years old teacher, he is known case of allergic rhinitis. He presented to your clinic for follow up, he is having a flare up of rhinitis symptoms, and he wants to get refills of the antihistamine pills that he used to get from his physician. Ibrahim is a 30 years old teacher, he is known case of allergic rhinitis. He presented to your clinic for follow up, he is having a flare up of rhinitis symptoms, and he wants to get refills of the antihistamine pills that he used to get from his physician. You wonder should you prescribe intranasal steroids or refill the antihistamines?! You wonder should you prescribe intranasal steroids or refill the antihistamines?!

173. Patient : Patients with Allergic Rhinitis Patient : Patients with Allergic Rhinitis Intervention : Intranasal steroids Intervention : Intranasal steroids Comparison : Antihistamines Comparison : Antihistamines Outcome : Symptoms Control Outcome : Symptoms Control

174. Step 2

175. SEARCHING FOR THE Best EVIDENCE

176. Identifying The Evidence Primary Sources Secondary Sources Medline Embase Systematic Reviews Clinical Guidelines

177. Medline search Medline search Medline search Medline search

178. Secondary sources of Evidence

179. Where to Find the Best Evidence ? Invest in evidence databases Invest in evidence databases Using Prefiltered sources

180. They do steps 3 and 4 They do steps 3 and 4 Focus on relevant Focus on relevant information information Evaluate its validity. Evaluate its validity.

182. Aspirin and Primary Prevention Benefit CER=4.8% CER=4.8% EER=4.2% EER=4.2% ARR=4.8-4.2=0.6% ARR=4.8-4.2=0.6% NNT=167 NNT=167Harms IC bleeds: NS EC bleeds: ARI=0.8-0.5=0.3% ARI=0.8-0.5=0.3% NNH=333 NNH=333

183. 3rd session:

184. Boolean Operators A AND B

185. Boolean Operators A OR B

187. SPECIALIST (MEDICINE SPECIFIC) SEARCH ENGINE e.g. i-TRIP Database e.g. i-TRIP Database ii- OMNI (Organization Medical Network Information) ii- OMNI (Organization Medical Network Information)

188. Agency for Health Care Research & Quality (AHRQ) Include a comprehensive guidelines for 19 separate conditions. Include a comprehensive guidelines for 19 separate conditions. http://www.ahrq.gov/clinic/cpgarchv.htm. http://www.ahrq.gov/clinic/cpgarchv.htm. Include recommendations on a wide range of clinical preventive services. Include recommendations on a wide range of clinical preventive services. Evidence-based Practice Centers (EPC) Reports: Evidence-based Practice Centers (EPC) Reports: http://www.ahrq.gov/clinic/epcindex.htm http://www.ahrq.gov/clinic/epcindex.htm

189. Other sources of systematic reviews CFP Critical Appraisal Index CFP Critical Appraisal Index The Therapeutics Initiative The Therapeutics Initiative

190. Canadian Practice Guidelines Infobase The most up-to-date Canadian based guidelines site. The most up-to-date Canadian based guidelines site. Most of the guidelines are evidence-based. Most of the guidelines are evidence-based. http://mdm.ca/cpgsnew/cpgs/index.asp http://mdm.ca/cpgsnew/cpgs/index.asp

191. National Guideline Clearinghouse Include structured abstracts of guidelines with links to full-text guidelines. Include structured abstracts of guidelines with links to full-text guidelines. Not all guidelines are evidence-based. Not all guidelines are evidence-based. http://www.guidelines.gov http://www.guidelines.gov

192. Guideline Advisory Committee Gives quick access to recommended guidelines for common medical conditions. Gives quick access to recommended guidelines for common medical conditions. Include summaries and ratings of the guidelines with full text links to guidelines. Include summaries and ratings of the guidelines with full text links to guidelines. http://www.gacguidelines.ca/ http://www.gacguidelines.ca/

193. Other sources of Evidence-based Guidelines The Scottish Intercollegiate Guidelines Network (SIGN) The Scottish Intercollegiate Guidelines Network (SIGN) http://pc47.cee.hw.ac.uk/sign/clinical.htm. http://pc47.cee.hw.ac.uk/sign/clinical.htm. The New Zealand Guidelines Group The New Zealand Guidelines Group http://www.nzgg.org.nz/index.cfm. http://www.nzgg.org.nz/index.cfm. The NHS and department of Health Technology assessment programme. The NHS and department of Health Technology assessment programme. http://www.hta.nhsweb.nhs.uk/htapubs.htm http://www.hta.nhsweb.nhs.uk/htapubs.htm

194. The Canadian Task Force on Preventive Health Care A practical guide for a wide variety of preventive health interventions using EBM recommendations. A practical guide for a wide variety of preventive health interventions using EBM recommendations. Include age and sex specific recommendation tables. Include age and sex specific recommendation tables. http://www.ctfphc.org/ http://www.ctfphc.org/

195. Canadian Practice Guidelines Infobase The most up-to-date Canadian based guidelines site. The most up-to-date Canadian based guidelines site. Most of the guidelines are evidence-based. Most of the guidelines are evidence-based. http://mdm.ca/cpgsnew/cpgs/index.asp http://mdm.ca/cpgsnew/cpgs/index.asp

196. National Guideline Clearinghouse Include structured abstracts of guidelines with links to full-text guidelines. Include structured abstracts of guidelines with links to full-text guidelines. Not all guidelines are evidence-based. Not all guidelines are evidence-based. http://www.guidelines.gov http://www.guidelines.gov

197.  Be open to questions; never avoid or ignore a question.  Show interest in the patient’s story; never act bored.

198.  Do not give the patient false reassurance.

199. « Two million articles /year « 500 meters high! Introduction

200. JASPA* (Journal associated score of personal angst) J: Are you ambivalent about renewing your JOURNAL subscriptions? A: Do you feel ANGER towards prolific authors? S: Do you ever use journals to help you SLEEP? P: Are you surrounded by PILES of PERIODICALS? A: Do you feel ANXIOUS when journals arrive? * Modified from: BMJ 1995;311:1666-1668 0 (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions)

201. Systematic review of bed rest after medical procedures Allen, Glasziou, Del Mar. Lancet, 1999 10 trials of bed rest after spinal puncture 10 trials of bed rest after spinal puncture no change in headache with bed rest no change in headache with bed rest Increase in back pain Increase in back pain Protocols in UK neurology units - 80% still recommend bed rest after LP Serpell M, BMJ 1998;316:1709–10 Protocols in UK neurology units - 80% still recommend bed rest after LP Serpell M, BMJ 1998;316:1709–10 …evidence of harm available for 17 years preceding... …evidence of harm available for 17 years preceding...

202. 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 DOE POEM The cardiac arrhythmia suppression trial. N Engl J Med 1991.

203. 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 DOE POEM The cardiac arrhythmia suppression trial. N Engl J Med 1991.

204. 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 DOE POEM The cardiac arrhythmia suppression trial. N Engl J Med 1991.

205. Primary Sources of Evidence PubMed PubMed is a Web-based retrieval system developed by the National Center for Biotechnology Information (NCBI) at the NLM. PubMed is a Web-based retrieval system developed by the National Center for Biotechnology Information (NCBI) at the NLM. The database is updated weekly The database is updated weekly Approximately 12 million citations Approximately 12 million citations Citations from over 3,900 journals Citations from over 3,900 journals

206. PubMed 85% of citations are in English 85% of citations are in English 75% of citations have abstracts 75% of citations have abstracts Data is leased to commercial providers (e.g., OVID) Data is leased to commercial providers (e.g., OVID)

207. Guidelines « Center for Disease Control http://www.cdc.gov/ http://www.cdc.gov/ « This is an easy to navigate site with a good section on Traveler's Health. Travel map Internet Page http://www.cdc.gov/travel/travelmap.html http://www.cdc.gov/travel/travelmap.htmlhttp://www.cdc.gov/travel/travelmap.html « National Cancer Institute http://cancernet.nci.nih.gov/pdq.htm http://cancernet.nci.nih.gov/pdq.htm

208. Systematic Reviews Well-formulated question Well-formulated question Comprehensive data search Comprehensive data search Unbiased selection and abstraction process Unbiased selection and abstraction process Critical appraisal of data Critical appraisal of data Synthesis of data Synthesis of data

209. Evidence-Based Guidelines

210. The Canadian Task Force on Preventive Health Care A practical guide for a wide variety of preventive health interventions using EBM recommendations. A practical guide for a wide variety of preventive health interventions using EBM recommendations. Include age and sex specific recommendation tables. Include age and sex specific recommendation tables. http://www.ctfphc.org/ http://www.ctfphc.org/

211. Guideline Advisory Committee Gives quick access to recommended guidelines for common medical conditions. Gives quick access to recommended guidelines for common medical conditions. Include summaries and ratings of the guidelines with full text links to guidelines. Include summaries and ratings of the guidelines with full text links to guidelines. http://www.gacguidelines.ca/ http://www.gacguidelines.ca/