Evidence Based Medical PracticeIntroduction :1 Evidence Based Medical PracticeIntroduction EVIDENCE BASED MEDICINE WORKING GROUP KFSH & RC 2006 Habib Bassil, MD, MPH


Goals :2 Goals Overview of medical decision-making and the traditional sources of knowledge? EBM = Evidence Based Practice How to ask an answerable question The five A’s of Evidence Based Medicine? Only basic notion of statistic needed The levels of evidence Why EBM and where to?


Clinical scenario :3 Clinical scenario Mr. M presents to your clinic for his scheduled dental extraction. He is a 60 year old gentleman coming to see you from Gizan. He is on warfarin after he underwent mitral valve replacement several years ago. As you prepare him for the procedure you ask him if he had stopped his warfarin 2 days ago and checked his INR this morning. He said that he forgot about it but did not take his warfarin yesterday and shows you the INR result done yesterday of 2.5


Different opinions :4 Different opinions The doctor: we need to reschedule the patient, extracting the tooth will cause a major bleeding The assisstant: let’s repeat the blood test now The resident: in my previous rotation we were told to never extract a tooth if the INR is more than 1.5


On what do we base Clinical Decisions? :5 On what do we base Clinical Decisions? Knowledge vs. Evidence


Slide 6:6 Where do we get knowledge? Reported Observed % % Print Source: 62 27 General/speciality textbooks 25 3 Pharmaceutical textbooks 14 9 Journals 18 7 Drug Company Information 1 1 Self Made Compendia 4 7 Human Sources 33 53 Gorman P et al. Bull Med Libr Assoc 1994; 82(2): 140-6


Slide 7:7 Expansion of the medical literature


Slide 8:8 21 5 10 1 1 2 8 7 8 12 4 3 1 1 2 8 7 2 1 1 1 2 8 1 5 15 6 Not Mentioned Routine Experimental Rare/Never Specific M M M M M M Textbook/Review Recommendations Odds Ratio (Log Scale) 0.5 1.0 2.0 Guyat, with permission Favors Treatment Favors Control RCTs Pts 1 23 2 65 3 149 4 316 7 1793 10 2544 11 2651 15 3311 17 3929 22 5452 P<.01 23 5767 27 6125 30 6346 33 6571 43 21 059 54 22 051 67 47 531 65 47 185 70 48 154 P<.001 P<.00001 Cumulative Year 1960 1965 1970 1980 1985 1990 Thrombolytic Therapy


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What is Evidence-Based Medicine? :10 What is Evidence-Based Medicine? Evidence Based Medicine is the integration of best research evidence with clinical expertise and patient values “Evidence Based Practice”


Slide 11:11 Clinical circumstances Patient preference Evidence Clinical expertise


Slide 12:12 What are the skills needed to practice evidence-based medicine? Define the question Efficient search for the evidence Appraise the evidence Apply the evidence understand; values Guyat, with permission


How do we actually practice EBM?5 A’s of EBM :13 How do we actually practice EBM?5 A’s of EBM Step 1: Ask an answerable question Step 2: Find an Article (the evidence) Step 3: Critically Appraise the evidence (validity, Impact, Applicability) Step 4: Apply Step 5: Assess


Yalla, let’s try it ! :14 Yalla, let’s try it !


Back to our scenario :15 Back to our scenario 60 y/o male with an INR of 3.0 scheduled for a tooth extraction


Slide 16:16 What are the skills needed to practice evidence-based medicine? Define the question Efficient search for the evidence Appraise the evidence Apply the evidence understand; values


Step 1: Ask an answerable question (PICO) :17 Step 1: Ask an answerable question (PICO) Population Intervention Comparison Outcome


Slide 18:18 Population: patient on warfarin undergoing tooth extraction Intervention: continuing warfarin Comparison: holding warfarin Outcome: major bleeding


An answerable question :19 An answerable question In patients on warfarin treatment and undergoing tooth extraction , does continuing warfarin (vs. d/c warfarin) increase major bleeding?


Step 2: Find an Article? :20 Step 2: Find an Article? www.pubmed.org Ovid Up-to-date


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Step 3: Appraise the Article :38 Step 3: Appraise the Article Is the study Valid? What were the results? Does it apply to my patient?


Hierarchy of Evidence :39 Hierarchy of Evidence Meta-analysis of RCTs systematic review of RCTs Individual RCT Observational studies patient-important outcomes Basic research lab, animal, human physiology Clinical experience


Step 4: Apply the evidence :40 Step 4: Apply the evidence Literature search resulted in changes to decision making in 47% of clinical queries


Step 4: Assess :41 Step 4: Assess


Why The Sudden Interest in EBM? :42 Why The Sudden Interest in EBM? Our daily need about valid information about diagnosis, therapy , prognosis.. The inadequacy of traditional sources for this information Disparity between clinical practice and up-to-date knowledge Inability to afford more than a few minutes for finding and assimilating the evidence


What made it possible? :43 What made it possible? Information systems and electronic databases Identification and application of effective strategies to search, appraise and apply evidence The creation of systematic reviews, concise summaries and creation of evidence based journals


(Perceived) Barriers to EBM :44 (Perceived) Barriers to EBM The most frequently reported barrier to implementing EBM in general practice is a perceived lack of personal time. 1986: effective literature search, undertaken at the bedside was feasible in less than 10 minutes


So, Hype or Hope? :45 So, Hype or Hope? Hope, I hope


EBMWGEvidence Based Medicine Working GroupKFSH & RC :46 EBMWGEvidence Based Medicine Working GroupKFSH & RC East Wing Conference Room Saturdays 12:30 – 13:30 hbassil@kfshrc.edu.sa


THANK YOU! :47 THANK YOU!