The appraisal and assimilation of scientific evidence, and its application to patient care: A key competency in the design of the professional curriculum Robert H. Roswell, M.D. Senior Associate Dean and Professor of Medicine, College of Medicine Professor of Health Administration and Policy, College of Public Health

Why EBM? Managing the medical knowledge explosion Improving patient safety and quality Controlling health care costs and enhancing efficiency

2007

Can we continue to use a traditional approach to train physicians in view of this growth? NO!

To Err is Human 44,000 to 98,000 deaths occur in the United States each year due to preventable medical errors. - Institute of Medicine, 1999

Building a Better Delivery System “an estimated thirty to forty cents of every dollar spent on health care… a half trillion dollars a year… is spent on costs associated with: overuse, underuse, misuse, duplication, system failures…and inefficiency.” - Institute of Medicine, 2005

Efficiency and Value in Health Care “Use evidence more effectively in decisions by care givers and patients… (to increase appropriate use and decrease misuse and overuse)” - Harvey Fineberg, President, IOM

21 st Century Medicine Physicians must understand "what works, why it works and who it works for." -HHS Secretary Mike Leavitt, Sept. 20, 2007

ACGME General Competencies Patient Care Medical Knowledge Practice-based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-based practice

ACGME General Competencies Patient Care Medical Knowledge Practice-based Learning and Improvement Interpersonal and Communication Skills Professionalism Systems-based practice

Practice-based Learning and Improvement: required skills Analyze own practice for needed improvements Use of evidence from scientific studies Application of research and statistical methods Use of information technology Facilitate learning of others

Towards Evidence Based Medicine Access to relevant literature Critical evaluation of quality of evidence Meta-analysis Formulation of EBM Guidelines Incorporation of EBM into Health Information Systems

JAMA. 2005;293: Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes Amit X. Garg, MD; Neill K. J. Adhikari, MD; Heather McDonald, MSc; M. Patricia Rosas- Arellano, MD, PhD; P. J. Devereaux, MD; Joseph Beyene, PhD; Justina Sam, BHSc; R. Brian Haynes, MD, PhD

JAMA. 2005;293: Methods We included English-language randomized and nonrandomized trials with a contemporaneous control group that compared patient care with a CDSS to routine care without a CDSS and evaluated clinical performance (ie, a measure of process of care) or a patient outcome.

JAMA. 2005;293: Results From 3997 screened citations, we retrieved 226 full-text articles, and 100 trials met our criteria for review.

JAMA. 2005;293: Results Practitioner performance improvement Overall 64% Diagnostic systems 40% Reminder systems 76% Disease management 62% Drug-dosing or prescribing 66%

JAMA. 2005;293: Conclusions Many CDSSs improve practitioner performance, however their effects on patient outcomes are less clear.

Summary EBM will be essential to successfully manage the continued rapid growth of medical literature EBM must be an integral part of physician training EBM offers great promise to improve care delivery and patient outcomes, while reducing health care costs