evidence based decision making

Evidence based individual decision making:

Evidence based individual decision making Dr. Mohammed Abdalla Damietta general hospital 2011 EBID

EBM is not only the best research evidence :

EBM is not only the best research evidence But the clinical expertise and the patient values are also integrated

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5,000? per day 1,400 per day 55 per day A lot of

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Ia Evidence obtained from meta-analysis of randomised controlled trials. Ib Evidence obtained from at least one randomised controlled trial. IIa Evidence obtained from at least one well-designed controlled study without randomisation. IIb Evidence obtained from at least one other type of well-designed quasi-experimental study. III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies. IV Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities.

Which doctor do you want?:

Which doctor do you want? William Osler, 1900 Smart young doctor

Which doctor do you want?:

Which doctor do you want? Wise & experienced smart young doctor

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Our practice must be based on evidence from good quality research, such as RCT, or SRv.

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overall results may not be always applicable for patients seen in everyday practice. As they may differ in age, severity of illness, and presence of comorbidity.

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is the healthiest possible outcome for mother and baby . The goal

IS EBM A QURAN ?:

IS EBM A QURAN ?

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“ In God we trust ” - But all others must show data …

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Over the years, the prevailing medical wisdom can swing as dramatically as clothing fashions and gasoline prices. there are often serious disagreements … …

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Vioxx: On September 30, 2004 heart attack and stroke . Fen phen and Redux: heart or lung damage Trasylol: 2007 , increased the risk of complications or death Propulsid: withdrawn from the market . Thiomersal controversy : some parents continue to be persuaded thiomersal is linked to autism

Things To do but we don't:

Things To do but we don't

Bed rest during pregnancy for preventing miscarriage:

Bed rest during pregnancy for preventing miscarriage There is insufficient evidence of high quality that supports a policy of bed rest in order to prevent miscarriage in women with confirmed fetal viability and vaginal bleeding in first half of pregnancy. Cochrane Database of Systematic Reviews 2005 , Issue 2. Art. No.: CD003576. DOI: 10.1002/14651858.CD003576.pub2. > 80% still recommend bed rest to prevent miscarriage .

Progestogen for preventing miscarriage:

Progestogen for preventing miscarriage There is no evidence to support the routine use of progestogen to prevent miscarriage in early to mid-pregnancy. Cochrane Database of Systematic Reviews 2008 , Issue 2. Art. No.: CD003511. DOI: 10.1002/14651858.CD003511.pub2. > 80% still recommend progestrone to prevent miscarriage .

Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus:

Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus magnesium sulphate therapy has a The neuroprotective role when given to women at risk of preterm birth for the preterm fetus. > 80% still don't use it. Cochrane Database of Systematic Reviews 2009 , Issue 1. Art. No.: CD004661. DOI: 10.1002/14651858.CD004661.pub3.

Magnesium sulphate for preventing preterm birth in threatened preterm labour:

Magnesium sulphate for preventing preterm birth in threatened preterm labour Magnesium sulphate is ineffective and its use Cochrane Database of Systematic Reviews 2002 , Issue 4. Art. No.: CD001060. DOI: 10.1002/14651858.CD001060. is associated with an increased mortality for the infant.

VBAC . (Green-top 45) :

VBAC . (Green-top 45) New evidence is emerging to indicate that VBAC may not be as safe as originally thought. Jan 2007

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VBAC rate was 5% in 1985. due to recommendations favoring TOLAC By 1996 VBAC rises to 28.3% . reports of uterine rupture and other complications during TOLAC also rises consequently.. By 2006 , the VBAC rate had decreased to 8.5%. and the total cesarean delivery rate had increased to 31.1%

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In a 2010 consensus conference, (NIH) examined the safety and outcome of TOLAC and VBAC and factors associated with decreasing rates. The NIH panel recognized that TOLAC was a reasonable option for many women with a prior cesarean delivery and called on organizations to facilitate access to TOLAC. In addition, the panel recognized that “concerns over liability have a major impact on the willingness of physicians and healthcare institutions to offer [TOLAC]” .

Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality :

Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality Antenatal corticosteroids should be given to all women at risk of iatrogenic or spontaneous preterm birth up to 34+6 weeks of gestation. April 1996 Antenatal corticosteroids should be given to all women for whom an elective caesarean section is planned prior to 38+6 weeks of gestation. October 2010 > 80% did it before this recommendation. Evidence level 1++

The considerable gap between what we know from research and what is done in clinical practice is well known:

The considerable gap between what we know from research and what is done in clinical practice is well known

Aspirin or anticoagulants for treating recurrent miscarriage in women without antiphospholipid syndrome:

Aspirin or anticoagulants for treating recurrent miscarriage in women without antiphospholipid syndrome There is a paucity in studies on the efficacy and safety of aspirin and heparin in women with a history of at least two miscarriages without apparent causes other than inherited thrombophilia , the use of anticoagulants in this setting is not recommended. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD004734. DOI: 10.1002/14651858.CD004734.pub3.

Cervical assessment by ultrasound for preventing preterm delivery :

Cervical assessment by ultrasound for preventing preterm delivery Currently there is insufficient evidence to recommend routine screening of asymptomatic or symptomatic pregnant women with TVU CL. future studies should include a clear protocol for management of women based on TVU CL results, so that it can be easily evaluated and replicated. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD007235. DOI: 10.1002/14651858.CD007235.pub2

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If you received a notice from the ultrasound department that your patient— a primigravida at 21 weeks' gestation—has a cervical length of 19 mm with funneling. What are your management options if the patient reports no contractions or changes in vaginal discharge ?

the same cervix, 20 seconds apart, without and with applying pressure :

the same cervix, 20 seconds apart, without and with applying pressure funneling Dynamic change Without fundal pressure With fundal pressure

Cervical assessment by ultrasound for preventing preterm delivery :

Cervical assessment by ultrasound for preventing preterm delivery Currently there is insufficient evidence to recommend routine screening of asymptomatic or symptomatic pregnant women with TVU CL. future studies should include a clear protocol for management of women based on TVU CL results, so that it can be easily evaluated and replicated. Cochrane Database of Systematic Reviews 2009 , Issue 3. Art. No.: CD007235. DOI: 10.1002/14651858.CD007235.pub2

She has got pregnant by icsi.:

She has got pregnant by icsi. Your patient is 37 years age

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Urgent, or therapeutic, cerclage often is recommended for women who have ultrasonographic changes consistent with a progressive shortening cervix or evidence of funneling. ACOG Practice Bulletin No. 48, appeared in the November 2003 issue Therapeutic cerclage is the short answer

How to fix the evidence–practice gap:

How to fix the evidence–practice gap

conclusion:

conclusion

EBM firm adherence may blocks many things that could be useful if you're in need now. :

EBM firm adherence may blocks many things that could be useful if you're in need now. OR, the firm evidence you need now has not yet been developed - or has been developed, and hasn ' t been published yet.

( EBID )  is evidence-based medicine as practiced by the individual HEALTH CARE PROVIDER.:

( EBID ) is evidence-based medicine as practiced by the individual HEALTH CARE PROVIDER. ( Ebg ) is the practice of evidence-based medicine at the organizational or institutional LEVEL.

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With today's emphasis on evidence-based medicine, it often is difficult to decide on an appropriate action, especially when conflicting reports abound.

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Best research evidence ,Assessment of maternal risk ,quality of human judgment and decision making, are the gate for prevention of adverse pregnancy outcomes.

Thank you:

Thank you