EVIDENCE-BASED MEDICINE

Dr. Gerry GormleyClinical Research RegistrarDept. 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

List several methods of how to

evaluate your performance

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?

‘The process of systematically finding, appraising and using

contemporaneous research findings as a

basis for clinical decisions’.

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?

• Medical students

• PRHOs

• SHOs

• SpRs

• Consultants

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

patients?

• Medical students

120mins

• PRHOs

10mins

• SHOs

• SpRs

• Consultants

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

patients?

• Medical students

120mins

• PRHOs

10mins

• SHOs 30mins

• SpRs 45mins

• Consultants

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? ‘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

‘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)

• 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 EXAMPLEPATIENT 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

General search strategy:-

• Define searchable question

• Select evidence resource

• Design search strategy

EVIDENCE RESOURCES

• Up-to-date text books

• Journals

• Databases print

electronic

• Consult experts

• Department of health

bulletins

EVIDENCE RESOURCES

• Up-to-date text books

• Journals

• Databases print

electronic

• Consult experts

• Department of health

bulletins

EVIDENCE RESOURCES

• Up-to-date text books

• Journals

• Databases print

electronic

• Consult experts

• Department of health

bulletins

EVIDENCE RESOURCES

• Up-to-date text books

• Journals

• Databases print

electronic

• Consult experts

• Department of health

bulletins

EVIDENCE RESOURCES

• Up-to-date text books

• Journals

• Databases print

electronic

• Consult experts

• Department of health

bulletins

COMPUTER BASED SEARCHES

• Permit evidence search in real time.

• Hierarchy of resources:

Cochrane collaboration Bandolier web siteUK Primary care EB

databaseMedlineLycos, yahoo etc.

CRITICALLY APPRAISE EVIDENCE

Hierarchy of study designs:-

• Systematic reviewMeta-analysisRCT (DB/SB)Cohort studyCase controlled studyCross sectional studyCase series

CAN YOU APPLY THIS EVIDENCE INTO CLINICAL

PRACTICE?• Can the results be extrapolated to your

patient?

• Availability of tests/treatment

• Affordability of tests/treatment

• Are there adverse risks?

• Are there alternatives?

• What are the patient preferences?

EVALUTE PERFORMANCE

Audit

Clinical efficacy

Cost analysis

Patient surveys

Prescribing / referral rates

Mortality / morbidity rates