Evidence based medicine

BY DR. BALGIS MSC. CM FM.

 The science of medicine is
continuously changing if
we do not adapt to this
change, the following
might happen;
a. We may have not give our
patient effective treatments
b. We may have wasted
precious resources.
 Old model of decision making
 The traditional model of medical education
depended on learning collection facts, principles
and rules of thumbs that would serve individual
for a professional life.
 The method; passive dissemination of information
(didactic lecture in large session halls)
 The “ Professor” or the “ Expert” become the
standard source of information for decision
making
 Problem can be answered by asking colleagues
and local expert, reading text books ( out of date
by the time they are published), or browsing
journals (but which journal should you look at)
New model of medical decision making
There is now a strong trend towards the view
that medical education should be lifelong,
oriented towards problem solving and based
on the principle that;
1. Clinical experience is important but
observations must be recorded systematically
and without bias
2. Regular reference must be made to original
literature
3. The results of studies must be critically
examined using rules of evidence before
applying it to practice
Evidence-Based
Evidence-Based Medicine
Medicine
Definition
Definition

“the
the conscientious,
conscientious,
explicit
explicit and
and judicious
judicious
use
use of
of current
current best
best
evidence
evidence in in making
making
decisions
decisions about
about the
the care
care
of
of the
the individual
individual
patient”
patient
Ways of Reaching The Truth
of Reaching The Truth

Faith — The “seductive” approach

 “Trust me”
 “In my experience”
Ways of Reaching The Truth The
Truth
It “makes sense” — logical
The “Inductive” Approach
 Based on pathophysiology

“It ought to work”

 These “ought to,” but don’t:

External fetal monitoring

Right heart catheterization
oWays of Reaching The Truthf
A Medical “Paradigm Shift”

Evidence-Based Medicine:
“The Deductive” Approach
Based on outcomes research
 “Putting it all back together”
 Demonstration that it does or doesn’t work
The
The practice
practice of
of EBM
EBM requires
requires the
the integration
integration of
of
 individual
 individual clinical
clinical expertise
expertise and
and patient
patient values
values
with
with the
the
 best
 best available
available external
external clinical
clinical evidence
evidence from
from systematic
systematic
research
research..
    
Best Clinical Evidence

Clinical Patient’s Needs/

Experience Preferences
 What evidence-based
medicine is:
• Good doctors use both individual clinical
expertise and the best available external
evidence, and neither alone is enough.
– Without the former, practice risks becoming
evidence-tyrannised, for even excellent
external evidence may be inapplicable or
inappropriate for an individual patient.
– Without the latter, practice risks becoming
rapidly out of date, to the detriment of
patients and patient-care.
The patient 1. Start with the patient -- a clinical problem or question
arises out of the care of the patient

The question 2. Construct a well built clinical question derived from the
case  and classify it into one category

The resource 3. Select the appropriate resource(s) and conduct a search

The evaluation 4. Appraise that evidence for its validity (closeness to the
truth) , importance and applicability (usefulness in clinical
practice)
The patient 5. Return to the patient – Make a clinical dicesion to apply
or not to apply the result of the study /integrate that
evidence with clinical expertise, patient factors to carry out
the dicesion
Self-evaluation 6. Evaluate your performance with this patient
Types of Questions

Diagnosis Question
Therapy
/prevention Question
A question concerning
the ability of a test to
A question concerning the effectiveness predict the likelihood of a disease
of a treatment or preventative measure

A question concerning outcome of

Harm Question
A patient with a particular condition

A question concerning the likelihood

Prognosis Question
of a therapeutic intervention to cause harm
“Best Available Clinical Evidence”

 Therapy
 Double-blind, placebo-controlled, randomized clinical trial
 Diagnosis
 Independent, blind comparison with a reference standard
 Prognosis
 Representative and well-defined prospective cohort of patients at a
similar point in the course of disease

 See Centre for Health Evidence

Type of Question Suggested best type of Study

Therapy RCT>cohort > case control > case series

Diagnosis Prospective, blind comparison to a gold standard
Etiology/Harm RCT > cohort > case control > case series
Prognosis Cohort study > case control > case series
Prevention RCT>cohort study > case control > case series
Clinical Exam Prospective, blind comparison to gold standard
Cost Economic analysis
Evidence Pyramid

Meta-Analysis

Systematic Review

Randomized Controlled Trial

Cohort studies

Case Control studies

Case Series/Case Reports

Animal research
Levels of Evidences

 (I-1) a well done systematic review of 2 or more RCTs

 (I-2) a RCT
 (II-1) a cohort study
 (II-2) a case-control study
 (II-3) a dramatic uncontrolled experiment
 (III) respected authorities, expert committees, etc..
 (IV) ...someone once told me....
 http://www.phru.org/casp/
 See also AAFP
Conducting an efficient computer-aided
literature search
 MEDLINE

 Is the largest database of publication in health-related topics and most

widely used medical bibliographic available in the market
 Covering years since 1966
 It is being maintained by US National Library of Medicine
 Indexing journals only
 ± International coverage
 It covers more than 4800 journal derived from 70 countries around the
world and 75% of the articles are in english.
 From the guru of EBM -
‘MEDLINE is the best general source of
current best evidence at present because of
its breadth and constant maintenance. Thus,
it is important to evidence-based practice
that clinicians develop and hone MEDLINE
searching skills and acquire local access.’

Evidence-based Medicine: how to practice & teach

EBM - Sackett D L et al 1998
Clinical scenario

 Patients usually come in to the clinic for problems.

Unfortunately these problem are vague and sometimes
not clearly stated.
 To state the problem clearly, you must bear in mind that
there are only three important elements that the patient
want to know
1. What their disease are
2. What treatment they should be given
3. What is the result to expect
• Before attempting to
search for the evidence
in the literature,
construct a well-built or
clearly structured
question that could be
broken into the
following four parts
Three important elements in clinical research
are baically
 PICO analysis):
 PIO analysis):
 P - Patient/Population
 P - Patient/Population
 I - Intervention
 I - Intervention
 C – Comparison
 O - Outcome
 O - Outcome

Some time the researcher

can add Method
How to do a literature search - search
techniques

 The most regular search techniques available.

1. Keywords
2. Boolean searching
3. Combining words
4. Phrase searching
5. Truncation / wildcard searching
6. Focusing a search
The Boolean Principle

 The venn diagram depicts 3 sets

 Which are designated as setA, set B, set C
 Each set has contents which are referred to elements
 The element consist of some numbers.
 Note that the different sets haveoverlapping
elements
 Boolean logic can be used to express the relationships between
the various sets in this diagram, or to identify specific elements.
 This achieved using connectives ”AND” or “OR”. The union
between set A and Set B can be expressed in Boolean logic as
A OR B
in the diagram, this would be represented by elements 1,2,3,4,5
and 6
 OR is MORE

 The union between set A and Set B

can be expressed in Boolean logic as
A OR B
in the diagram, this would be
represented by elements 1,2,3,4,5
and 6
2. The Intersect of sets A and B can be expreseed as
A AND B
in the diagram, this would be repsented by elements 2 and 3.
 Note that unions / OR tend to increase the number of elements included,
while Intersects / AND tend to do the opposite
 To make things more exciting, brackets “()” can help us use
unions and intersects in the same expression for example:
( A AND B) OR C
would refer to elements 2,3,4,6 and 7 but the similar
expressions
A AND (B OR C)
would refer to elements 2,3, and 4.
 Still too much?
• Use the most specific subject
headings
• Use focus
• Use subheadings
• Use AND
• Use limits
• Restrict textword searching to title
 Or too little?
• Use OR
• Use explode
• Use All Subheadings
• Don’t use focus
• Consider synonyms, alternative
spellings or truncation
Clinical Scenario

 Supposing a patient with hypecholesterolemia came into your clinic and asks for an anti-
cholesterol drug because he wants to avoid sudden death.
 How you formulate the problem
Types of questions

 If you stated your problem as” among

patients with hypercholesterolemia will anti-
cholesterol drug prevent sudden death’
The key concepts

 1. hypercholesterolemia
 2. Anti-cholesterol OR statin
 3 sudden death
Type these word in the MEDLINE

 Term Articles
1. Hypercholesterolemia 34.089
2. Anti-cholesterol OR statin 12.343
3. Sudden death 102.367

Naturally, I don’t have time to read thousands of articles! So I limit my serach

further to
4. #1 AND #2 AND #3 1.835
Still a lot of articles to read, so I added some limiters like focusing only on
randomized controlled trials
5. Randomized controlled trial 6.098
6. #4 AND #5 12
I scanned the titles and come up with one study to read and confident that this
study is the most recent, up todate and relevant
Clinical Question: Therapy

Does using botulism toxins improve

spastic muscle symptoms commonly
experienced by patients after a stroke?
PICO Elements

 P= stroke

 I= botulism toxins

 C= No treatment

 O= reduce spastic muscle symptoms

Building A Search

1 exp Botulinum Toxins/ 3794

2 exp Muscle Spasticity/ 1384
3 exp Cerebrovascular Accident/ 22606
4 1 and 2 and 3 43
5 limit 4 to (humans and english language and "therapy (optimized)") 18
Clinical Question: Etiology

Are lifestyle changes effective in reducing the development of diabetes mellitus for
patients with impaired glucose tolerance?
Building A Search

1 exp DIABETES MELLITUS/ 72656

2 exp Glucose Intolerance/ 2073
3 exp Life Style/ 16604
4 1 and 2 and 3 92
5 limit 4 to (humans and english language and
"etiology (optimized)") 38