What Is This Thing What Is This Thing Called EBM?Called EBM?

Cleo Pappas, MLIS, AHIPCleo Pappas, MLIS, AHIP

Maureen Clark, MHS, MLISMaureen Clark, MHS, MLIS

DefinitionsDefinitions

Sackett et al define EBM as “the Sackett et al define EBM as “the integration of best research evidence with integration of best research evidence with clinical expertise and patient values”. 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 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.and Teach EBM. Edinburgh: Churchill Livingstone; 2000.

Acronyms Acronyms

EBMEBM EBPEBP EBHCEBHC EBDEBD EBSEBS

MeSHMeSH

Evidence-Based Medicine is a Medical Subject Evidence-Based Medicine is a Medical Subject Heading. Heading.

Modern Environment Demands EBMModern Environment Demands EBM

Increase in federal funding for researchIncrease in federal funding for research Explosion of medical knowledge and Explosion of medical knowledge and

article publication article publication Technological development of databases Technological development of databases

capable of holding huge datasets capable of holding huge datasets NLM creation of MedLineNLM creation of MedLine

How much effort effort is required and how How much effort effort is required and how long would it take to “translate” the long would it take to “translate” the research into clinical practice?research into clinical practice?

Explosion of Medical KnowledgeExplosion of Medical Knowledge

A 2004 study estimated it would take 29 A 2004 study estimated it would take 29 hours per weekday or 351 hours per hours per weekday or 351 hours per month for a physician to stay abreast of month for a physician to stay abreast of primary care literature. primary care literature.

Alper et al. How Much Effort Is Needed to Keep Up with the Literature Relevant for Primary Care? Journal of the 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 October; 92 (4): 429 – 37.Medical Library Association. 2004 October; 92 (4): 429 – 37.

Another definitionAnother definition

EBM is…”an evolutionary progression of EBM is…”an evolutionary progression of knowledge based on the basic and clinical knowledge based on the basic and clinical sciences and facilitated by the age of sciences and facilitated by the age of information technology.” information technology.”

Doherty, Steve. Evidence-based medicine: Arguments for and Against. Emergency Medicine Australasia 2005; Doherty, Steve. Evidence-based medicine: Arguments for and Against. Emergency Medicine Australasia 2005; 17: 307-13.17: 307-13.

Awakening to the Need For Awakening to the Need For Evidence-Based Practice Evidence-Based Practice

In 1972, Dr. Archie Cochrane publishes:

Effectiveness and Efficiency: random reflections on health services

Who Was Dr. Cochrane?Who Was Dr. Cochrane?1909: Born in Galashiels, Scotland. 1917: Father killed in the Battle of Gaza1927-30: King's College Cambridge. Honours: Natural Sciences. 1931: Research student with Dr N. Wilmerat on tissue cultures1931-34: Psychoanalysis with Theodor Reik (Vienna, Berlin)1934-6: Medical student, University College Hospital 1936: International Brigade, Spanish Civil War. 1939-46: Captain, Royal Army Medical Corps. 1941: PoW medical officer in Greece and Germany. 1947-48: Studied tuberculosis epidemiology in the US. 1948-60: Medical Research Council Pneumoconiosis Research. 1960-69: Professor of Tuberculosis and Chest Diseases, Wales. 1960-74: Dir., Medical Research Council Epidemiology Research1972: Effectiveness and Efficiency - Random Reflections on Health Services. 1974-86: Completed 20 & 30-year follow-up of Welsh miners.

What Dr. Cochrane SawWhat Dr. Cochrane Saw

A.A. The body’s innate healing powerThe body’s innate healing power

B.B. 1976, Cochrane estimated: less than 10% of 1976, Cochrane estimated: less than 10% of medical interventions objectively demonstrated medical interventions objectively demonstrated more good than harm more good than harm

C.C. Laymen had an uncritical belief in medicine’s cure Laymen had an uncritical belief in medicine’s cure for everythingfor everything

D.D. Concern: the “pursuit of a cure at all costs may Concern: the “pursuit of a cure at all costs may restrict the supply of care” restrict the supply of care”

E.E. Solution: randomized clinical trials: “open up a new Solution: randomized clinical trials: “open up a new world of evaluation and control which will… be the world of evaluation and control which will… be the key to a rational health service” key to a rational health service”

Cochrane CollaborationCochrane Collaboration

David SackettDavid Sackett

““Why on earth should you Why on earth should you take any advice from any take any advice from any of us old farts who of us old farts who (through inattention, (through inattention, greed, or simple greed, or simple incompetence) got incompetence) got academic medicine into academic medicine into the simply awful mess in the simply awful mess in which you find it today?”which you find it today?”

BMJ 2004; 329:294 (31 July)BMJ 2004; 329:294 (31 July)

Dr. David SackettDr. David Sackett

M.D. (UIC), Doctor of Science (Bern), M.D. (UIC), Doctor of Science (Bern), M.S. in Epidemiology (Harvard)M.S. in Epidemiology (Harvard)

Professor Emeritus of Clinical Professor Emeritus of Clinical Epidemiology and Biostatistics at Epidemiology and Biostatistics at McMaster University. McMaster University.

Physician-in-chief of medicine at Physician-in-chief of medicine at Chedoke-McMaster hospitalsChedoke-McMaster hospitals

Dr. David SackettDr. David Sackett

Head of the division of general Head of the division of general internal medicine at McMasterinternal medicine at McMasterProfessor of clinical epidemiology Professor of clinical epidemiology at Oxfordat OxfordFounding director of the National Founding director of the National Health Service R&D Centre for Health Service R&D Centre for Evidence-Based Medicine at Evidence-Based Medicine at OxfordOxfordCanadian Medical Hall of Fame in Canadian Medical Hall of Fame in 20002000

The ProcessThe Process

EBM begins and ends EBM begins and ends with the individual with the individual clinician treating the clinician treating the individual patient.individual patient.

What are we asking?What are we asking?

EtiologyEtiology DiagnosisDiagnosis TherapyTherapy Prognosis/HarmPrognosis/Harm

ProcessProcess

Formulating the Formulating the questionquestion

PICO PICO

PatientPatient InterventionIntervention ComparisonComparison OutcomeOutcome

PatientPatient

InterventionIntervention

ComparisonComparison

OutcomeOutcome

The ProcessThe Process

Conducting the Conducting the searchsearch

The ProcessThe Process

Appraising the Appraising the evidence - evidence -

ValidityValidity

Is there a clearly defined question?Is there a clearly defined question? Was the question focused in terms of the Was the question focused in terms of the

population group actually studies, the population group actually studies, the intervention received, and the outcomes intervention received, and the outcomes considered?considered?

Is there a control groupIs there a control group

ValidityValidity

Were the groups randomized? Were the groups randomized? Were all the patients accounted for at the Were all the patients accounted for at the

conclusion? (Intention to Treat)conclusion? (Intention to Treat) After finding a study that addresses our After finding a study that addresses our

question, the study needs to be analyzed further question, the study needs to be analyzed further in terms of its statistical quality.in terms of its statistical quality.

EBM begins and ends with the individual EBM begins and ends with the individual clinician treating the individual patient.clinician treating the individual patient.

ToolsTools

Clinical Queries in PubMedClinical Queries in PubMed Meta-analysis in PubMedMeta-analysis in PubMed Online calculatorsOnline calculators Specialized databases: Cochrane, Pier Specialized databases: Cochrane, Pier

ResourcesResources

Studying a Study and Testing a Test Studying a Study and Testing a Test (Lippincott Williams & Wilkins; 5th edition (October 1, 2004)(Lippincott Williams & Wilkins; 5th edition (October 1, 2004)

ISBN:0781745764ISBN:0781745764 ))

Evidence-based Medicine Toolkit Evidence-based Medicine Toolkit (Blackwell (Blackwell

Publishing Limited; 2 edition (April 1, 2006)Publishing Limited; 2 edition (April 1, 2006) ISBN:0727918419 ISBN:0727918419 ))

Evidence-based Medicine: How to Evidence-based Medicine: How to Practice and Teach EBM Practice and Teach EBM ((Churchill Livingstone; 3 Churchill Livingstone; 3

edition (April 29, 2005)edition (April 29, 2005) ISBN: 0443074445) ISBN: 0443074445)