INTRODUCTION TO THE

EVIDENCE BASED MEDICINE

GENERAL PRACTICE #1 DEPARTMENT

ayatemir@gmail.com

ASTANA
2018
AIMS OF THE LECTURE

• Rules
• EBM definition.
• Evidence hierarchy in EBM;
• Description of basic research types in EBM;
• EMB steps
• SR and MA
Is it the right thing that we do?
• «My students are discouraged when I tell them that
half of what you are taught in 10 years will be
recognized as erroneous. The only problem is that no
one knows what it will be like»
S. Barwell
Harvard medicine Dean (1956)
Why we need it?
- easy access to medical information;
-increasing volume of scientific papers (annually more than 10000
articles publishing in the world, MEDLINE consist of more than 18,8
mln scientific papers);
- «knowledge survival»;
- «delay effect»
- lack of resources;
- subjective factor of information assessment
How we make clinical decisions nowadays?
First approach- experience,intuition, – «like professor said…»,
«written in the textbook…», «department chief order…»,
«pharmaceutical company advertisement».

«Some clinicians for 20 years make the same mistakes and call it a clinical
experience» Noya Fabricant, amer.phisician
How we make clinical decisions nowadays?
• Second approach -logic of scientific ideas (albumin at burn
shock, antihistamine at BA, distilben at pregnancy).
• Third approach– experimental data.
Our practice
1/3 interventions and treatment procedures has proven
effectiveness, and we provide them
1/3 interventions and treatment procedures has no proven
effectiveness, but we still keep to provide them
1/3 interventions and treatment procedures has proven
effectiveness, but we don’t use them in our clinical practice
Medical errors classification and
quality problems

1. Excessive using
2. Insufficient using
3. Misusing
4. Use with an unsettled result:
treatment or intervention, the results of
which are unknown
Evidences
There is no evidence that intravenous nitroglycerin,
commonly used in intensive care units during the acute
phase of myocardial infarction, can really affect the
prognosis of this disease
There is no difference in the effectiveness of different
NSAID groups
There is no evidence that ARBs are more effective than
ACE inhibitors in preventing vascular complications
There is no evidence of the effectiveness of antiviral
drugs Arbidol, Tamiflu, Relenza in the prevention and
treatment of influenza
There is no evidence of efficacy of nootropics in the
prevention of mortality from vascular events
There is no evidence of the effectiveness of
hepatoprotectors in prolonging life expectancy in the
treatment of liver diseases
There is no evidence of efficacy of dipyridamole, trental
in the treatment of diabetic microangiopathy
There is no evidence of the effectiveness of Echinacea as
an immunomodulatory
In the western pharmaceutical reference
books there are no groups of following drugs

Hepatoprotectors
Angioprotectors
Cholagogue
Nootropics
Рассасывающие
Imuunomodulators
Examples of non-existent in the world diagnoses and
"diseases".

Neurocirculatory dystonia
Hypertensive syndrome at children (intracranial hypertension)
Intestine dysbacteriosis
Chronic bronchitis with asthmatic component
Chronic enterocolitis
 Frequently and unreasonably
presented diagnoses:
Chronic cholecystitis (95% - calculous).
Chronic pyelonephritis (without
bacterial culture of urine, using
outdated tests, based only on kidney US).
Others
Ignored or no sufficient diagnostic of very
common diseases

Hypertension (20-40% adult population).

Asthma (approximately 10% population, children – 16-
18%).
COPD (10% adults).
irritable bowel syndrome.
Depression (60% of people who visit PHC have depression).
Diabetes mellitus 2 type.
 Why?
- The
lack of a culture of critical evaluation
of scientific publications and lack of
knowledge of the EBM principles
 Barriers to practice EBM
Most practitioners do not know the principles of
critical evaluation of publications, they think that
mastering such skills is difficult.
People prefer quick and simple answers. Scientific-
based medical practice requires additional time and
effort.
There is no enough support from administration
There are many clinical situations, where are still lack
scientifically grounded evidence.
Many doctors do not have enough empowerment to
change their practice.
80% of medical publications in the world are
published in English
Implementing evidence based technologies
1601Captain Lancaster proved that lеmon juice prevents scurvy
146 years later
1747 British military navy repeated Lancaster’s study results
48 years later
1795British military navy decided to give lemon juice to all military
sailors
70 years later
1865 British merchant fleet started to give lemon juice to all sailors
Why we should study EBM?
To:
1. Wider use proven interventions in our practice
2. Learn how to search for evidence in electronic databases
3. Identify the most reliable sources of information to find
answers to questions that arise in everyday practice
4. learn how to critically evaluate information
5. Change your own practice to use the best interventions
6. Improve the quality of care provided to patients and
clients
7. develop a professional commitment to continuous
learning throughout your life
8. Be prepared for the challenges of time: a constantly
changing world
Definition of EBM

-conscientious, explicit, and judicious use

of current best evidence in making
decisions about the care of individual
patients
(1996//David Sackett, William Rosenberg, Muir Gray, Brian Haynes &
Scott Richardson. Evidence based medicine: what it is and what it isn’t
);
“EBM– integrates
clinical experience and
patient values with the Patient interests
best available research
information” EBM
David Sackett Clinical expertise
Best evidence
 EBM is not a
science
statistics
epidemiology
Study method
Form of economic analysis
mechanism to reduce costs
BUT
Way of clinical practice
Can be used for a reasonable choice of interventions
 Brief history of EBM
• 1st randomized controlled trial (streptomycin to TB treatment)
1940 y
• Concentration on process (thalidomide tragedy)
1960 y
• FDA rules established in USA 1962y
• Cochrane rise up the question about the insufficient scientific basis
1971 y
• Focus on the need for systematic reviews in the development of clinical
guidelines 1980-90 yy
The main postulate of the EBM
•Each clinical
decision must be
based on strong
scientific data!
 Sources, textbooks
• Our library:
• Kameshwar Prasad Fundamentals of EBM, 2014
• Mayer, D Essential evidence-based medicine , 2nd
Edition//Cambridge, UK, New York : Cambridge University Press, 2010
• Clinical Epidemiology: The Essentials 5th (fifth) Edition by Fletcher MD MSc, Robert,
Fletcher MD MSc, Suzanne W. published by Lippincott Williams & Wilkins (2012)
• O.S. Miettinen. Up from CLINICAL EPIDEMIOLOGY & EBM. – Springer Science +
Business Media B. V. 2011. – 199 p.
• Haroon M, Phillips R: "There is nothing like looking, if you want to find something" -
asking questions and searching for answers - the evidence based approach. Arch Dis
Child Educ Pract Ed. 2010, 95 (2): 34-39. 10.1136/adc.2009.161570.
• Schardt C, Adams MB, Owens T, Keitz S, Fontelo P: Utilization of the PICO framework
to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak.
2007, 7: 16-10.1186/1472-6947-7-16.
•THANK YOU !