2. Is the conscientious explicit and judicious use of current best evidence in making decision about the care of the individual patient (Dr. David Sackett) It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

3. EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care Clinical expertise- the clinician’s cumulated experience; education and clinical skills

4. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology.

5. Explosion of Literature Healthcare Literature with clinically applicable findings is published at a rate that is impossible for individual clinician to keep up with

6. Information needs Practitioners information needs are not being met. For every three patients seen. Two questions are generated Only 30% of those questions are being answered during visits

7. Implementation Delays Takes an average of 17yrs for clinical research to be fully integrated into everyday practice The emerging discipline of translational medicine or translational research seeks to breech this divide.

9. Evidence, by itself, does not make a decision for you, but it can help support the patient care process Integration of all the three components enhances the opportunity for the best clinical outcome and quality of life The practice of EBP is usually triggered by patient encounters which generate questions about the effects of therapy, the utility of diagnostic tests, the prognosis of diseases, or the etiology of disorders.

10. ASSESS the patient 1. Start with the patient -- a clinical problem or question arises from the care of the patient ASK the question 2. Construct a well built clinical question derived from the case ACQUIRE the evidence 3. Select the appropriate resource(s) and conduct a search APPRAISE the evidence 4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice) APPLY: talk with the patient 5. Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice Self-evaluation6. Evaluate your performance with this patient

11. EBM always begins and ends with the patient

12. Remember PICO – contains components of a well focused question P = The patient or Problem I = Intervention, Prognostic Factors, Exposure C = Comparison O = Outcomes

13. After successfully formulating the clinical question (step 1) you need to find relevant evidence.

15. Used to illustrate the evolution of the literature. The base of the pyramid is where information usually starts with an idea or laboratory research. As these ideas turn into therapies and diagnostic tools they are tested with laboratory models, then in animals, and finally in humans.

16. The human testing may begin with volunteers and go through several phases of clinical trials before the therapy or diagnostic tool can be authorized for use within the general population. Controlled trials are then done to further test the effectiveness and efficacy of a drug or therapy. As you move up the pyramid the amount of available literature decreases, but increases in its relevance to the clinical setting.

17. Case series and Case reports consist of collections of reports on the treatment of individual patients or a report on a single patient. Have little statistical validity. (use control group)

18. Case control studies are studies in which patients who already have a specific condition are compared with people who do not have the condition Cohort studies take a large population who are already taking a particular treatment or have an exposure, follow them forward over time, and then compare them for outcomes with a similar group that has not been affected by the treatment or exposure being studied.

19. Randomized, controlled clinical trials introduce a treatment or exposure to study its effect on real patients. They include methodologies that reduce the potential for bias (randomization and blinding) and that allow for comparison between intervention groups and control groups (no intervention).

20. Systematic Reviews focus on a clinical topic and answer a specific question. An extensive literature search is conducted to identify studies with sound methodology Meta-analysis examine a number of valid studies on a topic and combine the results using accepted statistical methodology to report the results as if it were one large study.

21. The pyramid serves as a guideline to the hierarchy of study design. You may not always find the highest level of study to answer your question. In the absence of the best evidence, you then need to consider moving down the pyramid.

22. Clinical trial involves several components: Pre- Clinical Trial - report of a pre- planned clinical study of the safety, efficacy and pharmacokinetic properties. Non-human subjects(animals) Phase 0 – Pharmacokinetic and pharmacokinetic properties. half life, bioavailability. Small number of volunteers(about 10)

23. Phase 1- controlled clinical study of the safety and efficacy of diagnostic, therapeutic or prophylactic drugs at different dosages, based on a small number of healthy persons and conducted over the period of about one year. About 100 people.

24. Phase 2 - report based on several hundred volunteers(up to 300), including a limited number of patients, and conducted over a period of about two years.Test of efficacy and safety. Phase 3 - A large enough group of patients is studied (up to 2000)and closely monitored by physicians for adverse response to long-term exposure, over a period of about three years

25. Phase 4 - Post-marketing study of diagnostic, therapeutic, or prophylactic drugs, devices, or techniques that have been approved for general sale after clinical trials, phases I, II, and III.

26. Cross-sectional studies describe the relationship between diseases and other factors at one point in time (usually) in a defined population. Cross sectional studies lack any information on timing of exposure and outcome relationships and include only prevalent cases.

27. The practice of Evidence-Based Practice advocates that clinicians search the primary literature to find answers to their clinical questions

28. Journal of the American Medical Association, JAMA The New England Journal of Medicine British Medical Journal PubMed/Medline Essential Evidence Clinical Evidence Journal Watch

29. 3 basic questions that need to be answered for every type of study: Are the results of the study valid? What are the results? Will the results help in caring for my patient?