Ghada Aboheimed, Msc

Review the principles of an evidence based approach to clinical practice. Appreciate the value of EBM Describe the 5 steps of evidence based medicine Know and identify the hierarchy of evidence based resources (6S) Definitions of clinical guidelines Review principles and system of developing a drug formulary.

The judicious use of evidence in decision making for individual patients. Five Steps?

1-Formulate a clear clinical question from a patient's problem. (PICO as in the DI lab) 2-Search the literature for relevant clinical articles. 3-Evaluate (critically appraise) the evidence for its validity and usefulness. Next lecture RCT evaluation 4-Implement useful findings in clinical practice. 5-Evaluate process and outcomes.

1.It requires the integration of evidence with clinical expertise and patient values Patient Concerns Best Research Evidence Clinical expertise

What is Evidence ? Consider whether these hypothetical scenarios represent clinical evidence A patient tells you that ibuprofen is the best treatment for toothache A group of specialists from the local area has decided by consensus that pravastatin should be used as the first choice for every patient who requires treatment with a statin A RCT of 3,500 people shows lower incidence of hip fracture in those treated with risedronate compared with calcium

The Hierarchy of Evidence for effectiveness Systematic reviews of RCTs, or mega RCTs Cohort studies Case-control studies Cross-sectional studies, case reports, case series Consensus/expert opinion Bias

Level of evidence Sometimes used in guidelines to identify which type of evidence informs a recommendation. For example: Evidence Level 1 (EL 1): evidence based on a systematic review or a large RCT. Evidence Level 4: consensus or opinion. EL 2 and 3 reflects the evidence type on the hierarchy in between the top and bottom.

Pick a box Google search PubMed Micromede x colleague guidelin es Pharmacot herapy book Lecture notes from college

Use a “6S” approach to EB information access

 approach for finding the best research evidence with the least amount of time and effort.  Each level of the pyramid draws on research evidence from the lower layers  searching at the top enables you to find the highest quality and most synthesized research evidence first. Evid Based Nurs 2009, 12:99-101

An electronic systems which can be sophisticated enough to link patient records and to prompt practitioners about guidelines assessment and recommendations Computerized decision support systems

1. Provide clinicians, staff, patients, and other individuals with knowledge and specific, individualized information, intelligently filtered and presented at appropriate times, to enhance clinical performance and patient outcomes. 2. variety of tools and interventions: computerized alerts and reminders, clinical guidelines, order sets, patient data reports.

 Provide an outline of management options for a given health issue.  Summaries incorporate the highest quality and most synthesized sources of research evidence.

Example:  Evidence based clinical practice guidelines  Evidence based text books  ACP PIER (physician information and education resources)  First consult  Clinical Evidence  UpToDate  DynaMed

Summarize the findings and implications of high quality systematic reviews Example  ACP Journal Club  Evidence-based medicine textbooks  DARE(Database of Abstracts of Reviews of Effects)

Are systematic reviews that provide rigorous summary of all primary research evidence that could be found relevant to a particular focused question Example: Cochrane database of Systematic Review PubMed Systematic review (clinical queries)

Provide brief summaries of results and implications of single high quality studies Example:  TRIP (Turning Research into Practice)  ACP journal Club

Original articles published about a particular focused question Example: PubMed Clinical Queries Cochrane central of clinical trials Google Scholar

Why is it important to use EBM? Assurance that decision-making is based on scientific evidence and effective practice. Ensure the retrieval of up-to-date and reliable information about what works, and its implementation.

When is it important to use EBM? To support decision making. To evaluate the effectiveness and cost benefits of health programs. To implement new health programs. To establish new policies.

Clinical guideline Formulary Drugs & Therapeutics Committees (DTCs)

Based on the best available evidence. Provide recommendations for practice about specific clinical interventions for specific patient populations. – Best available evidence = effectiveness and cost- effectiveness evidence Can be national or local. – When are local guidelines more appropriate? Examples of guidelines?

A continually updated list of medications and related information, representing the clinical judgement of physicians, pharmacists, and other experts in the diagnosis and/or treatment of disease and promotion of health. Example?

Drugs & Therapeutics Committees (DTCs) An advisory committee that is responsible for developing, managing, updating, and administering the drug formulary Membership includes: – Clinicians – Pharmacists – Other health care professionals – Finance – Clinical governance leads – Commissioners

Clinical effectiveness Safety Cost effectiveness Equity(value) Affordability

Sources of Information National Institute for Health and Care Excellence NHS Evidence Joint Formulary Committee. British National Formulary. BMJ Group & Pharmaceutical Press. index.htm Sources of useful information regarding searching and/or evidence-based practice: Centre for Evidence-Based Medicine, Oxford University ( MeReC briefings on Using Evidence to Guide Practice merec_briefing_no30.pdf and merec/mastery/mast2/resources/ merec_briefing_no30_suppl.pdf