An Approach to Evidence-Based

Medicine

Updated for the third edition of the Users' Guides to the Medical Literature.

Users’ Guides to the Medical Literature

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Overview

• Evidence-based medicine (EBM)

• What is EBM?
• Three principles of EBM
• Five A’s of EBM information cycle
• Clinical scenario

Users’ Guides to the Medical Literature

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Copyright © American Medical Association. All rights reserved.
What Is Evidence?
• Evidence represents the necessary basis
for effective problem solving and clinical
decision making
• Serves to enhance or diminish our
confidence in a particular claim
• EBM suggests broad definition of potential
evidence
• Any empirical observation relevant to clinical
care

Users’ Guides to the Medical Literature

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Evidence-Based Medicine
• EBM is integration of best available
evidence with clinical experience and
patient values and preferences
• Involves conscientiously working with
patients to help them resolve or cope with
issues related to physical, mental, and
social health
• EBM involves 3 fundamental principles

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Three Principles of EBM
• Optimal clinical decision making requires
awareness of the best available evidence
• Ideally from best evidence summaries
• Not all evidence is equal
• A hierarchy of evidence guides clinical
decision making
• Evidence alone is never enough
• Decision makers balance risks and benefits
of alternative management strategies in the
context of patient values and preferences

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Best Evidence Summaries
• Systematic reviews and meta-analyses
provide summaries of the best available
evidence
• Such summaries provide the best
evidence for clinicians to consider in the
context of patients’ needs and dilemmas
and their personal values and preferences

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Not All Evidence Is Equal
• Hierarchy of evidence
N-of-1 clinical trial

Multiple-patient randomized trials

Observational studies
Patient-important outcomes

Basic research
Laboratory, animal, human physiology

Clinical experience
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Not All Evidence Is Equal
• Hierarchy is not absolute
• GRADE approach allows you to rate
confidence in estimates of effects
• High
• Moderate
• Low
• Very low

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The GRADE Framework
Study Design Confidence in Estimates Lower If … Higher If …
Risk of bias
–1 Serious
High –2 Very serious
Randomized trial
Inconsistency
–1 Serious
Moderate
–2 Very serious Large effect
+1 Large
Indirectness +2 Very large
Low –1 Serious
–2 Very serious Dose response
+1 Evidence of a
Observational Imprecision gradient
study –1 Serious
–2 Very serious
Very low
Publication bias
–1 Likely
–2 Very likely

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There Is Always Evidence
• EBM approach implies clear course for
addressing patient problems
• Find highest-quality evidence available to
guide clinical decisions
• Available evidence may warrant low
confidence (eg, unsystematic
observations), but there is always
evidence
• However, evidence alone is not enough

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Evidence Alone Is Never Enough
Knowledge and skills necessary for optimal evidence-
based practice
• Diagnostic experience • In-depth physiologic
• In-depth background understanding that allows
knowledge application of evidence to the
• Effective searching skills individual
• Sensitivity and communication
• Effective critical appraisal
skills for full understanding of
skills
patient context
• Ability to define and
• Ability to elicit and understand
understand benefits and
patient values and
risks of alternatives
preferences and work with
patients in shared decision
making
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Evidence Alone Is Never Enough

Evidence Circumstances

Values

CONTEXT

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Evidence-Based Practice
• Patient management decisions are
consistent with principles of evidence-
based health care
1. Decisions will be consistent with best
evidence about benefits and risks of
available management strategies
2. Decisions will be consistent with values and
preferences of patient

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Five A’s of EBM
• Five A’s help guide clinicians through
steps of using medical literature to provide
optimal patient care

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Five A’s of EBM

Ask Act

Acquire Patient
Apply

Appraise
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Clinical Scenario
• Parents of a 14-year-old child with
persisting opaque nasal discharge seek
antibiotics

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Five A’s of EBM: Assess
• Identify the problem
• What is the central concern?
• Collapse observations
• Recognize uncertainty
• Determine need for explanation

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Five A’s of EBM: Assess
• Prioritize issues
• What decisions are made by whom?
• What might be done differently?
• What choices matter most to the patient?

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Five A’s of EBM: Assess
• Causal C’s
• Critical (urgent)
• Correctable (fixable)
• Common (frequent)
• Contextual (doable)
• Comprehensive (interest)

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Five A’s of EBM: Assess
• Objective criteria
• Prevalence of the health condition
• Cost of the health practices commonly used to
manage the condition
• Variation in health practices used to manage the
health condition
• Subjective criteria
• Burden of illness
• Potential to change health processes
• Potential to change health outcomes
• Potential to change costs
• Potential to affect ethical, legal, or social issues

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Return to the Clinical Scenario
• You just heard about treating adults with
a 3-day course of antibiotics rather than
10 days
• You wonder whether you should try the
shorter course with this patient

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Five A’s of EBM: Ask

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Five A’s of EBM: Ask
• Build the question using PICO
• Patient
• Intervention
• Comparator
• Outcome

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Framing Clinical Questions: PICO
• Patients or Population: Who are the relevant patients?
• Intervention(s) or Exposure(s): For example,
diagnostic tests, foods, drugs, surgical procedures, time,
or risk factors. What are the management strategies we
are interested in comparing or the potentially harmful
exposures about which we are concerned?
• Comparator: For issues of therapy, prevention, or harm,
there will always be both an experimental intervention or
putative harmful exposure and a control, alternative, or
comparison intervention or state to which it is compared.
• Outcomes: What are the patient-relevant consequences
of the exposures in which we are interested? We may
also be interested in the consequences to society,
including cost or resource use. It may also be important
to specify the period of interest.
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Return to the Clinical Scenario
• In adolescents with acute maxillary
sinusitis, does a 3-day course of
trimethoprim-sulfamethoxazole yield the
same cure rates as a 10-day course, with
fewer adverse effects and costs?

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5 A’s of EBM: Acquire
• Sources of evidence
• What types of evidence could exist?
• What levels of evidence might exist?
• Where is evidence likely to be found?

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From Evidence to Evidence-Based Resources

Users’ Guides to the Medical Literature

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Return to the Clinical Scenario
• Adolescents with acute maxillary sinusitis:
a question of therapy
• Seek a systematic review of randomized
clinical trials
• Seek recent evidence about common drug
medications, with attention to adverse effects
and costs
• Use best evidence
• ACP Journal Club
• McMaster PLUS
• The Cochrane Library
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Categories of EBM Resources
• Summaries and guidelines
• Preappraised research
• Nonpreappraised research
• Federated searches

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Copyright © American Medical Association. All rights reserved.
Summaries and Guidelines
• Layers
• Online summary resources
• Summary of a body of evidence at a topic level
(not limited to a question, intervention, or outcome)
• Examples: UpToDate, DynaMed
• Databases of clinical practice guidelines
• Often with actionable recommendations for clinical
decision making
• Example: Clinical Evidence Best Practice
• Regularly updated
• Example: US National Guidelines Clearinghouse

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Preappraised Research
• Layers
• Synopses of systematic reviews
• Structured abstracts or 1-page summaries of selected
systematic reviews or studies
• Systematic reviews
• Synopses of studies
• Various degrees of preappraisal
• Selection according to methodologic criteria
• Clinicians’ ratings
• Clinicians’ comments
• Experts’ structured appraisal
• Examples: ACP Journal Club, McMaster PLUS, DARE
Cochrane
• Continuously updated
• Source of evidence alerts
• Example: EvidenceUpdates
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Copyright © American Medical Association. All rights reserved.
Nonpreappraised Research
• Layers
• Filtered studies
• All primary studies with no preappraisal
• Examples: PubMed (MEDLINE), CINAHL,
CENTRAL
• Unfiltered studies
• Automatic filtering of databases for specific
study designs or clinical content
• Example: filters in Clinical Queries in PubMed

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Copyright © American Medical Association. All rights reserved.
Federated Searches
• Layers
• All layers of resources searched at once
• Search engines that retrieve evidence from
summaries and preappraised and
nonpreappraised research, and organize the
results accordingly
• Examples: ACCESSSS, Trip, SumSearch,
Epistimonikos

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Five A’s of EBM: Appraise
• Appraisal includes 2 questions
• How serious is the risk of bias?
• What are the results?

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Five A’s of EBM: Appraise
• Risk of bias
• Can I trust the information?
• Results
• Best estimates and associated certainty
• Applicability
• What do the results mean for my patient?

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Return to the Clinical Scenario
• Therapy, single randomized trial
• Did experimental and control (or comparison)
groups begin the study with a similar
prognosis?
• Did experimental and control (or comparison)
groups retain a similar prognosis after the
study started?
• What is the magnitude and precision of the
relative and absolute effects?

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Copyright © American Medical Association. All rights reserved.
Five A’s of EBM: Apply
• How can I apply the results to patient
care?
• Were the study patients similar to the patient
in my practice?
• Were all patient-important outcomes
considered?
• Are the likely treatment benefits worth the
potential harm and costs?

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Return to the Clinical Scenario
• In this family coping with acute maxillary
sinusitis, would the improved compliance
associated with a shorter treatment period
improve outcomes?

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Copyright © American Medical Association. All rights reserved.
Conclusion
• Focus inquiry on evidence that
• Is directly relevant to care
• Is the best evidence available
• Addresses knowledge gaps

Users’ Guides to the Medical Literature

JAMA | Centre for Health Evidence | The McGraw-Hill Companies, Inc.
Copyright © American Medical Association. All rights reserved.
Summary
• Key concepts
• Three principles of EBM
• Optimal clinical decision making requires
awareness of the best available evidence
• Not all evidence is equal
• Evidence alone is never enough
• Three functions of EBM
• Knowing, doing, and understanding
• Five A’s of EBM
• Assess, ask, acquire, appraise, and apply

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Copyright © American Medical Association. All rights reserved.
Original slides created by Robert Hayward, MD,
Centre for Health Evidence

Updated by Gordon Guyatt, MD,

Kate Pezalla, MA, and Annette Flanagin, RN, MA

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