EVIDENCE BASED MEDICINE (EBM) Nandinii Ramasenderan

080100332
OVERVIEW
Definition
History
Factors driving EBM
Steps in EBM
Case discussion
 WHAT IS EBM?
A systematic approach to
clinical problem solving which Patient
Concerns
allows the integration of the
best available research EBM
evidence with clinical Best research Clinical
evidence Expertise
expertise and patient values
-Dave Sackett-
INTEGRATED WITH CLINICAL EXPERTISE
expertise in performing the history and physical examination

knowledge of the patient, the family, and the community which creates a
context for therapeutic decision-making

a relationship with the patient informed by his or her beliefs and values

practical knowledge of the availability of resources in the

community
RISE OF EVIDENCE BASED MEDICINE

Other “evidence-
based”
First A new approach approaches: ethics,
A “revolution” in psychotherapy,
described in to teaching medical practice occupational
1992 medicine therapy, dentistry,
nursing, and
librarianship
 Overwhelming
size of the
literature

Reproducible Inadequacy
evidence of textbooks
strategies

Factors
driving
EBM Difficulty
Available synthesizing
computerize evidence and
d databases translating
into practice

Increased
number of
RCTs
 LIFE LONG LEARNING
The hardest conviction to get into the mind of
a beginner is that the education upon which
he is engaged is not … a medical course,
but a life course, for which the work of a
few years under teachers is but a
preparation.

Sir William Osler (1849-1919), from: The Student of

Medicine
STEPS IN PRACTISING EBM
Convert the need for information into an answerable
question

Track down the best evidence with which to answer

that question

Critically appraise the evidence for its validity, impact,

and applicability

Integrate the evidence with our clinical expertise and

our patient’s characteristics and values

Evaluate effectiveness & efficiency in executing steps 1

till 4 & seeking ways to improve for next time
STEP 1 : FORMULATE QUESTION
Background Question
-Ask for general knowledge about a condition or thing
-Have 2 essential components:
a) A question root (who, what, where, when how, why) and a verb
b) A disorder, test, tx, or other aspect of health care.
Eg: -how does heart failure cause ascites?
-what causes SARS?
STEP 1 : FORMULATE QUESTION
Foreground Question
-Ask for specific knowledge to inform clinical decision / actions
-4 essential components:
a) Patient and /or problem
b) Intervention (or exposure)
c) Comparison, if relevant
d) Outcome (clinical), including time if relevant
Eg: “ In adults with heart failure who are in sinus rhythm, would adding warfarin to standard
therapy reduce morbidity or mortality from thromboembolism enough over 3-5 years to be
worth warfarin’s harmful effects and inconveniences.”
STEP 1 : Formulate Question
The nature of the question asked is
critically experience dependent.

FOREGROUND
TYPE OF
QUESTION

BACKGROUND

CLINICAL EXPERIENCE
STEP 2: USE BEST EVIDENCE TO ANSWER QUESTION

Systems Computerized decision support system (CDSS)

Synopses Evidence-based journal abstracts

Syntheses Cochrane reviews

Studies Original published articles in journals

STEP 2: USE BEST EVIDENCE TO ANSWER QUESTION

System
-Evidence based clinical information,
researches
-Electronic based
BMJ Clinical Evidence
(http://www.clinicalevidence.com)
UpToDate (http://www.uptodate.com)
PIER: The Physician’s Information and
Education Resource
(http://pier.acponline.org/index.html).
Synopses
-A brief summary/ review of individual
studies
-Provide only information to support a
clinical action
ACP [American College of Physicians]
Journal Club(http://www.acpjc.org
EBM (http://ebm.bmj.com).
 STEP 2: USE BEST EVIDENCE TO ANSWER QUESTION

Syntheses
-summaries of articles/ reviews
The Cochrane Library Web site
(http://www3.interscience.wiley.com/
cgibin/mrwhome/106568753/HOME)
DARE(www.york.ac.uk/inst/crd/welcome.htm)
Studies
-original research journal
Medline/ PubMed Clinical Queries
(www.pubmed.com)
EMBASE (OVID) (www.ovid.com)
HIERARCHY OF EVIDENCE PYRAMID
 LEVEL OF EVIDENCE

Level type of investigation

Ia Evidence obtained from meta analysis of randomized
controlled trials
Ib Evidence obtained from at least one randomized
controlled trial
IIa Evidence obtained from at least one well designed
controlled study without randomization
IIb Evidence obtained from at least one other type of well
designed quasi experimental study
III Evidence obtained from well designed non experimental
studies, such as comparative studies, correlational studies,
and case studies
IV Evidence obtained from expert committee reports or
opinions
 STEP 3: CRITICALLY APPRAISE EVIDENCE
To understand the methods and results of research and to assess the quality of the research

THREE MAIN ASPECTS TO BE APPRAISED: VIA

1. VALIDITY :
VALID (CLOSENESS TO THE TRUTH)  IN THE METHODOLOGY SECTION

2. IMPORTANCE :
IMPORTANT (USEFULNESS)  IN THE RESULTS SECTION

3. APPLICABILITY :
APPLICABLE (CAN BE APPLIED IN CLINICAL PRACTICE)  IN THE DISCUSSION SECTION
STEP 4: INTEGRATE FINDINGS INTO PRACTISE
Making a concise decision based on research finding & information found.
Discuss with patient regarding our findings & risk-benefit assessment
CASE DISCUSSION
68 years old Malay Female
Hx of Congestive Heart Failure & Hypertension
Surgical Hx: CABG 10 years ago
On medication: Digoxin, Lasix, Isosorbide nitrate
Mild increase of dysnea on exertion past 4 days
Having acute Shortness of breath 1hour prior to admission
On examination:
BP: 188/104 mmHg
Pulse rate:122 bpm
Respiratory rate: 30
Temp: 37.5 Celsius
SpO2: 90% (On Non-rebreather mask)
Lung auscultation: Crackles to ½ bilateral
Jugular vein distended, S3 gallop
Pretibial edema bilaterally
PLAN & INVESTIGATION
IV, O2, & vital sign Monitoring
Chest Xray, ECG, Cardiac markers, Digoxin level
ECG: Sinus tachycardia, old inferior myocardial infarction, no st-elevation changes
CXR: acute pulmonary edema (pulmonary venous congestion, small bilateral effusion)
Treatment
 GTN
 Lasix
 Morphine
QUESTION—GENERAL STATEMENT
What about using ACE inhibitors for acute pulmonary edema?
BACKGROUND
Describe pathophysiology of CHF and acute pulmonary edema
Discuss causes of decompensation of CHF
Discuss Differential Diagnosis of acute pulmonary edema
Relate pathophysiology of CHF to treatment, especially role of ACE-I in CHF
Describe treatment goals
Describe standard treatment of CHF
EBM QUESTION
Patients: Acute Pulmonary Edema
Intervention: ACE Inhibitor
Comparison: Placebo
Outcome:
 Mortality
 Intubation
 Hemodynamic parameters
 ICU/CCU admission
THANK YOU