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Bosede B Afolabi, FRCOG (UK), FWACS, FMCOG, DM Associate Professor & Consultant Obstetrician and Gynaecologist , CMUL/LUTH Consultant Obstetrician & Gynaecologist , Paelon Memorial Clinic, VI. evidence based medicine IN THE 21 ST CENTURY . Outline. What is evidence based medicine - PowerPoint PPT Presentation
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Bosede B Afolabi, FRCOG (UK), FWACS, FMCOG, DM
Associate Professor & Consultant Obstetrician and Gynaecologist, CMUL/LUTHConsultant Obstetrician & Gynaecologist, Paelon Memorial Clinic, VI
Outline
What is evidence based medicine
Role in clinical effectiveness
Five steps in evidence based practice
Quality issues and way forward
EBM - Definition
Practising health care based on real evidence
“The integration of individual clinical expertise (and experience) with the best available clinical evidence from systematic research.”
David L Sackett, W Scott Richardson, William Rosenberg, R Brian Haynes Evidence Based Medicine--How to Practice and Teach EBM, 1996
PURPOSE OF EBM
Primarily to assist in clinical decisions
EBM sounds strange as medicine practice should typically be based on evidence
Not been the case in the past
Evidence based practice. Hoffman et al, 2010.
Hoffman et al
The essence of evidence based practice All evidence is sought and examined
systematically Evidence is wherever possible
quantified Evidence is considered in All decisions
in healthcare Evidence doesn’t make decisions:
human beings do
Origin of EBM
McMaster University in Canada in 1970s
3 yr curriculum
Students had to be given skills to carry out their own learning instead of didactic teaching
EBM – precisely…
Evidence from systematic reviews
Randomised controlled trials
Meta-analysis
Randomised controlled trial
All participants are RANDOMLY allocated to groups
Have equal chances of being in either group
No bias in outcome assessment Participants are not lost to follow up Control group or placebo being
compared
Systematic Review (–not just another review)
‘review of a clearly formulated question that uses systematic and explicit methods to identify, select and critically appraise relevant research and to collect and analyse data from the studies that are included in the review. Statistical methods (meta-analysis) may or may not be used to analyse and summarise the results of the included studies’
Clark M and Oxman AD 2003. Cochrane Reviewers’ Handbook 4.2.0 Oxford: The Cochrane Library
Levels of evidence
I: At least one properly designed randomized controlled trial.
II: Well-designed controlled trials without randomization.
III: Well-designed cohort or case–control analytic studies, preferably from more than one center or research group.
IV: Opinions of respected authorities, based on clinical experience, descriptive studies, case reports or reports of expert committees
V: Expert opinion
Five steps to EBM process 1.Formulate an answerable clinical
question 2.Find the best evidence to answer it 3.Critically appraise the evidence for its
validity, impact and applicability 4.Integrate the evidence with clinical
expertise, patient values and context 5.Evaluate the efficiency &
effectiveness of the above and find ways to improve perfomance
Answerable question
PICO Patient – type of disorder or disease
Intervention – diagnostic tool, treatment
Comparison – pre-existing treatment or placebo
Outcome – what is expected
Example
A 9 year old girl has abdominal pain and diarrhoea and appendicitis is suspected. What is the best method of making the diagnosis? CT or Ultrasound?
EBM
Evidence not always available
When unavailable, use next best evidence
Least evidence is the one from experts
Role in clinical effectiveness Why should we practice EBM
Best possible effect
Least side effects may be more than others eg misoprostol versus foley catheter for induction of labour
Role in cost effectiveness The use of the most effective drug
available will ensure saving money as it will be used in a shorter time than less effective ones e.g.
Non-steroidal anti-inflammatory
drugs for dysmenorrhoea instead of buscopan
Quality
Efficacy of diagnosis, treatment – surgical and medical
Efficiency of prescription and management
Cost effectiveness
Drawbacks
Huge amount of information – no time or skills
Where to look – Good IT access essential
Evidence must be backed by experience
Experts are afraid of not knowing
Way forward
Diagnose current situation and set goals Where are we now, where do we want to be
Develop strategy and action plan
Determine method to use and ACT
Evaluate and monitor
I THANK YOU ALL FOR LISTENING
References
Evidence-Based Medicine: Tools, Techniques, Results, Harold P. Lehmann, MD PhD, Cindy Sheffield, MLS
Evidence based practice (not medicine): perspectives of an editor. Richard Wright, former editor, BMJ
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