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EVIDENCE-BASED MEDICINE. Dr. Gerry Gormley Clinical Research Registrar Dept. of General Practice QUB. OBJECTIVES. Define the term EBM Understand the components involved in EBM Describe how to develop an ‘answerable question’ List several resources of evidence

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evidence based medicine

EVIDENCE-BASED MEDICINE

Dr. Gerry Gormley

Clinical Research Registrar

Dept. of General Practice

QUB

objectives
OBJECTIVES
  • Define the term EBM
  • Understand the components involved in EBM
  • Describe how to develop an ‘answerable question’
  • List several resources of evidence
  • List several methods of how to evaluate your performance
how do we make clinical decisions
How do we make clinical decisions?
  • Toss coins
  • Guess
  • "Do no harm." (Hippocrates)
  • Ask colleagues
  • Text books?
  • Browse journals
  • Searching bibliographic databases
what is ebm
What is EBM?

‘The process of systematically finding, appraising and using contemporaneous research findings as a basis for clinical decisions’.

why bother
WHY BOTHER?
  • New evidence is being produced every day which could make major changes in the way that we care for our patients.
  • Clinical governance / Revalidation.
  • Without keeping up-to-date our clinical performance may deteriorate.
  • EBM has been shown to keep doctors up to date and ultimately improve health care.
  • GMC regulations.
  • General public have greater access to health care information eg the web, media etc.
how many minutes a week did you spend last week reading around your patients
How many minutes a week did you spend last week reading around your patients?
  • Medical students
  • PRHOs
  • SHOs
  • SpRs
  • Consultants
how many minutes a week did you spend last week reading around your patients1
How many minutes a week did you spend last week reading around your patients?
  • Medical students 120mins
  • PRHOs
  • SHOs
  • SpRs
  • Consultants
how many minutes a week did you spend last week reading around your patients2
How many minutes a week did you spend last week reading around your patients?
  • Medical students 120mins
  • PRHOs 10mins
  • SHOs
  • SpRs
  • Consultants
how many minutes a week did you spend last week reading around your patients3
How many minutes a week did you spend last week reading around your patients?
  • Medical students 120mins
  • PRHOs 10mins
  • SHOs 30mins
  • SpRs
  • Consultants
how many minutes a week did you spend last week reading around your patients4
How many minutes a week did you spend last week reading around your patients?
  • Medical students 120mins
  • PRHOs 10mins
  • SHOs 30mins
  • SpRs 45mins
  • Consultants
how many minutes a week did you spend last week reading around your patients5
How many minutes a week did you spend last week reading around your patients?
  • Medical students 120mins
  • PRHOs 10mins
  • SHOs 30mins
  • SpRs 45mins
  • Consultants 60mins
what are the important elements of ebm
WHAT ARE THE IMPORTANT ELEMENTS OF EBM?

‘EBM begins and ends with patients’

1) Convert patient health care needs into answerable questions.

2) Track down the best evidence.

3) Critically appraise evidence.

4) Apply the results into clinical practice.

5) Evaluate your performance.

ask clinical questions that you can answer
ASK CLINICAL QUESTIONS THAT YOU CAN ANSWER

‘Answerable questions are the backbone of practising EBM’

In practice, good questions usually include:-

  • Patient’s clinical needs
  • Intervention(s)
  • comparison intervention
  • clinical outcome(s)
slide14
John, a retired 78yr old gentleman is your last patient of the day. He has a long history of AF and asks you ‘my friend has atrial fibrillation and he is on warfarin - should I be on warfarin?’
element example
ELEMENT EXAMPLE

PATIENT In patients with

AF and who are >65….

INTERVENTION ….would adding

warfarin….

COMPARSION ….when compared with

aspirin ….

OUTCOME ….lead to lower mortality or morbidity from VTE. Is this enough to be worth the increased risk of bleeding?

evidence search
EVIDENCE SEARCH

General search strategy:-

  • Define searchable question
  • Select evidence resource
  • Design search strategy
evidence resources
EVIDENCE RESOURCES
  • Up-to-date text books
  • Journals
  • Databases print

electronic

  • Consult experts
  • Department of health bulletins
evidence resources1
EVIDENCE RESOURCES
  • Up-to-date text books
  • Journals
  • Databases print

electronic

  • Consult experts
  • Department of health bulletins
evidence resources2
EVIDENCE RESOURCES
  • Up-to-date text books
  • Journals
  • Databases print

electronic

  • Consult experts
  • Department of health bulletins
evidence resources3
EVIDENCE RESOURCES
  • Up-to-date text books
  • Journals
  • Databases print

electronic

  • Consult experts
  • Department of health bulletins
evidence resources4
EVIDENCE RESOURCES
  • Up-to-date text books
  • Journals
  • Databases print

electronic

  • Consult experts
  • Department of health bulletins
computer based searches
COMPUTER BASED SEARCHES
  • Permit evidence search in real time.
  • Hierarchy of resources:

Cochrane collaboration

Bandolier web site

UK Primary care EB database

Medline

Lycos, yahoo etc.

critically appraise evidence
CRITICALLY APPRAISE EVIDENCE

Hierarchy of study designs:-

  • Systematic review

Meta-analysis

RCT (DB/SB)

Cohort study

Case controlled study

Cross sectional study

Case series

can you apply this evidence into clinical practice
CAN YOU APPLY THIS EVIDENCE INTO CLINICAL PRACTICE?
  • Can the results be extrapolated to your patient?
  • Availabilityof tests/treatment
  • Affordabilityof tests/treatment
  • Are there adverse risks?
  • Are there alternatives?
  • What are the patient preferences?
evalute performance
EVALUTE PERFORMANCE

Audit

Clinical efficacy

Cost analysis

Patient surveys

Prescribing / referral rates

Mortality / morbidity rates