EBMEVIDENCE BASED MEDICINE

RESOURCES

Lobna Al Juffali, Msc

Spring 2010

A DRUG INFORMATION QUESTION

“ My 8 month baby has a severe earache for 2 days

Should I treat him with Antibiotics?”

ON WHAT BASES SHOULD I ANSWER THE QUESTION?

1. On my current knowledge depending on my practice

2. By experts opinion 3. By the well structured studies that justifies

the use or non use of antibiotics

COMMONSENCE I shook the tree, and a coconut fell on my

head.   Hmm....maybe shaking the tree caused

the coconut to fall on my head!   Better not shake trees without first watching for falling coconuts...

EBM

I gave my patient who has had bronchitis for 4 or 5 days an antibiotic, and 3 days later she

felt better. Hmm...maybe giving the patient the

antibiotic caused her to feel better!  I better give all of my patients with bronchitis an

antibiotic...

EBM

ON WHAT BASES SHOULD I ANSWER THE QUESTION?

1. On my current knowledge depending on my practice

2. By experts opinion 3. By the well structured studies that justifies

the use or non use of antibiotics

EBM

INTRODUCTIONIn the early 1990s, a group of clinicians and

epidemiologists at McMaster University in Ontario, Canada, officially lead by Dr. David Sackett which coined the term

"evidence-based medicine ”.

The concept faced mixed reviews: excitement from those in the academic and research worlds and suspicion from

those in the "real world," who found EBM impractical in a busy medical office.

EBM

“Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values”

DR. SACKETT DEFINES EBM AS:

EBM

Patient Values

Research Evidence

Clinical Expertise

WHY DO WE NEED EVIDENCE BASED MEDICINE?

Clinical examples that we practice without the best evidence which lead to harm for our patients.

Failure of common sense .

The wide variation in current clinical practice among practitioners.

The difficulty of managing medical information, when results conflict and thousands of articles are published every month .

The knowledge declines over time, and traditional CME doesn't work

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WHAT WERE THEY PRACTICING IN THE

PAST 50 YEARS?

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Opinion Based Medicine

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EBM VS TBMTBM

opinion based medicine own experience asking relatively few colleagues Guidelines, but they were

consensus-based. opinions not backed up by science." "BOGSATs,"

SO they fail to search for evidence which might cause them to reach a different conclusion or allow them to come to a more balanced decision

EBM Demands better evidence

external clinical evidence

Guidelines. systematic reviews meta-analyses

own experience Patients preference

evidence that matters

Focuses on outcomes that matter to the patient

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EBMHOW DO WE PRACTICE EVIDENCE BASED MEDICINE

5 STEPS IN PRACTICING EBM

FormattingAn answerable question(well built clinical question)

tracking down the best evidence with which to answer that question

critically appraising that evidence for its validity ,impact and applicability

integrating the critical appraisal with our clinical expertise and with our patient’s

evaluating our effectiveness and efficiency in executing steps 1–4

PICO

TRACKING DOWN THE BEST EVIDENCE

To be useful, medical information should be relevant to everyday practice, correct (valid) and easy to obtain. 

Usefulness equation

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Relevance x Validity

Work

VALIDITY The hard part of Information Mastery

The “Truth”-Probability statement that what we do does more good than harm.

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RELEVANCE

Frequency Type of evidence presented Evidence that can change my practice

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RELEVANCE: TYPE OF EVIDENCE

POE: Patient-oriented evidence mortality, morbidity, quality of life

DOE: Disease-oriented evidence pathophysiology, pharmacology, etiology

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Comment Patient-Oriented Evidence

that Matters

Disease-Oriented Evidence

Example

The results of the POEM study are contrary to what the DOE study would suggest

Antiarrhythmic drug X increases mortality

Antiarrhythmic drug X decreases PVCs on ECGs

Antiarrhythmic therapy

The results of the POEM study are in concordance with DOEs

Antihypertensive drug treatment decreases mortality

Antihypertensive drug treatment lowers BP

Antihypertensive therapy

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Type of Evidence

WORK Basic law of human behavior: lowest amount

of work you can get away with

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Information source Relevance Validity Work Usefulness

Evidenced based textbook High High Low High

Standard textbook High Low Low Mod

Drug reference book ( PDR) High Mod Low High- Mod

Systematic review EB High High Low High

Practice Guidelines EB Mod High Low Mod-High

Practice guidelines consensus

Mod Mod Low Mod

Drug advertising Mod Low Low Low

Drug company representatives

High Low Low Low

Colleagues High Mod Low High- Mod

Internet in 10 years High High Low High

Internet now Low Low High Low

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IS ALL EVIDENCE CREATED EQUALLY ?

HOW DO WE SEARCH

LITERATURE RESOURCES

FILTERED RESOURCES

appraise the quality of studies and often make recommendations for practice

Systematic ReviewsAuthors of a systematic review ask a specific

clinical question, perform a comprehensive literature search, eliminate the poorly done studies and attempt to make practice recommendations based on the well-done studies.

A meta-analysis is a systematic review that

combines all the results of all the studies into a single statistical analysis of results.

EXAMPLES OF SYSTEMIC REVIEWS/ METAANYLSIS

The Cochrane Database of Systematic Reviews The Database of Abstracts of Reviews of Effects (DARE) Ovid MEDLINE: Enter your search query. Click on "More

Limits"; select “Systematic Reviews” under “Subject Subsets.”

PubMed: Click on “Clinical Queries” on the left side of the screen; select “Find Systematic Reviews” and enter your search query.

FILTERED RESOURCES

Critically-Appraised Topicsevaluate and synthesize multiple research

studiesClinical evidenceNational Guideline Clearinghouse

Critically-Appraised Individual ArticlesAuthors of critically-appraised individual articles evaluate and summarize individual research studies.

The ACP Journal clubDaily POEMSEvidence updates

FILTERED RESOURCES

“Evidence-Based…” Journal series (e.g., Evidence-Based Medicine, Evidence-Based Mental Health, Evidence-Based Nursing)

UNFILTERED RESOURCES

Evidence is not always available via filtered resources. Searching the primary literature may be required. It is possible to use specific search strategies in MEDLINE and other databases to achieve the highest possible level of evidence

PubMed Ovid Medline

BACKGROUND INFORMATION/EXPERT OPINION

Evidence in these resources may vary from expert opinion to high levels of evidence. UpToDate e-Medicine E-Books at Galter ACP Medicine

5S APPROACH TO EVIDENCE BASED INFORMATION ACCESSS

ummari

es

synopses

Synthesis

Studi

es

Computerized decision support system (CDSS)

Evidence based-textbooks

Evidence based-journal abstracts

Cochrane reviews

Original published articles from journals

SYSTEMS

Decision support tools. They integrate and concisely summarize all

relevant and important research evidence about a clinical problem and would automatically link, through an electronic medical record, a specific patient’s circumstances to the relevant information.

updated whenever important new research evidence becomes available.

would not tell decision-makers what to do. to ensure that the cumulative research evidence

concerning the patient’s problem is immediately at hand.

to maximize speed of use

Su

mmaries

synopses

Synthesis

Studies

SUMMERIES

These are critically appraised topics Summaries that integrate best available

evidence to provide a full range of evidence concerning management options for a given health problem (eg, acute coronary syndromes [ACS]).

Su

mmaries

synopses

Synthesis

Studies

Clinical Evidence PIER (Physicians' Information and Education Resources) DynaMed

DYNAMED

is updated daily monitors the content of over 500 medical

journals and systematic evidence review databases

clinically-organized summaries for more than 3,000 topics,

PIER (PHYSICIANS' INFORMATION AND EDUCATION RESOURCES)

Link: http://online.statref.com/UserLogin.aspx Is an American College of Physician product summarizes and evaluates current evidence

for patient care. It grades clinical recommendations based on

the strength of the evidence available.

SYNOPSES

Critically appraised journal article/study •Concise short statements that summarized

the evidence for a particular clinical question •Available of multiple sources over the

internet •Some are downloadable to handheld

devicesExample of Synopses •ACP Journal Club •BMJ Updates •Bandolier •Essential Evidence Plus

Su

mmaries

synopses

Synthesis

Studies

BMJ UPDATES

From BMJ Publishing Group and McMaster University's Health Information Research Unit.

Quality articles from over 110 clinical journals are selected by research staff, then rated for clinical relevance and interest by an international group of physicians.

Includes a searchable database of the best evidence from the medical literature and an email alerting system

ACP JOURNAL CLUB

published by the American College of Physicians-

American Society of Internal Medicine. The editors of this journal screen the top

100+ clinical journals and identify studies that are methodologically sound and clinically relevant.

An enhanced abstract, with conclusions clearly stated, and a commentary are provided for each selected article

SYNTHESIS

If more detail is needed or no synopsis is at hand, then databases of systematic reviews (syntheses) are available,

Examples Cochrane Library Ovid’s EBMR service.

Su

mmaries

synopses

Synthesis

Studies

COCHRANE DATABASE OF SYSTEMATIC REVIEWS (COCHRANE REVIEWS)

'Gold Standard' for high-quality systematic reviews

Full-text included in Cochrane Library Cochrane Reviews includes complete reviews

and protocols (reviews that are still in progress). Cochrane Reviews abstracts are in PubMed

COCHRANE DATABASE OF SYSTEMATIC REVIEWS (COCHRANE REVIEWS) DATABASES

Cochrane Database of Systematic Reviews (Cochrane Reviews)

Database of Abstracts of Reviews of Effects (Other Reviews)

Central Register of Controlled Trials (Clinical Trials)

Cochrane Methodology Register (Methods Studies)

Health Technology Assessment Database (Technology

Assessments)

NHS Economic Evaluation Database (Economic Evaluations)

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DATABASE OF ABSTRACTS OF REVIEWS OF EFFECTS (OTHER REVIEWS - DARE)

prepared by the National Health Service Centre for Reviews and Dissemination, University of York, England.

Complements the Cochrane Reviews by offering a selection of quality assessed reviews in those subjects where there is currently no Cochrane review.

Brief critical appraisals of previously published reviews of the effects of health care.

Structured abstracts, not full-text DARE not indexed in PubMed, but original

research articles may be Also available at no charge on the web from

University of York | www.crd.york.ac.uk/crdweb/

PUBMED MEDLINE - SYSTEMATIC REVIEWS

part of PubMed's Clinical Queries Identifies systematic reviews and other

similar types of studies found in biomedical journals included in PubMed database.

No evaluation of comparative quality of different reviews on a topic.

Abstracts supplied by authors/journals. No separate evaluation of quality of research. Identify systematic reviews in the biomedical

area - gathers together much larger collection than other evidence-based practice resources.

STUDIES

original studies It takes time to summarize new evidence,

and systems, synopses and syntheses necessarily follow the publication of original studies, usually by at least 6-12 months.

Su

mmaries

synopses

Synthesis

Studies

EXAMPLE OF STUDIES There are also at least two levels of evidence-based databases to search

directly: specialized and general. If the topic falls within the areas of internal medicine, primary care,

nursing or mental health, then ACP Journal Club (www.acpjc.org, formerly Best Evidence) Evidence Based Medicine (http://ebm.bmjjournals.com/), Evidence Based Nursing (http://ebn.bmjjournals.com/) Evidence Based Mental Health (http://ebmh.bmjjournals.com/)

If the search is for a treatment, the Cochrane Library includes the Cochrane Central Register of

Controlled Trials also available as part of EBMR on Ovid, where it is integrated with ACP

Journal Club and DARE. For original articles and reviews MEDLINE itself is freely available and

the Clinical Queries screen If you still have no luck and the topic is, say, a new treatment (that one

of your patients has asked about but you don’t yet know about …), then you can try Google (http://www.google. com

EXPERT OPINION

Evidence in these resources may vary from expert opinion to high-level evidence but

updates are generally less frequent and level-

of-evidence grading systems are lacking. –UpToDate –eMedicine –Harrison's Online

UP TO DATE

Provide comprehensive reviews on primary care,

internal medicine, and pediatric topics. Content is enhanced by –many graphics links –Lexi-Comp's drug reference –PubMed abstracts. Evidence gaps are filled by expert opinion.

EBMEXAMPLE OF EBM SEARCH ENGINES