Improving Health Care with Evidence-Based Medicine Author: dr. Martin Rusnák

1. Project: TECHNICAL ASSISTANCE FOR THE DEVELOPMENT OF A CONTINUOUS QUALITY IMPROVEMENT (CQI) PROGRAMME AND ESTABLISHMENT OF A CLINICAL GOVERNANCE SYSTEM FOR THE SAINT LUCIA HEALTH SECTOR - Request 2015/365-620 – Version 1 • Improving Health Care • with • Evidence-Based Medicine • Author: dr. Martin Rusnák Implemented by: AGREE II Introduction rusnakm@icloud.com Financed by the European Union

2. Where does it all come from? • Evidence-based medicine developed from a practical application of clinical epidemiology to a philosophy of rational clinical decision making. • Epidemiology is concerned with the quantitative research of distribution, determinants & risk factors of health & disease in populations (population groups) & the application of this evidence to control (prevent & treat) disease.

3. Where does it all come from? • Modern epidemiology found out i.e. that: • There are huge geographic variations in the treatment of patients with the same health problems. • There is great uncertainty about the effects of medical therapies (only 10-20% of all medical interventions are scientifically sound, e.g. proved by controlled studies)

4. Where does it all come from? • In the 90’s: a group around David Sackett & Gordon Guyatt, McMaster University, Canada developed a concept, which does not only qualify scientists to understand and interpret research literature, but • it is the conscientious, explicit and rational use of current best evidence in making decisions about the care of individual patients.

5. Evidence Based Medicine – What it is • The practice of evidence-based medicine means integrating individual clinical expertise and patient values with the best available external clinical evidence from systematic research. • Sackett DL et al. Evidence-based medicine: What it is and what it isn‘t, BMJ 312 (1996) 71-72

6. Work-experience External evidence Doctors, Nurses, other Time of work-experience Internal evidence – Intuition

7. What does EBM provide?

8. Problems, questions Evaluation of performance The patient Individual experience & external evidence Search for best external evidence Critical appraisal und clinical applicability EBM is the conscientious, explicit and rational use of current best evidence in making decisions about the care of individual patients

9. Step 1 – Converting the need for information into an answerable question • Does mammography-screening • In women over 50 years • Compared with no screening • change mortality • By e.g.10% ? question

10. Step 1 – Converting the need for information into an answerable question • Does mammography-screening I • In women over 50 years P • Compared with no screeningC • change mortality O • By e.g.10% ? • PICO-Approach: Patients, Intervention, Control, Outcome

11. Step 2 – Search for best external evidence • Data base search (Medline,…) • Systematic reviews (Best Evidence, Cochrane reviews,…) • Other scientific articles • Experts External evidence

12. Step 2 – Search for best external evidence • Hierarchy of Evidence • Metaanalysis, systematic review • Randomised controlled trials (RCT) • Observational designs (Cohort- or case-control-studies) • Expert opinion, consensus conferences

13. Spread of the idea of evidence Evidence-belt Eminence-belt

14. Step 3 – Critically appraising that evidence for its validity, impact & applicability • Systematic reviews, RCT,… • Methodologically sound (randomisation, concealment, blinding, complete data set, ...) • Is the information valid for our patient? Validity and applicability

15. Step 4 • Integrating the critical appraisal with clinical experience & patients values Clinical experience & external evidence

16. Step 5 – Evaluation of performance Does it help my patient? Evaluation of performance

17. Practical work – Interpreting a RCT