1. What Is This Thing Called EBM?
Cleo Pappas, MLIS, AHIP
Maureen Clark, MHS, MLIS

2. Definitions
Sackett et al define EBM as “the integration of best research evidence with clinical expertise and patient values”.
Sackett D L, Straus S E, Richardson W S, Rosenberg W Haynes R B. Evidence-based Medicine: How to Practice and Teach EBM. Edinburgh: Churchill Livingstone; 2000.

3. Acronyms
EBM
EBP
EBHC
EBD
EBS

4. MeSH Evidence-Based Medicine is a Medical Subject Heading.
The process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions. Evidence-based medicine asks questions, finds and appraises the relevant data, and harnesses that information for everyday clinical practice. Evidence-based medicine follows four steps: formulate a clear clinical question from a patient's problem; search the literature for relevant clinical articles; evaluate (critically appraise) the evidence for its validity and usefulness; implement useful findings in clinical practice. The term "evidence based medicine" (no hyphen) was coined at McMaster Medical School in Canada in the 1980's to label this clinical learning strategy, which people at the school had been developing for over a decade. (From BMJ 1995;310:1122) Year introduced: 1997

5. Modern Environment Demands EBM
Increase in federal funding for research
Explosion of medical knowledge and article publication
Technological development of databases capable of holding huge datasets
NLM creation of MedLine
“From 1957 to 1963, the NIH budget increased by an average of 40% annually.”[i]
[i] Perry GJ, Kronenfeld MR. Evidence-Based Practice: A New Paradigm Brings New Opportunities for Health Sciences Librarians. Medical Reference Services Quarterly. 2005; 24 (4): 1-16.
Medline is the ibliographic database and computerized counterpart of the print Index Medicus.[i] [i] National Library of Medicine. The Basics of Searching MEDLINE. Bethesda, Maryland: National Library of Medicine; 1989.

6. How much effort effort is required and how long would it take to “translate” the research into clinical practice?
. “Studies show that it takes an average of 17 years to implement clinical research studies in daily practice, a remarkably slow and inefficient practice.” [i]Second, the sheer volume of publication is prohibitive. Alper et al stated in their study to determine how much effort would be needed to keep up with primary care literature , “Adjustment for journal publication frequency yielded an estimate of 7,287 articles monthly that would need to be considered to comprehensively and systematically update the primary care knowledgebase.” [ii] Furthermore, an ACP Jou Journal Club article quoted Cochrane Collaboration personnel estimating that it would take 30 years to synthesize existing trials into systematic reviews. [i]
[i] Mallett S, Clarke M. How Many Cochrane Reviews are Needed to Cover Existing Evidence on the Effects of Health Care Interventions? ACP Journal Club. 2003; 139 :A11 as quoted in Perry G J, Kronenfeld M R. Evidence-Based Practice: A New Paradigm Brings New Opportunities for Health Sciences Librarians. Medical Reference Services Quarterly. 2005; 24 (4):1-16.
[i] Alper et al. How Much Effort Is Needed to Keep Up with the Literature Relevant for Primary Care? Journal of the Medical Library Association. 2004; 92 (4): 429 – 437. quoting Balas EA. Information Systems Can Prevent Errors and Improve Quality. Journal Am Med Inform Assoc. 2001; 8:
[ii] Alper et al. How Much Effort Is Needed to Keep Up with the Literature Relevant for Primary Care? Journal of the Medical Library Association. 2004; 92 (4): 429 – 37.

7. Explosion of Medical Knowledge
A 2004 study estimated it would take 29 hours per weekday or 351 hours per month for a physician to stay abreast of primary care literature.
Alper et al. How Much Effort Is Needed to Keep Up with the Literature Relevant for Primary Care? Journal of the Medical Library Association October; 92 (4): 429 – 37.
“Studies show that it

8. Another definition
EBM is…”an evolutionary progression of knowledge based on the basic and clinical sciences and facilitated by the age of information technology.”
Doherty, Steve. Evidence-based medicine: Arguments for and Against. Emergency Medicine Australasia 2005; 17:

9. Awakening to the Need For Evidence-Based Practice
In 1972, Dr. Archie Cochrane publishes:
Effectiveness and Efficiency: random reflections on health services
“The 1972 publication of Archie Cochrane’s now classic treatise, Effectiveness and Efficiency, was a fundamental event in the genesis of health services research. Cochrane was one of the first to advance the notion that health services must be evaluated on the basis of scientific evidence rather than on clinical impression, anecdotal experience, ‘expert’ opinion, or tradition.” Dickersin and Manheimer, 1998.

10. Who Was Dr. Cochrane? 1909: Born in Galashiels, Scotland.
1917: Father killed in the Battle of Gaza
: King's College Cambridge. Honours: Natural Sciences.
1931: Research student with Dr N. Wilmerat on tissue cultures
: Psychoanalysis with Theodor Reik (Vienna, Berlin)
1934-6: Medical student, University College Hospital
1936: International Brigade, Spanish Civil War.
: Captain, Royal Army Medical Corps.
1941: PoW medical officer in Greece and Germany.
: Studied tuberculosis epidemiology in the US.
: Medical Research Council Pneumoconiosis Research.
: Professor of Tuberculosis and Chest Diseases, Wales.
: Dir., Medical Research Council Epidemiology Research
1972: Effectiveness and Efficiency - Random Reflections on Health Services.
: Completed 20 & 30-year follow-up of Welsh miners.

11. What Dr. Cochrane Saw The body’s innate healing power
1976, Cochrane estimated: less than 10% of medical interventions objectively demonstrated more good than harm
Laymen had an uncritical belief in medicine’s cure for everything
Concern: the “pursuit of a cure at all costs may restrict the supply of care”
Solution: randomized clinical trials: “open up a new world of evaluation and control which will… be the key to a rational health service”
A. During WW2, Cochrane was assigned 20,000 patients with diphtheria, typhoid, and other serious diseases. Although Cochrane had very little by way of medicine to treat his patients and had expected many to die, only 4 patients – and these were from gunshot wounds.
B. Cochrane’s war experiences helped him realize the body’s marvelous powers to repair itself and brought him to question the “perceived benefit” of therapies versus their actual benefit.
Dickersin and Manheimer, 1998.
C. In Effectiveness and Efficiency, Cochrane wrote:
[there was a] a widespread belief that for every symptom or group of symptoms there was a bottle of medicine, a pill, an operation, or some other therapy which would at least help…The patient expected the doctor to do something to help him: the more the better. The doctor wanted to help, and he could think of some new drug he had not tried (ably abettede by the pharmaceutical companies) or of some new diagnostic test (ably assisted by medical research) he had not tried out.”
D. During the early days of the National Health Service in Britain saw a great escalation of in diagnostic and therapy interventions, and he feared drastic inflation in medical costs.
E. Cochrane believed that the randomized clinical trial could reliably evaluate healthcare and thus could lead to the transformation of the National Health Service. Services that were harmful, not effective, or not cost effective would be eliminated , and those that were meritorious but under used would be promoted. “Dickersin and Manheimer, 1998.

12. Cochrane Collaboration
Established in Oxford, England, the Cochrane Collaboration has over 10,000 people from over 80 countries working to contribute reviews electronically to what is now known as the Cochrane Library. [i]
[i] Volmink J, Siegfried N, Robertson K, Gulmezoglu AM. Research synthesis and dissemination as a bridge to knowledge management: the Cochrane Collaboration. Bull World Health Organ Oct; 82(10):

13. David Sackett
“Why on earth should you take any advice from any of us old farts who (through inattention, greed, or simple incompetence) got academic medicine into the simply awful mess in which you find it today?”
BMJ 2004; 329:294 (31 July)
David Sackett is one of the founding fathers of academic medical instruction in evidence-based medicine.

14. Dr. David Sackett
M.D. (UIC), Doctor of Science (Bern), M.S. in Epidemiology (Harvard)
Professor Emeritus of Clinical Epidemiology and Biostatistics at McMaster University.
Physician-in-chief of medicine at Chedoke-McMaster hospitals

15. Dr. David Sackett
Head of the division of general internal medicine at McMaster
Professor of clinical epidemiology at Oxford
Founding director of the National Health Service R&D Centre for Evidence-Based Medicine at Oxford
Canadian Medical Hall of Fame in 2000

16. The Process
EBM begins and ends with the individual clinician treating the individual patient.

17. What are we asking? Etiology Diagnosis Therapy Prognosis/Harm
Etiology: Used with diseases for causative agents including microorganisms and includes environmental and social factors and personal habits as contributing factors. It includes pathogenesis.
Diagnoisis: The determination of the nature of a disease or condition, or the distinguishing of one disease or condition from another. Assessment may be made through physical examination, laboratory tests, or the likes. Computerized programs may be used to enhance the decision-making process.
Therapy: Procedures concerned with the remedial treatment or prevention of diseases
Prognosis
A prediction of the probable outcome of a disease based on a individual's condition and the usual course of the disease as seen in similar situations.
Harm: The probability that an event will occur. It encompasses a variety of measures of the probability of a generally unfavorable outcome.

18. Process Formulating the question
Determine what kind of information you are seeking: diagnosis, prognosis, therapy, harm/ etiology,

19. PICO Patient Intervention Comparison Outcome
By encouraging us to focus on the major concepts needed for our search, the PICO format helps to create a focused search.

20. Patient How would I describe a group of patients similar to mine?
Demographics – age – prior exposure to disease – co-morbidity – presenting condition or symptoms

21. Intervention
What main treatment am I considering?

22. Comparison
What else am I considering: another form of therapy or no therapy or placebo??

23. Outcome
What do I wish to accomplish?

24. The Process Conducting the search Refer to the PICO
Choose the database you wish to search: PubMed, Embase, Cinahl,
Develop a list of search terms (keywords and subject headings)
Consider any limits you wish to apply such as age, sex, human subjects, core journals, years of publication.
Run the search

25. The Process Appraising the evidence -
There is a different process of appraisal for each of the types of questions that we ask, eg therapy, diagnosis, etc
The issues examined in all of the questions include:
Is the study valid?
Are the results important?
Does it relate to my patient?
Is it feasible for me to apply this in my situation?

26. Validity Is there a clearly defined question?
Was the question focused in terms of the population group actually studies, the intervention received, and the outcomes considered?
Is there a control group
What are the hallmarks of a valid study?
Is there a clearly defined question?
Was the question focused in terms of the population grouop actually studies, the intervention received, and the outcomes considered?
Is there a control group
Were the groups randomized?
Were all the patients accounted for at the conclusion?
After finding a study that addresses our question, the study needs to be analyzed further in terms of its statistical quality.

27. Validity Were the groups randomized?
Were all the patients accounted for at the conclusion? (Intention to Treat)
After finding a study that addresses our question, the study needs to be analyzed further in terms of its statistical quality.

28. EBM begins and ends with the individual clinician treating the individual patient.
The clinician uses the information from the study.
The clinician then evaluates the findings of the study in the context of the individual patient.

29. Tools Clinical Queries in PubMed Meta-analysis in PubMed
Online calculators
Specialized databases: Cochrane, Pier

30. Resources
Studying a Study and Testing a Test (Lippincott Williams & Wilkins; 5th edition (October 1, 2004) ISBN: )
Evidence-based Medicine Toolkit (Blackwell Publishing Limited; 2 edition (April 1, 2006) ISBN: )
Evidence-based Medicine: How to Practice and Teach EBM (Churchill Livingstone; 3 edition (April 29, 2005) ISBN: )