Evidence Based Medicine Dr. Mansour AlZahrani SB-FM,ABFM,MRCGP[INT] Consultant and Associate professor of Family Medicine

Objectives Discuss the importance of evidence-based practice   Define ‘evidence-based practice’   Discuss the importance of evidence-based practice    Engage in evidence-based practice (including literature search)

Definition Evidence-based medicine requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances. Patient Values Clinical Expertise Best research evidence EBM Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-based medicine: how to practice and teach EBM 3d ed. London: Churchill Livingstone, 2005

Why is EBM important? Physician is taking a decision all the time. Physicians asked 2 questions for every 3 patients. Only 30% of physicians' information needs were met during the patient visit, usually by a colleague. EBM can confirm your plan but it can change it totally. Is EBM a "cook book medicine“ ?!!

Steps in Evidence Based Research Asking answerable questions Finding the best evidence Critically appraising the evidence Applying a decision Evaluation Heneghan C, Badenoch D. Evidence-based medicine toolkit. 2d ed. Malden, MA: Blackwell, 2007 5

The Answerable Question

Background questions It is all about conditions address normal human physiology and the pathophysiology associated with a medical condition. answered by standard textbooks Consist of two parts: The root question (W5H) + verb, eg. what causes ...? [W5H = who, what, when, where, why, how] Problem, eg. influenza

Examples What is type 2 diabetes mellitus? Why does this patient have polyuria? Why does this patient have numbness and pain in his/her legs? What treatment options are available?

Clinical questions Asking answerable questions – focused, searchable, clinical PICO Patient, Problem, Population (subjects) Intervention or therapy Comparison, Control Outcome (results) 9

Can You Identify PICO? In children under 6 months, how does sleeping on back compared to sleeping on the stomach in terms of risk of SIDS? In children under 6 months (P), how does sleeping on back (I) compared to sleeping on the stomach (C) in terms of risk of SIDS (O)?

Formulate PICO question Does hand washing among healthcare workers reduce hospital acquired infections?

Step 2 Finding the best evidence with which to answer the question through structured searches and understanding the literature 12

Um Ahmed is a new patient in your clinic Um Ahmed is a new patient in your clinic. She is 70 year old and has a history of congestive heart failure brought on by several myocardial infarctions.

She has been hospitalized twice within the last 6 months for worsening of heart failure. Her medications (enalapril, aspirin and simvastatin). You think she should also be taking digoxin but you are not certain if this will help keep her out of the hospitalization. You decide to research this question before her next visit.

Step 1 PICO designed question. In elderly patients with congestive heart failure, is digoxin effective in reducing the need for hospitalization?

Types of studies

Medline Over 5,000 journals indexed, with worldwide coverage The world’s largest biomedical database Over 5,000 journals indexed, with worldwide coverage Covers all aspects of biosciences and healthcare Database of 19+ million journal citations, 1950 to the present 90% are in English ; 79% have abstracts The primary component of PubMed

So What Is PubMed? PubMed is a tool to search: Produced by NCBI MEDLINE (1950 to present) Produced by NCBI National Center for Biotechnology Information, part of NLM Accessible worldwide on the Web at no charge

Accessing PubMed Directly at: http://pubmed.gov Or, National Library of Medicine’s homepage: http://www.nlm.nih.gov

Move to pubmed

Assignment

Assignment Clinical scenario: 5 yo with asthma now in severe acute asthma exacerbation. Intern gave 2x ventolin and pulmicort with good improvement. Intern asks how good is pulmicort for prevent hospitalization?

Question formulate a PICO question Do a literature review using Pubmed website Assignment should be submitted next Thursday 26/4/2018 to the module coordinator

Thank you