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