WEEK 2: Implementing evidence in practice Flashcards
What is Evidence Based Medicine (EBM)?
Evidence based medicine is the integration of best research evidence with clinical expertise and patient values.
Discuss the THREE DIMENSIONS OF EBM.
- PATIENT
*Values, Concerns Preferences, Expectations
*Life predicament - PHYSICIAN
*Training & Experience
*Current Expertise
*Continued learning
*Demand for proof - INFORMATION
*Clinical relevance
*Proved by research
*Best up to date evidence
In 1980’s several studies in the USA demonstrated tremendous variation in the care that patients of similar background were receiving-surgical treatment of prostate cancer and cataracts and indications for a hysterectomy were extremely variable.
The investigators concluded that physicians were obviously using different standards to decide on treatment of patients.
What standards were being utilized to manage patients by doctors?
Why were there such differences in the management of these patients?
Weren’t they all reading the same textbooks and journal articles? Why wasn’t their treatment more uniform
Everyday clinicians are confronted with issues related to patient management.
EBM stems from his/her need to have proven (evidence based) therapies to offer to patients and represents a move form the usual hierarchical system of medical management to the acceptance of scientific methods as the governing force in advancing the field of medicine.
EBM is not
*Old hat or impossible to practice- everybody is not practicing it, even busy clinicians not just “academics” must find time for this if they have to give the patients the best care
*Cook Book Medicine- clinical expertise must also be incorporated with evidence
*Not restricted to randomized controlled trials and meta-analyses
Discuss the 6 steps of evidence-based medicine.
- Crafting a clinical question
Questions can be divided into two types
- Searching the medical literature
- Finding the best studies to answer the question you are asking
- Perform a critical appraisal of each study to determine the validity of the results
- Determine how the results will help you care for the patient
6.Evaluate the results in your patient/population
Discuss crafting a clinical question.
*Background- questions answered in the past and are part of the accepted medical practice
*Foreground-found at the cutting edge of medicine-issues related to recent therapies, diagnostic tests or concepts on disease causation.
As experience increases so does background knowledge.
Discuss the PICO model used to help to ask the right question.
The PICO model is used to help to ask the right question.
*Patient
Patient or population or group to which you want to apply the information.
You may not always start with a very specific definition of the patient/population.
*Intervention
The therapy or diagnostic test which you are interested in applying to your patient/population.
Can also be used in looking for etiology.
*Comparison
What is the diagnostic test, intervention, therapy that you are comparing your planned intervention against?
*Outcome
The end point that is of interest to you or your patient.
This may be tumor shrinkage, change in blood pressure, survival, risk of another event, prevention of disease.
Discuss searching the Medical Literature.
Most evidence comes from peer review journals e.g New England Journal of Medicine, British Medical Journal, The Lancet or a journal specific to the area of interest.
Non peer review journal may sometimes provide useful information.
Remember regardless of journal type no study is perfect and each study should be reviewed critically.
State the types of articles which can be used for literature review.
Types of articles
*Animal/Basic science
*Editorials/Commentaries
*Clinical Research studies
*Meta-analysis/systematic reviews
Where to find the articles of interest?
Where to find the articles of interest
Databases- MEDLINE, PUBMED, Cochrane library
Hand search of journals
Discuss how to Find the Best Studies to Answer the question you are asking.
The strategy used for searching the literature is important in order to obtain the articles in which you are interested.
The research question is very important in this process.
Discuss how to Perform a Critical Appraisal of Each Study to decide on the validity of the results.
- Identify the type of study
- Review the methodology-population selected, measurement performed, the instruments used.
- Look for possible sources of bias or error-this will be determined by the study design
- Make a decision about the validity of the results
Outline the Hierarchy of Evidence in research.
- Systematic Reviews and Meta-Analyses
- Randomized Controlled Trials (RCTs)
- Cohort Studies
- Case-Control Studies, Case Series and Case Reports.
- Background information/ expert opinion
Discuss how to determine how the results will help you care for your patient.
This combines the art with the science of medicine (requires discretion)- requires the integration of individual clinical expertise with the best available external evidence from systematic research.
Discuss how to evaluate the results in your patient/population.
May require a study in order to explore the effectiveness of an intervention on the patient or the population under consideration.
State the advantages of evidence based medicine.
*Clinicians update knowledge base routinely
*Improved understanding of research methods
*Physicians become more critical in use of data
*Increased confidence in management of decisions
*Increased computer literacy, data search technology
*Better reading habits
*Integrates medicals education, research and clinical expertise
State the disadvantages of evidence based medicine.
*Time consuming
*Information overload
*Time to learn and practice
*Time may be needed for team to conferencing, planning and review
