Evidence Based Medicine. Feb 18, 2009 Dr Ayham Moty

Transcription

1 Evidence Based Medicine Feb 18, 2009 Dr Ayham Moty

2 The new paradigm, probabilistic thinking current paradigm: the biomedical model the body can be approached as an engineering problem. the new paradigm: the probabilities what can we do for people that, on average, will help most of then most of the time.

3 What is EBM? an acknowledgment that there is a hierarchy of evidence and that conclusions related to evidence from controlled experiments are accorded greater creditability than conclusion grounded in other sort of evidence brian hurwitz, BMJ 2004

4 Evidence Based Medicine we are all learners and teachers

5 goal: deliver at point of care doing the right thing in the book, what they taught me, everyone else does. finding the truth does the right thing = truth?

6 Decision Making factors that influence most of decision making: patient request pharmaceutical rep recommendation local expert based CME level 0 proficiency

7 Information mastery proficiency level 1 use the highest quality information to guide the medical decision level 2 search, evaluate and make available speciality level 1 information. <1% level 3 create original research (primary) or systematic reviews (secondary).

8 ways of reaching the truth EBM - the deductive approach based on outcomes research the basic science of clinical medicine

9 ways of reaching the truth information mastery the practical approach to implementing EBM

10 place of EBM in medicine Goal of Medicine: to relief or prevent suffering to maintain or provide hope to prevent, treat or cure disease the science of medicine; knowing the best way to prevent, treat or cure disease the art of medicine; determining, using intuition, experience and judgement, what patient need the most. combining art and science clinical jazz

11 the information business good information + learning = better patient care will our survival in the future depend on our ability to manage information better?

12 The future (already here?) clinicians will be valued by how they think and not by what they know. tow tools needed to survive in the information age a forging tools to keep up to date a hunting tools to keep up relevant and valid information when it is needed.

13 Relevance: type of evidence POE: patient oriented evidence mortality, morbidity, quality of life live longer and/or better DOE: disease oriented evidence pathophysiology, pharmacology, etiology...

14 POEM patient oriented evidence that matters if valid, will require you to change your practice.

15 determine relevance read the title and the conclusion of the abstract it is a POEM? read on to validate the study ONLY if all answer are yes

16 Validity the hard part of information mastery did the researchers find what they think they found do the results reflect the truth? how well was the study done? do the results apply to your patients

17 LOE centre for EBM, oxford: expert opinion: LOE = 5 case series: LOE = 4 case control: LOE = 3b RCT: LOE = 1b SR with homogenesity LOE = 1a

18 hunting tools Dynamed PIER TRIP Database essential evidence plus BMJ clinical evidence UTD textbooks medline

19 foraging tools overview APC journal club journal watch Dynamed alert Medscape BMJ updates

20 Reviews- three basic types summary reviews synthesis reviews translation journal

21 summary reviews broadly paints landscap validity uncertain references often out of date and inaccurate expertise of the author varies inversly with the quality of the review.

22 synthesis reviews systematic reviews or meta analysis answer one or two specific questions review primary literature with strict criteria conclusion supported by available evidence LOE =1a meta analysis achieve power not possible by single study

23 systematic reviews excellent source for hunting and foraging the cochrane library.

24 evidence linked guidelines strength of evidence indicators evidence table new SORT classification

25 strength of recommendation taxonomy (SORT) A.consistent and good quality POE. A.standard LOE for validity, POE vs DOE for evidence B. inconsistent or limited quality POE C. consensus, usual care, opinion, DOE, case series..

26 Information Mastery exercise identify a clinical question, a question can concern a treatment or a diagnosis convert this question to PICO format look up question in different evidence based sources determine the answer to your clinical question, strength of your recommendation apply the answer to the original patient situation

27 clinical question PICO format P: patient / population / problem I: intervention C: comparison O: outcome

28 P 72 year old woman with osteoarthritis of the knee and moderate hypertension 72-year-old woman with osteoarthritis of the knees and moderate hypertension, accompanied by her daughter, The daughter wants you to give her mother a prescription for one of the new COX-2 inhibitors. She has heard that they cause less GI bleeding than Ibuprofen. I C use COX-2 Inhibitor other NSAIDS O less GI bleeding pain control

29 PICO Question In a 72 year old woman with osteoarthritis of the knee, can COX-2 Inhibitor use decrease the risk of GI Bleeding compared with other NSAIDs?

30 Evidence-based sources cochrane collaboration ACP (PIER) ACP journal club Dynamed TRIP database journal of family medicine BMJ clinical evidence

31 the usefulness equation usefulness = relevance x validity work