Evidence-Based Medicine: Overview

EVIDENCE-BASEDMEDICINE

PRACTICAL

IMPLEMENTING E.B.M. IN THE E.D.

NATHAN CLEVELAND, MD, MS UNIVERSITY MEDICAL CENTER 18 JULY 2012


EVIDENCE-BASED MEDICINEPRACTICAL

TITLE

WHAT IS EBM

THE QUESTION

HISTORY

GOALS 1

PURPOSE

EBM DEFINED

ASSUMPTIONS



PURPOSEEVIDENCE

TITLE

WHAT IS EBM

THE QUESTION

HISTORY

GOALS 1

PURPOSE

EBM DEFINED

ASSUMPTIONS



PURPOSEEVIDENCE

TITLE

WHAT IS EBM

THE QUESTION

HISTORY

GOALS 1

PURPOSE

EBM DEFINED

ASSUMPTIONS

EXPERT

Esoterica [es•o•ter•i•ca]

pl. n. Greek esṓterikә; see esoteric

1. Things that are impractical or specialized.



1. History of medicine2. What is EBM?3. Why practice EBM?4. Why not practice EBM?5. How to practice EBM (theory)?6. How to practice EBM (reality)?

GOALS: Part ITHE EXPERT

EVIDENCE

WHAT IS EBM

THE QUESTION

HISTORY

GOALS 1

PURPOSE

EBM DEFINED

ASSUMPTIONS



HISTORY OF MEDICINEWHY EBM?

THE EXPERT

EVIDENCE

WHAT IS EBM

HISTORY

GOALS 1

PURPOSE

EBM DEFINED

ASSUMPTIONS




THE EXPERT

EVIDENCE

WHAT IS EBM

HISTORY

GOALS 1

PURPOSE

EBM DEFINED

ASSUMPTIONS




THE EXPERT

EVIDENCE

WHAT IS EBM

HISTORY

GOALS 1

PURPOSE

EBM DEFINED

ASSUMPTIONS



WHAT IS EVIDENCE-BASED MEDICINE?

1. DOGMA

WHY EBM?

THE EXPERT

EVIDENCE

WHAT IS EBM

HISTORY

GOALS 1

EBM DEFINED

ASSUMPTIONS



1. DOGMA

WHY EBM?

THE EXPERT

EVIDENCE

WHAT IS EBM

HISTORY

GOALS 1

EBM DEFINED

ASSUMPTIONS



WHAT IS EVIDENCE-BASED MEDICINE?

PHILOSOPHY METHOD

1. DOGMA

WHY EBM?

THE EXPERT

EVIDENCE

WHAT IS EBM

HISTORY

GOALS 1

EBM DEFINED

ASSUMPTIONS



EBM DEFINED2. GESTALT

“The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient.”

Sackett DL, et al. BMJ 1996; 312(7023):71-2

1. DOGMA

WHY EBM?

THE EXPERT

EVIDENCE

WHAT IS EBM

HISTORY

EBM DEFINED

ASSUMPTIONS



EBM DEFINEDBEST

EXTERNAL EVIDENCE

PATIENTVALUES

CLINICALEXPERTI

SE

Sackett DL, et al. Evidence-based medicine: how to practice and teach EBM. 2000

EBM

2. GESTALT

1. DOGMA

WHY EBM?

THE EXPERT

EVIDENCE

WHAT IS EBM

HISTORY

EBM DEFINED

ASSUMPTIONS



EBM DEFINEDBEST

EXTERNAL EVIDENCE

PATIENTVALUES /ACTIONS

CLINICALSTATE

Haynes, Devereaux, Guyatt. Clinical expertise in the era of evidence-based medicine and patient choice. Evid Based Med 2002;7:36-38.

CLINICAL EXPERTISE

2. GESTALT

1. DOGMA

WHY EBM?

THE EXPERT

EVIDENCE

HISTORY

EBM DEFINED

ASSUMPTIONS

WHAT IS EBM



EBM ASSUMPTIONS3. THE TARGET

Norman GR. Examining the assumptions of evidence-based medicine. J Eval Clin Pract 1999; 5(2):139-47

1. Generalizable truth exists2. Methodology matters3. Research begets practice4. Clinicians can learn EBM5. EBM leads to better care6. Widespread use of EBM

2. GESTALT

1. DOGMA

WHY EBM?

THE EXPERT

EVIDENCE

EBM DEFINED

ASSUMPTIONS

WHAT IS EBM



• No physician preference circle

• We contribute the evidence

EVIDENCE RULES

4. QUALITY

BEST EXTERNAL EVIDENCE

PATIENTVALUES /ACTIONS

CLINICALSTATE

3. THE TARGET

2. GESTALT

1. DOGMA

WHY EBM?

THE EXPERT

EVIDENCE

EBM DEFINED

ASSUMPTIONS



EVIDENCE RULES


4. QUALITY

3. THE TARGET

2. GESTALT

1. DOGMA

WHY EBM?

THE EXPERT

EVIDENCE

EBM DEFINED

ASSUMPTIONS



EXPERT PARADIGM5. COST

4. QUALITY

3. THE TARGET

2. GESTALT

1. DOGMA

WHY EBM?

THE EXPERT

EVIDENCE

ASSUMPTIONS



WHY SHOULD WE PRACTICE ACCORDING

TO THE BEST AVAILABLE EVIDENCE??

WHY NOT EBM?

5. COST

4. QUALITY

3. THE TARGET

2. GESTALT

1. DOGMA

WHY EBM?

THE EXPERT

EVIDENCE



1. Dogma sucks:

WHY EBM?

1. NO EVIDENCE

WHY NOT EBM?

5. COST

4. QUALITY

3. THE TARGET

2. GESTALT

1. DOGMA

WHY EBM?

THE EXPERT



2. You (we) are not good enough:

WHY EBM?

2. EBM LIMITS

1. NO EVIDENCE

WHY NOT EBM?

5. COST

4. QUALITY

3. THE TARGET

2. GESTALT

1. DOGMA

WHY EBM?



2. You (we) are not good enough:

WHY EBM?

http://www.healthpartners.com accessed 7/3/2012

2. EBM LIMITS

1. NO EVIDENCE

WHY NOT EBM?

5. COST

4. QUALITY

3. THE TARGET

2. GESTALT

1. DOGMA

WHY EBM?



3. The target is moving:

WHY EBM?

3. EBM FAILS

“Clinical knowledge doubles every 18 months.”

-Nick van Terheyden

2. EBM LIMITS

1. NO EVIDENCE

WHY NOT EBM?

5. COST

4. QUALITY

3. THE TARGET

2. GESTALT

1. DOGMA



4. Quality:

WHY EBM?

4. DISTRACTION

BMJ Qual Saf 2011;20(Suppl 1):i13ei17

3. EBM FAILS

2. EBM LIMITS

1. NO EVIDENCE

WHY NOT EBM?

5. COST

4. QUALITY

3. THE TARGET

2. GESTALT



5. Cost:

WHY EBM?

5. THE PATIENT

4. DISTRACTION

3. EBM FAILS

2. EBM LIMITS

1. NO EVIDENCE

WHY NOT EBM?

5. COST

4. QUALITY

3. THE TARGET



WHY NOT PRACTICE EVIDENCE-BASED

MEDICINE??

HOW EBM?

5. THE PATIENT

4. DISTRACTION

3. EBM FAILS

2. EBM LIMITS

1. NO EVIDENCE

WHY NOT EBM?

5. COST

4. QUALITY



1. There is no evidence that evidence-based medicine works.

WHY NOT EBM?

P.I.C.O.

HOW EBM?

5. THE PATIENT

4. DISTRACTION

3. EBM FAILS

2. EBM LIMITS

1. NO EVIDENCE

WHY NOT EBM?

5. COST



2. EBM sucks (sometimes):

WHY NOT EBM?

2. SEARCH

BMJ 2003;327:20–27

1. P.I.C.O.

HOW EBM?

5. THE PATIENT

4. DISTRACTION

3. EBM FAILS

2. EBM LIMITS

1. NO EVIDENCE

WHY NOT EBM?



3. EBM fails:

WHY NOT EBM?

3. APPRAISE

Cochrane Database of Systematic Reviews 2012;6:CD002766.pub2

2. SEARCH

1. P.I.C.O.

HOW EBM?

5. THE PATIENT

4. DISTRACTION

3. EBM FAILS

2. EBM LIMITS

1. NO EVIDENCE



4. Too many regulations and competing interests.

WHY NOT EBM?

4. APPLY

3. APPRAISE

2. SEARCH

1. P.I.C.O.

HOW EBM?

5. THE PATIENT

4. DISTRACTION3. EBM FAILS

2. EBM LIMITS



5. EBM ignores the patient.

WHY EBM?

HOW EBM?

4. APPLY

3. APPRAISE

2. SEARCH

1. P.I.C.O.

HOW EBM?

5. THE PATIENT

4. DISTRACTION

3. EBM FAILS



HOW DO I PRACTICE EVIDENCE-BASED

MEDICINE??

REAL EBM

HOW EBM?

4. APPLY

3. APPRAISE

2. SEARCH

1. P.I.C.O.

HOW EBM?

5. THE PATIENT

4. DISTRACTION



Step 1: Formulate a question

P – Patient / population

I – Intervention / indicator

C – Comparison / control

O – Outcome

HOW TO EBM?

SUMMARY

REAL EBM

HOW EBM?

4. APPLY

3. APPRAISE

2. SEARCH

1. P.I.C.O.

HOW EBM?

5. THE PATIENT




Step 2: Search the literature

HOW TO EBM?

BREAK

SUMMARY

REAL EBM

HOW EBM?

4. APPLY

3. APPRAISE

2. SEARCH

1. P.I.C.O.

HOW EBM?





Step 3: Critically appraise literature

HOW TO EBM?

GOALS 2

BREAK

SUMMARY

REAL EBM

HOW EBM?

4. APPLY

3. APPRAISE

2. SEARCH

1. P.I.C.O.





Step 3: Critically appraise literature

Step 4: Apply to patient

HOW TO EBM?

THE DATA

GOALS 2

BREAK

SUMMARY

REAL EBM

HOW EBM?

4. APPLY

3. APPRAISE

2. SEARCH



HOW TO EBM?

RESOURCESStep 1: Formulate a question


Step 3: Critically appraise lit

Step 4: Apply to patient

THE DATA

GOALS 2

BREAK

SUMMARY

REAL EBM

HOW EBM?

4. APPLY

3. APPRAISE



NO SERIOUSLY, HOW DO WE PRACTICE EVIDENCE-BASED MEDICINE IN AN

EMERGENCY DEPT??

RESOURCES

THE DATA

GOALS 2

BREAK

SUMMARY

REAL EBM

HOW EBM?

4. APPLY

3. APPRAISE



1. Personal commitment• Know your resources• Commit to staying up to date• Start with EB clinical

guidelines• Common / important PICOs• Use it in your dictation• Don’t forget the patient

PRACTICAL EBM

PROMPT

RESOURCES

THE DATA

GOALS 2

BREAK

SUMMARY

REAL EBM

HOW EBM?

4. APPLY



2. Group Culture• Evidence above eminence

PRACTICAL EBM

PROMPT

RESOURCES

THE DATA

GOALS 2

BREAK

SUMMARY

REAL EBM

HOW EBM?

4. APPLY



2. Group Culture• Evidence above eminence• Geek it out

PRACTICAL EBM

PROMPT

RESOURCES

THE DATA

GOALS 2

BREAK

SUMMARY

REAL EBM

HOW EBM?

4. APPLY



2. Group Culture• Evidence above eminence• Geek it out • Pass it on

PRACTICAL EBM

PROMPT

RESOURCES

THE DATA

GOALS 2

BREAK

SUMMARY

REAL EBM

HOW EBM?

4. APPLY



SUMMARY

PULL1. History of medicine2. What is EBM?3. Why practice EBM?4. Why not practice EBM?5. How to practice EBM (theory)?6. How to practice EBM (reality)?

PROMPT

RESOURCES

THE DATA

GOALS 2

BREAK

SUMMARY

REAL EBM

HOW EBM?



PUSH

PULL

PROMPT

RESOURCES

THE DATA

GOALS 2

BREAK

SUMMARY

REAL EBM


PRACTICAL





GOALS: Part IITEXTBOOKS

PUSH

PULL

PROMPT

RESOURCES

THE DATA

GOALS 2

BREAK

SUMMARY

1. Define problem-based learning

2. Review hierarchy of evidence3. Introduce prompt / push / pull4. Provide specific resources to

help you implement EBM5. EBM caveats



“Half of what you are taught as medical students will in 10 years have been shown to be wrong. And the trouble is, none of your teachers know which half.” Sydney Burwell, MD,

Dean of Harvard Medical School

FINDING THE DATA

RESOURCES

TEXTBOOKS

PUSH

PULL

PROMPT

RESOURCES

THE DATA

GOALS 2

BREAK



The solution:Problem-based learning

FINDING THE DATA

RESOURCES

TEXTBOOKS

PUSH

PULL

PROMPT

RESOURCES

THE DATA

GOALS 2

BREAK



FINDING THE DATA


RESOURCES

TEXTBOOKS

PUSH

PULL

PROMPT

RESOURCES

THE DATA

GOALS 2

BREAK



FINDING THE DATA

DiCenso A, et al. Accessing pre-appraised evidence: fine-tuning the 5S model into a 6S model. Evid Based Nurs 2009;12(4):99-101.

RESOURCES

TEXTBOOKS

PUSH

PULL

PROMPT

RESOURCES

THE DATA

GOALS 2

BREAK



1. Prompt resources

2. Pull resources

3. Push resources

EBM RESOURCES

PULL DATA

RESOURCES

TEXTBOOKS

PUSH

PULL

PROMPT

RESOURCES

THE DATA

GOALS 2



EBM RESOURCES

PUSH DATAPROMPT

PULL DATA

RESOURCES

TEXTBOOKS

PUSH

PULL

PROMPT

RESOURCES

THE DATA



EBM RESOURCES

RESOURCES

PULL

PROMPTPUSH DATA

PULL DATA

RESOURCES

TEXTBOOKS

PUSH

PULL

PROMPT

RESOURCES



EBM RESOURCES

PULL - DEMO

PUSH

PULL

PROMPTRESOURCES

PUSH DATA

PULL DATA

RESOURCES

TEXTBOOKS

PUSH

PULL

PROMPT



• Background info• Lots of expert opinion• Out of date• Not for making clinicaldecisions

TEXTBOOKS

PUSH - DEMO

PULL - DEMO

RESOURCES

PUSH DATA

PULL DATA

RESOURCES

TEXTBOOKS

PUSH

PULL



Which resources should I be using?

EBM RESOURCES

PUBMED

TEACHERATTENDINGSR RESIDENT/FELLOWJR RESIDENTINTERNMED

STUDENT

TEXTS

REVIEWS / SUMMARIES

META-ANALYSES / LARGE STUDIES

SYSTEMATIC REVIEWS

RANDOMIZED CONTROLLED TRIALS

BASIC SCIENCE RESEARCHPUSH - DEMO

PULL - DEMO

RESOURCES

PUSH DATA

PULL DATA

RESOURCES

TEXTBOOKS

PUSH



PULL RESOURCES

ANNALS EM

PUBMED

PUSH - DEMO

PULL - DEMO

RESOURCES

PUSH DATA

PULL DATA

RESOURCES

TEXTBOOKS



PULL RESOURCES• Online texts with variable

degree of critical appraisal:ANNALS EM

PUBMED

PUSH - DEMO

PULL - DEMO

RESOURCES

PUSH DATA

PULL DATA

RESOURCES

TEXTBOOKS



PULL RESOURCES• EBM Search engines:

ANNALS EM

PUBMED

PUSH - DEMO

PULL - DEMO

RESOURCES

PUSH DATA

PULL DATA

RESOURCES

TEXTBOOKS



PULL RESOURCES• EBM Synopses:

ANNALS EM

PUBMED

PUSH - DEMO

PULL - DEMO

RESOURCES

PUSH DATA

PULL DATA

RESOURCES

TEXTBOOKS



PUSH RESOURCES

EBM CAVEATS• Relevant EBM literature

sent to you as it occurs:ANNALS EM

PUBMED

PUSH - DEMO

PULL - DEMO

RESOURCES

PUSH DATA

PULL DATA

RESOURCES



EBM RESOURCES

SUMMARY

EBM CAVEATS

ANNALS EM

PUBMED

PUSH - DEMO

PULL - DEMO

RESOURCES

PUSH DATA

PULL DATA



RESOURCES

Don’t like it?Don’t know it?

Won’t use it.

SUMMARY

EBM CAVEATS

ANNALS EM

PUBMED

PUSH - DEMO

PULL - DEMO

RESOURCES

PUSH DATA

PULL DATA



PULL RESOURCESAT WORK

END

SUMMARY

EBM CAVEATS

ANNALS EM

PUBMED

PUSH - DEMO

PULL - DEMO

RESOURCES

PUSH DATA

http://www.bestbets.org/index.php

http://www.thecochranelibrary.com/view/0/index.html

http://www.guideline.gov/index.aspx



PUSH RESOURCES

SUMMARY

EBM CAVEATS

ANNALS EM

PUBMED

PUSH - DEMO

PULL - DEMO

RESOURCES

END

http://emergency-medicine.jwatch.org/



EBM RESOURCES

SUMMARY

EBM CAVEATS

ANNALS EM

PUBMED

PUSH - DEMO

PULL - DEMO

END

http://www.ncbi.nlm.nih.gov/pubmed/



EBM RESOURCES

SUMMARY

EBM CAVEATS

ANNALS EM

PUBMED

PUSH - DEMO

END



1. EBM is not litigation-based medicine

2. EBM is not efficiency-based medicine

3. EBM is not a panacea

EBM CAVEATS

SUMMARY

EBM CAVEATS

ANNALS EM

PUBMED

END



1. EBM is the dominant philosophy

2. EBM will provide the safest, most efficient, best care for patients

3. We should adopt EBM personally and as a group

BIG SUMMARY

SUMMARY

EBM CAVEATS

ANNALS EM

END



4. Clinical questions should be answered with ‘best available’

5. Be proficient in accessing data• Prompt• Pull• Push

BIG SUMMARY

SUMMARY

EBM CAVEATS

ANNALS EM

END


PRACTICAL



Health & Medicine

Evidence-Based Medicine: Overview