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Bringing Evidence into Dju-Lyn Chng Account Development Manager. What will we cover today?. What is Evidence-Based Medicine? Why is EBM important? What is the traditional method of practicing EBM? How Clinical Evidence fits into the practice of EBM? Case Scenario.

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Bringing evidence into dju lyn chng account development manager

Bringing Evidence into

Dju-Lyn Chng

Account Development Manager


Bringing evidence into dju lyn chng account development manager

What will we cover today?

  • What is Evidence-Based Medicine?

  • Why is EBM important?

  • What is the traditional method of practicing EBM?

  • How Clinical Evidence fits into the practice of EBM?

  • Case Scenario


What is evidence based medicine

What is evidence based medicine?

“Evidence based medicine is the “conscientious, explicit and judicious use of current best evidence in making decisions about individual patients”.

Sackett DL et al 1996


Bringing evidence into dju lyn chng account development manager

Evidence Based Medicine

Evidence-based Medicine: How to teach and practice EBM. Straus SE, Richardson WS, Paul Glasziou, Haynes RB. Third Edition. Churchill Livingston: Edinburgh, 2005.


What is not evidence based medicine

What is not evidence based medicine?

Evidence based medicine does not tell healthcare professionals what to do.

Evidence based medicine identifies management options, and how well they are supported by evidence in defined populations.


Why is evidence based medicine important

Why is evidence based medicine important?

Evidence based medicine allows healthcare professionals to:

  • Identify gaps in knowledge

  • Choose effective treatments

  • Choose between effective treatments

  • Choose cost-effective treatments

  • Stop using treatments that do not work and / or that harm patients


Different levels of evidence the haynes pyramid

Different levels of evidence – The Haynes Pyramid

More time is needed as we go down the pyramid

R Brian Haynes. Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based healthcare decisions.Evidence-Based Medicine 2006;11:162-164.


Pubmed studies

PubMed: Studies: 原始研究文獻


Cochrane systematic reviews syntheses

Cochrane systematic reviews: Syntheses: 系統性綜述


Evidence based medicine journal synopses

Evidence based medicine journal: Synopses: 單篇循證文獻摘要性評述


Bmj clinical evidence summaries

BMJ Clinical Evidence: Summaries: 針對臨床問題結合證據的概述


What is bmj clinical evidence helping clinicians put evidence into practice

What is BMJ Clinical Evidence?Helping Clinicians Put Evidence Into Practice

Features

  • Provides systematic reviews offering evidence on over 3,100 interventions in over 650 clinical situations

  • Includes evidence based research sources from over 10,000 peer reviewed articles from Cochrane Library, Medline, Embase and evidence based journals

  • Produced by international panel of clinicians using rigorous searching and evaluation methods

  • Summary of the best evidence of benefits and harms of interventions

  • Updated regularly

  • Links to abstracts on PubMed


Bringing evidence into dju lyn chng account development manager

實證醫學的五個主要步驟

  • Assess

  • Ask clinical question

    提出一個可以被回答的問題

  • Acquire the evidence

    檢索文獻資料

  • Appraise the evidence

    嚴格評價證據的可信度和相關性

  • Apply the evidence

    結合實際作出臨床決策


Traditional steps of evidence based medicine

Traditional Steps of Evidence Based Medicine

Assess

Ask clinical question

Acquire the evidence

Appraise the evidence

Apply the evidence


How bmj clinical evidence relates to the steps of ebm

How BMJ Clinical Evidence relates to the steps of EBM?

  • “Ask clinical questions”

  • Review planning

  • “Apply the Evidence”

  • Combined into structured summaries

  • “Acquire the Evidence”

  • Appraise the evidence


Planning ask clinical questions

Planning – Ask clinical questions...

  • PICOT

    • Patient

    • Intervention/Risk factor

    • Comparison

    • Outcome

    • Type of Study (Systematic reviews? RCTs?)

  • Quality parameters

    • Size of study

    • Length of follow up

    • Loss to follow up


Searching acquire the evidence

Searching – Acquire the evidence...

PubMed

Medline

Cochrane Reviews

Embase

… and many more


Searching acquire the evidence1

Searching – Acquire the evidence...


Searching evidence for benefits of a treatment but what about the harms

Searching – Evidence for benefits of a treatment... But... What about the harms?

Systematic reviews often do not search for adverse effects (Ernst 2001)

RCTs are not big enough or long enough to detect many harms

Published trials including harms data can be difficult to find (Derry 2001)

Many observational studies to appraise


How bmj clinical evidence search for harms

How BMJ Clinical Evidence search for harms

Look for specific adverse effects identified at review planning

Decide which type of evidence will be appropriate

RCTs – for expected and common harms that happen soon after treatment

Unexpected, rare and delayed harms may require case-control/cohort search


Displaying the benefits and harms

Displaying the Benefits and Harms


Information categorised

Information categorised


Detailed evidence for each treatment

Detailed evidence for each treatment


Benefits

Benefits


Harms

Harms


Appraisal appraise the evidence bmj clinical evidence appraisal criteria

Appraisal – appraise the evidence…BMJ Clinical Evidence appraisal criteria


Appraisal selection of studies

Appraisal – Selection of studies

DO YOU WANT TO INCLUDE THIS ARTICLE? YES NOIF NO, INDICATE REASON FOR EXCLUSION BELOW:Irrelevant/wrong question Not RCTNot Blinded Wrong comparison Too small Wrong intervention Wrong patient group Surrogate Outcome Less than 80% follow upOther (please specify)..........................................................


Appraisal bmj clinical evidence makes the grade

Appraisal – BMJ Clinical Evidencemakes the GRADE


What is grade

What is GRADE?

Grading of

Recommendations

Assessment,

Development and

Evaluation system for grading evidence


What is grade1

What is GRADE?

  • Developed by international guideline developers

  • Explicit evaluation of the importance of outcomes

  • Explicit, comprehensive criteria for downgrading and upgrading quality of evidence ratings

  • Clear separation between quality of evidence and strength of recommendations


Grade categorisations quality of evidence

GRADE categorisations – Quality of Evidence

High:

  • Further research is very unlikely to change our confidence in the estimate of effect.

    Moderate:

  • Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

    Low:

  • Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

    Very low:

  • Any estimate of effect is very uncertain.


Grade strength of recommendations

GRADE – Strength of recommendations

Strong

  • desirable effects clearly outweigh undesirable effects, or the reverse

  • Most patients will make same decision about the treatment

    Weak

  • different patients will choose different approaches to treatment


What grade version of ce looks like

What GRADE version of CE looks like

Glossary

GRADE Table

Summary statements rewritten

Glossary links explain what GRADE scores mean

Links to GRADE table from each summary statement


Grade table

GRADE Table

Transparent explanation for why points were added/deducted

Linked to relevant references


Scoring system

Scoring system


Bmj clinical evidence updating cycle

BMJ Clinical Evidence Updating Cycle

Does it stop here?

  • Repeated every 6 to 12 months

  • Updated regularly


Bmj updates

BMJ Updates

  • Collaboration with McMaster University

  • Engages over 3,000 clinicians

  • Systematic survey of over 120 top clinical journals


Guidelines

Guidelines


Pop quiz 1

Pop Quiz 1:

  • Answer: The GRADE Table

What feature in Clinical Evidence will help you determine the quality of an evidence?


Looking back traditional steps of evidence based medicine

Looking back – Traditional Steps of Evidence Based Medicine

Assess

Ask clinical question

Acquire the evidence

Appraise the evidence

Apply the evidence


What makes a good ebm summary database

What makes a good EBM Summary Database?

  • Comprehensive literature search

  • Pre-appraised

    • Appraisal methods

    • Based around clinical questions and patient outcomes

    • Inclusion and Exclusion criteria

    • Preference for systematic reviews over individual studies

  • Regularly updated

  • Easy access and use

  • Links to original paper


Does bmj clinical evidence fit the bill

Does BMJ Clinical Evidence “fit the bill”?

  • Comprehensive literature search

  • Pre-appraised

    • Appraisal methods

    • Based around clinical questions and patient outcomes

    • Inclusion and Exclusion criteria

    • Preference for systematic reviews over individual studies

  • Regularly updated

  • Links to original paper

  • Easy access and use


Case scenario

Case Scenario:

  • You are an inexperienced junior hospital doctor. A 55 year old asthmatic man who has heart failure attends the out-patient clinic. Despite taking an ACE inhibitor his heart failure is inadequately controlled. You discuss the case with your senior who advises that you add an Angiotensin II reception blocker to his treatment.

  • 你是一名年輕的臨床醫生,接診一名55嵗男性氣喘者,同時患有心力衰竭。儘管服用血管緊張素轉化酶抑制劑 (ACE Inhibitor),但效果不明顯。你的資深同事建議加入血管緊張素II受体拮抗劑 (Angiotensin II Reception Blocker)治療。

  • You are worried, having never combined these two types of drugs before, and would like reassurance that this is a reasonable course of action…

  • 你擔心自己從沒有混合使用兩种藥物的先例,故希望找到可靠的證據。。。


Where do we start

Where do we start?


Does bmj clinical evidence fit the bill1

Does BMJ Clinical Evidence “fit the bill”?

  • Comprehensive literature search

  • Pre-appraised

    • Appraisal methods

    • Based around clinical questions and patient outcomes

    • Inclusion and Exclusion criteria

    • Preference for systematic reviews over individual studies

  • Regularly updated

  • Links to original paper

  • Easy access and use


Pop quiz 2

Pop Quiz 2:

  • Which of the following are features of Clinical Evidence?

    • Covers the benefits and harms of each intervention

    • Summarises the condition based on key questions asked by clinicians, summary and background of the condition

    • Produced by an international panel of clinicians using rigorous searching and evaluation methods

    • All of the above


Hands on exercise

Hands-On Exercise

How many references were excluded from the last update of the “Pre-eclampsia, eclampsia, and hypertension” review?

What was the search date for “Pre-eclampsia, eclampsia, and hypertension”?

What treatments have been found likely to be beneficial for varicose veins?

The search date for ear wax was June 2007. How many important studies have been published since then?


New and upcoming

New and Upcoming!

-New BMJ Evidence Centre

-Upcoming BMJ Best Practice


The new bmj evidence centre

The New BMJ Evidence Centre

The new hub of evidence-based medicine…

http://group.bmj.com/products/evidence-centre


New in january 2009

New in January 2009


What is bmj best practice

What is BMJ Best Practice ?

  • Point of Care tool / Decision Support tool

  • Combination of Evidence, Expert Opinion and Guidelines

  • Common conditions primary & secondary care

  • Structured and set by step approach

  • Summary, Basic / Background Info, Prevention, Diagnosis, Treatments, Evidence, Drugs, follow up & patient info


Key features

Key Features:

1At launch in January 2009, Best Practice will feature 500 conditions. These will be added to during the course of the year with more than 1000 conditions available by December 2009.

In-depth coverage of 1000 conditions1

Action-oriented and structured around the patient consultation

Advice on symptom evaluation, treatment approach and test ordering

International perspective, customisable for local needs

Integrated evidence from Clinical Evidence

Critical prescribing information with links to local drug formulary

Guideline summaries and expert opinion

192 patient support leaflets

Open URL Compliant


Evidence

Evidence


Evidence intervention table

Evidence > Intervention Table


Condition overviews

Condition Overviews


Differential diagnosis

Differential Diagnosis


Step by step diagnostic approach

Step-by-Step (Diagnostic Approach)


Step by step treatment approach

Step-by-Step (Treatment Approach)


Images

Images


My best practice

My Best Practice


Resource list

Resource list

  • BMJ Clinical Evidence www.clinicalevidence.com

  • BMJ Updates www.bmjupdates.com

  • Cochrane Library www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME?CRETRY=1&SRETRY=0

  • PubMed Clinical Queries www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml

  • National Guidelines Clearing House www.guidelines.gov/

  • Centre for Evidence based medicinewww.cebm.net/index.asp

  • Centre for Reviews and Disseminationwww.york.ac.uk/inst/crd

  • ScHARR www.shef.ac.uk/scharr/


Thank you

Thank you

Dju-Lyn Chng

BMJ Group

[email protected]


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