2. Objective What is EBM. How to apply it. How to make evidence base presentation.

3. What is evidence base medicine "using the best research evidence available, along with clinical expertise and patient values to inform decisions regarding clinical practice.“ (Sackett D, 2000)

5. BMJ. 2002 June 8; 324(7350): 1350.

6. Type of Questions. Background: This is the knowledge that usually stays the same over times (basics). Asked by what, when, why,..etc For example: definition of disease, sign and symptoms…etc. Usually we can collect this type of information from textbooks.

7. Type of Questions. Foreground: This is the knowledge that usually changes with times, modified or updated. For example: recommended treatment for certain disease. Usually we can collect this type of information from guidelines, systemic reviews and researches.

8. Difference between Textbooks and Articles. Books: Good for background questions(basics) Not updated articles: Good for foreground questions Up to date

9. Expansion of Knowledge

10. Steps to apply EBM ASSESS ASK ACQUIRE APPRAISE APPLY AND EVALUATE

11. Steps to apply EBM 1-ASSESS the patient A clinical problem or question arises from the care of the patient. ASSESS

12. Example This is a new patient who recently moved to the area to be closer to her son and his family. She is 73 years old and has a history of congestive heart failure and a left ventricular ejection fraction of 40%. She has been hospitalized twice within the last 9 months for worsening of heart failure. She is taking her medications (aspirin and b-blockers) in time and wants to stay out of the hospital. She lives alone with several cats and a canary.

13. Example She comes to you with an advertisement for a new drug (enalapril) and wants to know if this would help her. You are not certain of the evidence supporting this drug. You decide to research this question before discussing this with her during the next visit.

14. Steps to apply EBM 2- ASK the question If you search over internet in non-systematic way for certain evidence, it will take long time, but to minimize time and getting accurate result during search for evidence use this formula: ASK

15. Steps to apply EBM 2- ASK the question

16. Steps to apply EBM EXAMPLE:

17. Steps to apply EBM EXAMPLE: In elderly patients with heart failure and an ejection fraction of 40%, is enalapril effective in reducing the need for rehospitalization?

18. Example 2 Patient/Proble m Intervention Comparison Intervention Outcome Your next patient is a 72-year-old woman with osteoarthritis of the knees, accompanied by her daughter and she takes regular NASID. The daughter wants you to give her mother a prescription for one of the new COX-2 inhibitors. She has heard that they cause less GI bleeding.

19. Example 2 Patient/ProblemIntervention Comparison Intervention Outcome osteoarthritis of the knee COX-2 Inhibitor Regular NSAIDS  less GI bleeding Your next patient is a 72-year-old woman with osteoarthritis of the knees, accompanied by her daughter and she takes regular NASID. The daughter wants you to give her mother a prescription for one of the new COX-2 inhibitors. She has heard that they cause less GI bleeding.

20. Steps to apply EBM 3- ACQUIRE the evidence ACQUIRE

24. Steps to apply EBM 4- APPRAISE the evidence: Critical appraisal. Level and type of evidence. APPRAISE

25. Steps to apply EBM 4- APPRAISE the evidence: Critical appraisal: It is the process of assessment of evidence by systematically reviewing its relevance, validity and the results (out of our scope). APPRAISE

26. Type of evidence Types of sources for evidence: Primary sources: Original articles (studies): randomized clinical trial, cohort, case-control…etc. Secondary sources: Clinical practice guidelines (summaries) Evidence based abstraction journals (synopses of syntheses) Systematic reviews (syntheses)

27. Type of evidence

28. As the pyramid show, guidelines are the best and more valid evidence you can choose.

29. Level of evidence US Preventive Services Task Force (USPSTF): ranking the evidence based on the quality of it.

30. Level of evidence So if you have more than evidence it is better to choose the one with high grade and levels, if you did not do Critical appraisal.

33. Steps to apply EBM 5- APPLY and Evaluate. APPLY AND EVALUATE

34. Steps to apply EBM 5- APPLY and Evaluate. APPLY AND EVALUATE

36. How to make evidence base presentation

37. Getting the information Background: from textbook. Foreground: from articles.

38. Summarize the evidence Usually evidence range from 5 to 50 pages, you cannot add all of it. So make sure to add in your slide: title, high light of result, conclusion, summery table or graph, reference.

40. Summarize the evidence

41. Difference Journals and Pubmed.

43. Plagiarism representation of others works as one's own original work. academic dishonesty

44. summary ASSESS ASK ACQUIREAPPRAISE APPLY AND EVALUAT E

46. References: Fundamental tools for understanding and applying the medical literature and making clinical diagnoses. Includes online version of the Users' Guide to the Medical Literature (2008) and The Rational Clinical Examination (2009). Users' Guides to the Medical Literature: A Manual for Evidence- Based Clinical Practice, 2nd Edition Gordon Guyatt, Drummond Rennie, Maureen O. Meade, and Deborah J. Cook. 2008 Sharon E Straus, W. Scott Richardson, Paul Glasziou and R. Brian Haynes. Evidence-based Medicine: How to Practice and Teach EBM. 3nd edition. Elsevier, 2005. Evidence-Based Medicine Working Group Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine. JAMA 1992 Nov 4;268(17):2420-5.