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Educational objectives
Define EBM Learn the steps to implement EBM Apply your new knowledge! Identify barriers to EBM implementation Determine strategies to overcome those
barriers
Evidence based medicine
EBM is the integration of current best research evidence with clinical expertise and patient values
EBM shifts authoritarianism to scientific skepticism
EBM is an active process Life-long Problem based learning
History of EBM
Valid data: Randomized clinical trials rare into 1960s and beyond
“EBM” coined in 1992 – Guyatt et al @ McMaster Univ
0
500
1000
1500
2000
2500
3000
1992 2003
Overall
Ob/Gyn
“EBM” articles, PubMed
n = 6
The EBM paradigm shift
Understanding of pathophysiologic principles
Clinical experience Common sense Reliance on expert
opinion
Knowledge of pathophysiology is necessary but insufficient
Systematic approach increases certainty of diagnostic validity & management strategies
Formal rules of evidence
Strength of RecommendationsUSPSTF 2004
A. Strongly recommends that clinicians provide [the service] to eligible patients: good evidence that [the service] improves important health outcomes; benefits substantially outweigh harms.
B. Recommends that clinicians provide [this service] to eligible patients: at least fair evidence.
Strength of RecommendationsUSPSTF 2004
C. No recommendation for or against routine provision of [the service]; the balance of benefits and harms is too close to justify a general recommendation.
D. Recommends against routinely providing [the service] to asymptomatic patients.
E. Evidence is insufficient to recommend for or against routinely providing [the service].
Quality of EvidenceUSPSTF 2004
Good: Consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.
Fair: Evidence sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
Poor: Evidence insufficient to assess the effects on health outcomes.
The need for EBM
Daily need for valid information 5x/inpatients 2x/3 outpatients
Inadequacy of traditional sources – out of date or wrong
Disparity between skills and knowledge over time Time restrictions
seconds per patient max 30 min/wk
Developments which facilitate the practice of EBM
Strategies for appraising evidence (ex: meta-analysis)
Systematic reviews & concise summaries (ex: Cochrane Collaboration; practice guidelines)
Information systems to deliver data efficiently
Implementation of EBM
“EBM levels the intellectual playing field” * Everyone’s opinion counts equally –
regardless of rank Opinions valued only to the extent that they
are supported by scientific evidence When a question arises, it should be
addressed through formal review – rather than by faculty edict
* Grimes DA. OG 1995;86:451
EBM: the process
1. Convert information need into focused question2. Find the best evidence to answer the question3. Critically appraise the evidence for its validity and
clinical usefulness4. Integrate the critical appraisal with clinical expertise
and the patient’s unique circumstances5. Evaluate performance – seek ways to improve next
time
POEM trumps DOE
“ The influence of obesity and diabetes on the prevalence of macrosomia”
Ehrenberg et al
AJOG 2004;191;964
“The influence of obesity and diabetes on the risk of cesarean delivery”
Ehrenberg et al
AJOG 1004;191:969
EBM: individualization
Not all questions require the maximum work “just in time” sources for common questions
Low work; rely on someone else to do the critical analysis
ex: practice guidelines “just in case” sources for complex and
atypical casesHigh work; you must do the critical analysis
yourself
EBM: the process
1. Convert information need into focused question2. Find the best evidence to answer the question3. Critically appraise the evidence for its validity and
clinical usefulness4. Integrate the critical appraisal with clinical
expertise and the patient’s unique circumstances5. Evaluate performance – seek ways to improve
next time
Clinical case #1
A 29 yo obese white P1001 with HHT (hereditary hemorrhagic telangiectasia syndrome) and Type 2 diabetes presents for prenatal care at 14 weeks gestational age.
List 3 pertinent questions to help you provide optimal medical care to this patient.
1)
2)
3)
Well-formulated clinical questions
Background questions Ask for general
knowledge about a disorder
2 essential components Question root (who, what,
where … ) & a verb The disorder
Foreground questions Ask for specific knowledge
about pt management 3-4 essential components
Patient and/or problem Intervention Comparison intervention Clinical outcomes
Topics for well-formulated clinical questions
Clinical findings Etiology Clinical
manifestations Differential diagnosis
Diagnostic tests
Prognosis Therapy Prevention Experience &
meaning Self-improvement
Clinical case #2
A 29 yo obese white P1001 with Type 2 diabetes presents for prenatal care at 14 weeks gestational age. For the last 2 years she has taken glyburide to control her DM.
List 3 pertinent questions to help you provide optimal medical care to this patient.
1)
2)
3)
Clinical case #2
Regarding your most important question Question:
Your best answer (without searching):
Initial evidence resource:
EBM: the process
1. Convert information need into focused question2. Find the best evidence to answer the question3. Critically appraise the evidence for its validity and
clinical usefulness4. Integrate the critical appraisal with clinical
expertise and the patient’s unique circumstances5. Evaluate performance – seek ways to improve
next time
EBM on EBM
Does providing evidence based care improve outcomes for patients?
The data are not yet available! … (But that is not an excuse to ignore EBM)
Clinical case #2
A 29 yo obese white P1001 with Type 2 diabetes (Rx: glyburide) presents for prenatal care at 14 weeks gestational age.
Pertinent questions:
1) Glyburide’s mechanism of action?
2) Glyburide’s safety for pregnancy?
3) Glyburide’s efficacy during pregnancy?
Clinical case #2 most important questions
Question: Glyburide’s mechanism of action?
Your best answer (without searching): Promotes insulin secretion
Initial evidence resource: Micromedex
Clinical case #2most important questions
Question: Glyburide’s mechanism of action?
Your best answer (without searching): Promotes insulin secretion
Initial evidence resource: Micromedex
Your final answer:
Clinical case #2 most important questions
Question: Glyburide’s safety for pregnancy?
Your best answer (without searching): No great risk for teratogenesis
Initial evidence resource: PubMed search
Clinical case #2most important questions
Question: Glyburide’s safety for pregnancy?
Your best answer (without searching): No great risk for teratogenesis
Initial evidence resource: PubMed search
Your final answer:
Clinical case #2most important questions
Question: Glyburide’s efficacy during pregnancy?
Your best answer (without searching): Fairly effective BS control
Initial evidence resource: PubMed Search
Clinical case #2most important questions
Question: Glyburide’s efficacy during pregnancy?
Your best answer (without searching): Fairly effective BS control
Initial evidence resource: PubMed Search
Your final answer:
Barriers to EBM
Time Critical evaluation skills Institutional/academic chauvinism Reluctance to question authority Medical inertia Numerators of one Technological disability Lack of high quality evidence for many
clinical questions