1. Evidence-Based Medicine: Tools, Techniques, Results Balakrishnan S

2. Motivation: EBM “Successes” Theophylline and asthma –We were doing the wrong thing Littenberg, 1988 Beta blockers and MIs –We weren’t doing the right thing Yusuf, 1987

3. Uses of “EBM” Use of empirically-verified treatments in the care of patients Incorporation of research results into the process of care Ability to critically appraise research results

4. What is Evidence-Based Medicine? “The integration of individual clinical expertise with the best available clinical evidence from systematic research.” –David L Sackett, W Scott Richardson, William Rosenberg, R Brian Haynes Evidence Based Medicine--How to Practice and Teach EBM, 1996 »Various definitionsVarious definitions

5. “Clinical Evidence” Clinical vs physiological outcome –E.g., Sleeplessness rather than O 2 saturation Clinical outcomes: See Outcome Research InstituteOutcome Research Institute Effectiveness vs efficacy –In practice vs biology Effectiveness: See DAREDARE

6. “Best Available Clinical Evidence” Therapy –Double-blind, placebo-controlled, randomized clinical trial Diagnosis –Independent, blind comparison with a reference standard Prognosis –Representative and well-defined prospective cohort of patients at a similar point in the course of disease See Centre for Health EvidenceCentre for Health Evidence

7. Levels of Evidences (I-1) a well done systematic review of 2 or more RCTs (I-2) a RCT (II-1) a cohort study (II-2) a case-control study (II-3) a dramatic uncontrolled experiment (III) respected authorities, expert committees, etc.. (IV)...someone once told me.... –http://www.phru.org/casp/http://www.phru.org/casp/ –See also AAFPAAFP

8. “Systematic Research” “Meta-analysis” “Literature synthesis” –From Michael ScrivenMichael Scriven

9. “Integration of Individual Clinical Expertise” Informal Formal (Decision analysis)Decision analysis

10. Questions ARIF

11. Centre for EBM: http://163.1.212.5/docs/focusquest.html Questions: PICO

12. Search for the Best Evidence Review articles Community/professional standards Systematic reviews Original results

13. What are the Sources of Good Evidence? www.welch.jhu.edu

18. Cochrane Website

22. TRIP Database www.tripdatabase.com (75 resources…) Website

25. Getting to PubMed

26. PubMed Response

27. PubMed Clinical Query www4.ncbi.nlm.nih.gov/PubMed/

28. PubMed, Clinical Query, cont’d Question Context Subject matter Website

29. Click on “Details”-- ((("atrial fibrillation"[MeSH Terms] OR atrial fibrillation[Text Word]) AND (((randomized controlled trial[PTYP] OR "drug therapy"[Subheading]) OR "therapeutic use"[Subheading:noexp]) OR (((((((((((((((((((((((((((((((((((((((((((((((((((((random[WORD] OR randomaly[WORD]) OR randoman[WORD]) OR randomand[WORD]) OR randombred[WORD]) OR randombreds[WORD]) OR randomdigit[WORD]) OR randomdot[WORD]) OR randome[WORD]) OR randomed[WORD]) OR randomely[WORD]) OR randomer[WORD]) OR randomezed[WORD]) OR randomic[WORD]) OR randomicity[WORD]) OR randomil[WORD]) OR randomily[WORD]) OR randomingly[WORD]) OR randomisation[WORD]) OR randomisations[WORD]) OR randomise[WORD]) OR randomised[WORD]) OR randomisees[WORD]) OR randomisely[WORD]) OR randomises[WORD]) OR randomising[WORD]) OR randomisly[WORD]) OR randomiz[WORD]) OR randomizable[WORD]) OR randomizadely[WORD]) OR randomizado[WORD]) OR randomization[WORD]) OR randomizations[WORD]) OR randomize[WORD]) OR randomized[WORD]) OR randomizedly[WORD]) OR randomizely[WORD]) OR randomizer[WORD]) OR randomizes[WORD]) OR randomizing[WORD]) OR randomlike[WORD]) OR randomly[WORD]) OR randomlyselected[WORD]) OR randommess[WORD]) OR randommized[WORD]) OR randommobility[WORD]) OR randomnes[WORD]) OR randomness[WORD]) OR randomomized[WORD]) OR randoms[WORD]) OR randomsource[WORD]) OR randomyl[WORD]) OR randomyly[WORD]) OR randomzied[WORD]))) AND notpubref[sb])

30. Controlled Vocabulary for Subject Matter

31. UpToDate Website

34. CISMeF www.chu-rouen.fr/cismef/ Website

35. Dynamic Meta-Searching sumsearch.uthscsa.edu/searchform45.htm Website

37. Clinically Appraised Topic Websites

38. CAT Content

39. CAT Synthesis

41. Washington University: PedsCCM pedsccm.wustl.edu/EBJ/EB_Resources.html Website

43. Details Therapy/prevention Diagnostic test Prognosis Harm CPG Systematic review Economic analysis Outcomes research www.med.ualberta.ca/ebm/ebm.htm Website

44. Therapy Website

45. Apply the Evidence to the Individual

47. Evidence-Based MEDICINE Do you tell what you know? –Does the patient want to participate? What is the emotional impact of what you have to say? What is the meaning to the patient of this evidence?

48. Problems Should a 30-year-old woman with recurrent uncomplicated lower UTIs be advised to drink cranberry juice to prevent reinfection? For a 63 year old woman with Type 2 diabetes, is gabapentin superior to amitriptyline as first- line therapy for painful peripheral neuropathy?

50. Task Well formulated question? Discuss sites to go…everyone takes one Formulate the query Report back to your group on your success The whole group reports back at the and of 30 min

51. Gabapentin A. GABAPENTIN is a gamma- aminobutyric acid (GABA) analog currently indicated as adjunctive therapy in the treatment of partial seizures with and without secondary generalization. –Partial seizures; social phobia »Micromedex