EBM - Background

• A Canadian connection!– The term "evidence based medicine" was coined at

McMaster University’s Medical School in the 1980's to label a clinical learning strategy people at this school had been developing for over a decade. (BMJ 1995. 310:1122; MeSH, NLM, 2004)

– The term EBM now encompasses:• A philosophy• A clinical strategy• An application

EBM - Philosophy

“Evidence-Based Medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. [In] practice, [this] means integrating individual clinical experience with the best available external evidence from systematic research.”

(Sackett et al., 1996. Evidence based medicine: what it is and what it isn't.BMJ, 312: 71-2)

EBM – Clinical Strategy• EBM is the process of systematically finding, appraising,

and using contemporaneous research findings as the basis for clinical decisions.

• EBM encourages health professionals to ask questions, find and appraise relevant data, and then apply that information to their everyday clinical practice.

(MeSH, NLM, 2004)

EBM – Clinical Strategy

EBM EBHC

• Evidence-Based Health Care (EBHC) extends the application of the principles of EBM to all professions associated with health care. (CEBM, Oxford, 2004)

• Large scale adoption and adaptation across several practice areas/fields/disciplines – Why? EB Dentistry, EB Nursing, EB Mental Health, EB Pediatrics, EB Public Health, EB

Clinical Practice, EB Health Administration, etc.

• Evidence-based healthcare is part of a global movement in all the health science disciplines. It represents a philosophical shift in the approach to practice – a shift that emphasises evidence over opinion and, at the same time, judgement over blind adherence to rules. This approach provides a bridge between research and everyday patient care.

EBM - What is it?

Clinical Expertise

Research Evidence

Patient Preferences

• Evidence-based dentistry is a set of principles and methods intended to ensure that to the greatest extent possible, clinical decisions, guidelines, and other types of policies are based on and consistent with good evidence of effectiveness and benefit.

So, how does it work?

EBM Method

Acquire the best evidence

Appraise the evidence

Applyevidence to patient care

Assess your patient

Ask clinical questions

EBM Method

EBM – Clinical Application

• How to practice EBM:

– Five steps:• Question - Take your need for information about a patient problem

and formulate a clear, concise, clinical question (3 C’s)• Search the literature for best evidence to help you answer that

question;• Critically appraise the evidence for its validity and applicability;• Integrate this critical appraisal with clinical expertise and patient

information, such as values, unique biology, current health status, etc.;

• Evaluate your effectiveness and efficiency in executing Steps 1-4 and seek ways to improve them both for next time

• Sackett DL et al. (2000). Evidence-based Medicine: How to Practise and Teach EBM

Assess Your Patient

• History• Physical examination• Objective data – labs, x-rays

• Formulate differential diagnosis• Pretest probability of disease

Ask Clinical Questions

Patient/Population OutcomeIntervention/

Exposure Comparison

Components of Clinical Questions

In patients withacute MI

In post-menopausal

women

In women withsuspected

coronary disease

does early treat-ment with a statin

what is the accuracy of

exercise ECHO

does hormonereplacement

therapy

compared to placebo

compared to exercise

ECG

compared to noHRT

decrease cardio-vascular mortality?

for diagnosingsignificant

CAD?

increase therisk of

breast cancer?