1. EBM1 EVIDENCE-BASED MEDICINE Dr. Monica Hughes Clinical Research Registrar Department General Practice

2. EBM2 EBM- WHY NOW? 1)Consolidate your expertise 2)Prepare you for your job as an autonomous practitioner responsible for making decisions 3)Significant component Final MB

3. EBM3 LEARNING OUTCOMES  Define the term EBM  Understand the components involved in EBM  Discuss the merits of available evidence resources

4. EBM4 BUYING A MOBILE PHONE How do you choose your mobile phone???? From where do you get reliable information????

5. EBM5 BUYING A MOBILE PHONE Would you trust the information you get from this salesperson????

6. EBM6 BUYING A MOBILE PHONE What about the Carphone Warehouse website?

7. EBM7 BUYING A MOBILE PHONE Would you trust what your friends say?

8. EBM8 BUYING A MOBILE PHONE What about the OFCOM website?

9. EBM9 STRAW POLL Salesperson Carphone Warehouse Website Friends Ofcom Website

10. EBM10 HOW DO WE MAKE CLINICAL DECISIONS? Toss a coin? Guess? Ask a friend? Do what your consultant tells you! Do no harm? Text books or Journals?

11. EBM11 HOW DO WE MAKE CLINICAL DECISIONS? Dogma  Policy  Experiential  Whimsical  Nihilism  This is the best way to do it This is the way we do it around here This way worked the last few times This way might work It doesn’t really matter what we do Patient deferential  Expert deferential  How would you like us to proceed? What would you do? Schools Of Thought……..

12. EBM12 WHAT IS EBM? ‘ Evidence-based medicine is the process of systematically finding, appraising and using contemporaneous research findings as the basis for clinical decision making.’ Rosenberg 1995

13. EBM13 SHIFT IN PRACTICE Traditional Approach –Quantity of clinical experience indicates Dr quality –Experience of basic science is needed for decisions –Didactic medical training is sufficient  See loads of patients, know your science and do what the consultants says

14. EBM14 SHIFT IN PRACTICE EBM Approach –Inform all our decision making from best current evidence –Optimises our decisions –Allows every practitioner to formulate identical conclusions –Accept knowledge is continually evolving –never have all the information to answer every question –Know how to find and formulate the information in context  Apply knowledge consistently and objectively

15. EBM15 SHIFT IN PRACTICE ……..WHY BOTHER? Medicine is NOT static HRT & NSAIDs Government policy Clinical governance & Patient safety GMC Duties Of A Doctor & Revalidation Increasingly informed Jo Public www. etc,

16. EBM16 SHIFT IN PRACTICE ……..WHY BOTHER? But ultimately  EBM improves health care

17. EBM17 How many minutes did you spend last week reading around your patients? Medical students PRHOs SHOs SpRs Consultants

18. EBM18 How many minutes did you spend last week reading around your patients? Medical students 120mins PRHOs SHOs SpRs Consultants

19. EBM19 Medical students 120mins PRHOs 10mins SHOs SpRs Consultants How many minutes did you spend last week reading around your patients?

20. EBM20 Medical students 120mins PRHOs 10mins SHOs 30mins SpRs Consultants How many minutes did you spend last week reading around your patients?

21. EBM21 Medical students 120mins PRHOs 10mins SHOs 30mins SpRs 45mins Consultants How many minutes did you spend last week reading around your patients?

22. EBM22 How many minutes did you spend last week reading around your patients? Medical students 120mins PRHOs 10mins SHOs 30mins SpRs 45mins Consultants 60mins

23. EBM23 ELEMENTS OF EBM ‘EBM begins and ends with patients’ EBM – The search algorithm 1) Convert patient health needs into answerable questions 2) Track down best evidence 3) Critically appraise evidence 4) Apply results to clinical practice 5) Evaluate your performance

24. EBM24 ELEMENTS OF EBM ‘EBM begins and ends with patients’ EBM – The search algorithm 1) Convert patient health needs into answerable questions

25. EBM25 Formualting Answerable questions that you can answer…. ‘Answerable questions are the backbone of practising EBM’ In practice, good questions usually include:- ‘PICO’ Patient’s clinical needs Intervention or exposure Comparison intervention (if appropriate) Clinical Outcomes (diagnosis/prognosis/therapy/event)

26. EBM26 Applying the results to clinical practice….e.g. AF John, a retired 78yr old gentleman is your last patient of the day. He has a long history of AF and is on aspirin. He says to you ‘my friend has atrial fibrillation and he is on warfarin - should I be on warfarin?’

27. EBM27 Applying the results to clinical practice….e.g. AF PatientIn patients with AF and who are >65…. Intervention….would prescribing warfarin…. Comparison….compared to aspirin …. Outcome….lead to lower mortality or morbidity? ….. Cause any increased risk?

28. EBM28 Applying the results to clinical practice…. e.g. AF Stroke Risk with AF

29. EBM29 Applying the results to clinical practice….e.g. AF Stroke Risk with AF on WarfarinStroke Risk with AF on Aspirin

30. EBM30 Can you apply this evidence into clinical practice? Can the results be extrapolated to your patient? Availability of tests/treatment Affordability of tests/treatment (NB NICE etc) Are there adverse risks? Are there alternatives? What are the patient preferences?

31. EBM31 Applying the results to clinical practice…. e.g. AF Major bleeding risk –Population prevalence: 10/1000 –Aspirin: Not significantly different to placebo –Warfarin: 15/1000 Are you going to give him warfarin? John is very unsteady on his feet and is prone to falls Are you still going to give him warfarin???

32. EBM32 ELEMENTS OF EBM ‘EBM begins and ends with patients’ EBM – The search algorithm 1) Convert patient health needs into answerable questions 2) Track down the best evidence

33. EBM33 Tracking down best evidence….. General search strategy Select evidence resource Library/databases/guidelines/colleagues Design search strategy

34. EBM34 Tracking down best evidence….. Hierarchy of evidence Systematic review Meta-analysis RCT Cohort study Prospective e.g. Doll Case controlled study -Retrospective Cross sectional study -Snapshot Case series –Rare

35. EBM35 ELEMENTS OF EBM ‘ EBM begins and ends with patients’ EBM – The search algorithm 1) Convert patient health needs into answerable questions 2) Track down the best evidence 3) Critically appraise evidence

36. EBM36 Critically appraising the evidence….

37. EBM37 ELEMENTS OF EBM ‘ EBM begins and ends with patients’ EBM – The search algorithm 1)Convert patient health needs into answerable questions 2) Track down the best evidence 3) Critically appraise evidence 4) Apply the results into clinical practice

38. EBM38 Applying results to clinical practice….

39. EBM39 Applying results to clinical practice….e.g. MI John, a retired 78yr old gentleman is your last patient of the day. He had an MI 2months ago and was told his cholesterol is normal. He says to you ‘my friend had a heart attack and is on a drug called a statin- should I be on this?’

40. EBM40 Applying results to clinical practice…e.g. MI PatientIn patients >70 who had an MI but cholesterol is normal…. Intervention….would adding a statin…. Comparison….in addition to usual care... Outcome….lead to lower mortality or morbidity

41. EBM41 Applying results to clinical practice…. e.g. MI Heart Protection Study (Lancet 2002) –Statin therapy offers a 33% reduction in further CHD events in high risk patients EVEN when cholesterol normal or low John should get the statin prescription

42. EBM42 ELEMENTS OF EBM ‘ EBM begins and ends with patients’ EBM – The search algorithm 1) Convert patient health needs into answerable questions 2) Track down the best evidence 3) Critically appraise evidence 4) Apply the results into clinical practice 5) Evaluate your performance

43. EBM43 Evaluate Performance Audit Clinical efficacy Cost analysis Patient surveys Prescribing rates Referral rates Mortality/morbidity rates

44. EBM44 ELEMENTS OF EBM…….. In Summary ‘ EBM begins and ends with patients’ EBM – The search algorithm 1) Convert patient health needs into answerable questions 2) Track down the best evidence 3) Critically appraise evidence 4) Apply the results into clinical practice 5) Evaluate your performance

45. EBM45 EVIDENCE RESOURCES HIERARCHY Most reliable ----- 1] Systematic review databases 2] Review Journals 3] EBM guidelines and textbooks 4] Medline/Electronic databases 5] Opinions, texts ---least reliable

46. EBM46 EVIDENCE RESOURCES 1. Systematic review databases: The Cochrane Library:The Cochrane Library –Best source for structured systematic reviews (SR) –Explicit search & quality criteria –Numerical data presented in standardized graphics enabling quick decisions Database of Abstracts of Reviews of Effectiveness (DARE)Database of Abstracts of Reviews of Effectiveness –SR structured abstracts –Free

47. EBM47 EVIDENCE RESOURCES …….contd 2. Review Journals: Summarises systematic reviews Offers balanced commentary on selected papers from major journals Example Evidence-Based Medicine Evidence-Based Medicine http://ebm.bmjjournals.com

48. EBM48 EVIDENCE RESOURCES ……. contd 3. EBM guidelines and textbooks: Clinical practice guidelines –The best sources rate the strength of evidence SIGN -- http://www.sign.ac.uk/SIGN http://www.sign.ac.uk/ NICE -- http://www.nice.org.uk/NICE http://www.nice.org.uk/ –Always consider external validity to your patient Evidence-based textbooks –Least detail, but most efficient source for simple queries Clinical Evidence is the best (explicit protocols)Clinical Evidence

49. EBM49 EVIDENCE RESOURCES ……. contd 4. Medline/Electronic databases: Medline –The largest biomedical literature database, but: Misses some journal articles, misclassifies others, lacks comprehensiveness in psychology & sociology Can be overwhelming if not searching selectively PubMed –is a free Medline service

50. EBM50 EVIDENCE RESOURCES …….contd 5. The least reliable: Colleagues or expert opinion, & “throw-away” journals –Convenient and fast –Often invalid, incomplete, and biased information Textbooks –Generally not systematically researched –Usually based on “expert opinion” –Most are out of date - check for recent citations

51. EBM51 Some final thoughts…….. EBM Goal –Provide BEST patient care using current BEST evidence Issues –TIME required to ‘stay current’ –Research accumulating exponentially Challenge –Make BEST use of our limited time through DEVELOP information retrieval & management skills

52. EBM52 ON-LINE STUDENT RESOURCES Available on www.qub.ac.uk/cm/gp Or www.qub.ac.uk/qol Past papers www.qub.ac.uk/fmhs/5EBMpa per.htmwww.qub.ac.uk/fmhs/5EBMpa per.htm Also see School Medicine website for further practice sample questions

53. EBM53 Thanks for your attention…….. Any Questions…………….