Introduction to EBM dr. Ryan Herardi

What is evidence-based medicine? PRESENTATION ONE 13/04/2017 What is evidence-based medicine? “Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” - Dave Sackett Patient Concerns Clinical Expertise Best research evidence EBM Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2. This definition of what EBM is and isn’t has gained wide acceptance and made it easier for us to get our points across. Introduction to Evidence-Based Practice

History In the Past In the current era, Ancient Chinese medicine Post-revolutionary Paris In the current era, named EBM in 1992 by a group led by Gordon Guyatt at McMaster University in Canada

How do we actually practice EBM

Asking Background questions Foreground questions General knowlegde about a disorder (5W + H) + (a disorder / aspect of a disorder) Foreground questions Specific knowledge about managing patients PICO

PICO P = Patient / Population / Problem I = Intervention / Indicator / Index C = Comparation (if relevant) O = Outcomes

PICO

The uses of EBM Improving outcomes for patients (no such evidence) Improving clinical communication skills Improving skills for use in finding, appraising, and implementing evidence Doing a new research ?

Types Diagnosis how to select and interpret diagnostic tests Therapy how to select treatments to offer patients that do more good than harm and that are worth the efforts and costs of using them Prognosis how to estimate the patient's likely clinical course over time and anticipate likely complications of disease Harm/Etiology how to identify causes for disease (including iatrogenic forms)

VIA methods Validity: type of study, blinded?, number of subjects?, controlled? Importance: result? Applicability: patient’s characteristic

Levels of Evidence

What do we need ?

Find Evidence

Develop a search strategy Using OR then AND to broaden then focus the search P I O Sore throat* or tonsillitis pharyngitis Antibiotic* or antibacterial* penicillin Symptom relief Symptom alleviation and and The participants might have come up with different terms but suggest these as a start off point. Explain about role of truncation * Explain that once you have lots of keywords you need to combine in different ways – OR=Broad, AND=narrow – move to next 2 slides for further illustration

pharyngitis Combine terms with OR Sore throat Pharyngitis OR sore throat – either term can be present pharyngitis Sore throat Or = would bring everything up that falls in either of the 2 circles

Combine terms with AND Antibiotics AND sore throat – both terms must be present antibiotics sore throat And – will only bring up material in the overlap between the 2 circles

PubMed demonstration www.pubmed.gov

Pubmed

Pubmed

The Cochrane Library Specialist database including articles on clinical and cost effectiveness of interventions: Systematic reviews – Cochrane Database of Systematic Reviews & DARE RCTs – Central Economic evaluations - NHSEED Free access in the UK at http://www.thecochranelibrary.com Other countries check “access options” at http://www.cochrane.org Talk about Cochrane

Practice “Practice makes perfect, but nobody's perfect, so why practice?” ― Kurt Cobain

Scenario Gerry, has had a bad throat for a few days and it’s making him feel miserable. He goes to his friendly GP wanting some antibiotics. However, his doctor isn’t sure whether there’s any benefit in prescribing them. What’s the evidence? Allow the participants to read the scenario – but you might also want to talk through it a bit. This might be an opportunity to get some interaction – ask the group to identify the PICO components before we go onto the new slide.

Example 1 Jean is a 55 year old woman who quite often crosses the Atlantic to visit her elderly mother. She tends to get swollen legs on these flights and is worried about her risk of developing deep vein thrombosis (DVT), because she has read quite a bit about this in the newspapers lately. She asks you if she would wear elastic stockings on her next trip to reduce her risk of this. Type : P I C O

Example 2 Susan is expecting her first baby in two months. She has been reading about the potential benefits and harms of giving newborn babies vitamin K injections. She is alarmed by reports that vitamin K injections in newborn babies may cause childhood leukaemia. She asks you if this is true and, if so, what the risk for her baby will be. Type : P I C O

Example 3 Julie is pregnant for the second time. She had her first baby when she was 33 and had amniocentesis to find out if the baby had Down Syndrome. The test was negative but it was not a good experience, because she did not get the result until she was 18 weeks pregnant. She is now 35 and 1 month pregnant, and asks if she can have a test that would give her an earlier result. The local hospital offers serum biochemistry plus nuchal translucency ultrasound screening as a first trimester test for Down syndrome. You winder if this combination of tests is as reliable as a conventional amniocentesis Type P I C O

Example 4 Mr Thomas, who is 58 years old, has correctly diagnosed his inguinal lump as a hernia. He visits you for confirmation of his diagnosis and information about the consequences. You mention the possibility of strangulation, and the man asks ‘How likely is that?’ You reply ‘pretty unlikely’ (which is as much as you know at the time) but say that you will try to find out more precisely. Type P I C O

Your Clinical Questions Write down one recent patient problem What is the PICO of the problem? At a recent clinic or family or your own ….