Contents Preface to the Sixth Edition. Introduction. What is Evidence-Based Medicine? Why is Evidence-Based Medicine?. Forms of evidence. Hierarchy of evidenc Strength of recommendation taxonomy. Steps of EBM. Asking answerable question: Clinical Scenari Searching for the best evidence. Critically appraising the evidence. Critical appraisal Applying the evidence to individual patient care. Evaluating the proce The Logic Behind EBM Analyzing Information. Advantages and disadvantages in practicing EBM, Suggestive Guidelin At the Central Level. At the Peripheral. Implementation of the strategie: Glossary of Terms in EBI Evidence- jased Medicine Resources References for further readings. 20 20 20 20 21 21 22 22 22 23 23 25 25 25 26 27 59EVIDENCE-BASED MEDICINE Introduction t is worth to mention that practicing according to the results of clinical studies and experiments is not a new concept in clinical practice. Ibn Al-Razi (Rhazes 865-925) described the best clinical practice as: ‘the practice that has been agreed up on by practitioners and supported by experiments’. In addition he was the first sclentist to recognize the need for a comparison group in clinical studies. Ibn sina (Avicenna 981-1037) listed several requirements for studies evaluating new medications. These principles include the need for the drug to be tested on a well defined disease, the effect of the drug must be seen to occur constantly in many cases, and the study must be done on humans, for testing a drug on a lion or a horse might not prove anything about its effect on humans. All these principles are stil valid in the era of evidence based medicine. In 1992 a group of researchers from McMaster University started to use the term “Evidence-Based Medicine’. They wrote a series of articles in collaboration with the Journal of The American Medical Association (JAMA) where they established the principles of the concept of evidence based medicine. Evidence-based medicine (EBM) is a relatively new approach to the teaching and practice of medicine. Historically, physicians: clinical decision-making was based on the knowledge received during their medical training and experiences gained through individual patient encounters i.e. opinion-based. Evolution of epidemiology, and subsequently clinical epidemiology, resulted in methods that allowed the objective critique of therapies used in clinical practice. Epidemiologic principles were applied to problems encountered in clinical medicine and an increasing number of clinical trials and medical journals emerged. The past two decades have witnessed an acceleration of the information explosion and with it the volume of medical publications. The importance of keeping updated Is emphasized even more, given that the haif life of medicalThe practice of evidence-based medicine requires an understanding of simple and basic clinical epidemiology, as well as excellent communication skills, patience, and a commitment to provide the patient with the knowledge required to make informed choices. It is important that physicians become familiar with the meaning of EBM and its role in influencing the provision of care and use of health resources. What is Evidence-Based Medicine? Evidence-based medicine has been defined by David Sackett, as «the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients», to aid the delivery of optimum clinical care to patients. Evidence-based medicine can be practiced by the integration of individual clinical expertise with the best available clinical evidence from systematic research and patient values and circumstances. Simply put, EBM means applying the best information to manage patient problems, diagnosis, prognosis, harm, patient safety ..etc. It is based on the assumption that: 1) medical literature, and thus useful information about patient care, is growing at an alarming rate; and 2) in order to provide best care for patients, doctors must be able to continuously upgrade their knowledge, i.e. by accessing, appraising, interpreting and using medical literature in a timely fashion. Fig. 1. Practice of Evidence Based MedicineWhat is the problem? Why is there a need for EBM? Domt we already practice medicine fairly uniformly based on a common fund of evidence?. Bottom line: we are now often practicing medicine based on clinical judgment that is not well informed by the best evidence of medical research - a slippery slope to diminished affectivity and/or compromised competence. Why evidence-based medicine? The first reaction of any doctor to EBM is likely to be «Well, of course thas what | always do.» The second response, perhaps more thoughtful and certainly more honest, will be a degree of confusion: «What does it really mean? How does one actually do evidence based medicine? Surely there is not enough time? What kind of doctor am | if my medicine is not evidence based?» Some doctors perceived EBM as diminishing the role of clinical acumen and experience, fearing that the «art» of decision-making will be lost. It should be noted that EBM neither excludes the vital role played by experience, nor advocates the replacement of sound clinical judgment. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. EBM respects clinical skills while emphasizing the need to develop new skills in information management. Health care professional of the, whether physicians, nurses, pharmacists or others, require a basic understanding of steps for seeking out, assessing and applying the most useful information in concert with patients» preferences. Although we need new evidence daily, we usually fail to get it. The result is that both our up-to-date knowledge and our clinical performance deteriorate with time. Trying to overcome clinical entropy through traditional CME programs doesnt improve our clinical performance. A different approach to clinical learning has been shown to be effective in keeping practitioners up to date: EBM The premise of EBM is a simple one, that excellence in patient care correlates with the use of the best currently available evidence, and that phy s require @ unique set of skills which are not part of traditional medical education, in order to access and utilize this information. In EBM, Systematic Reviews are considered the best source of evidence.knowledge is extremely short. Clinicians face the difficult task of keeping track of a large amount of new and potentially important information. Although every one knows this, reports continue to demonstrate that the time devoted for reading among physicians can not by any means be enough to fill this gap. On the other hand the Continuing Medical Education (CME), as a means of keeping physicians up-to-date was growing, moving from lectures by experts to small group learning, tutorials and interactive feedback sessions. However studies have shown that CME had limited impact on modifying physician performance. A legitimate concern is that many physicians will fail to recognize new and necessary changes in practice and patient care will suffer as doctors become outdated and their performance deteriorates over time. Clinicians and health care workers face clinical questions on daily basis, regarding patient care. These could be about the interpretation of diagnostic tests, harm associated with treatments they provide, prognosis of a disease in a specific patient and the effectiveness of a preventive or therapeutic agent. Using traditional methods they get less than a third of the answers. Clinicians need simple yet scientifically sound ways to get answers to there questions. Existing research has many flaws. Archie Cochrane, the late British epidemiologist, estimated that only 15 to 20% of medical practice is based on scientific, statistically sound research. Much of our medical practice is based on either experiences of seniors or research of unknown validity. In fact, most of what we practice is based on ‘logic’ coming from knowing human biology, physiology and pathophysiology. For example, we treat arrhythmias leading to death, after coronary events in order to prevent death. We patch eyes of patients with corneal abrasions to protect them and enhance healing. However, when properly designed studies were performed looking specifically at important outcomes that matter to patients, it turned out that our logic didn't really help patients. In the first situation, randomised controlled trials showed that treating arrhythmia improved ECG’s but in increased death. Similarly, in the second case, patients with their eyes patched had longer healing durations than those treated conservatively. Studies looking at pathophysiologic outcomes are known as DOE's (Disease Oriented Evidence), whereas studies looking at important clinical outcomes are known as POEMs (Patient Oriented Evidence ‘that Matters).