Implementation of Evidence Based Medicine in Clinical Teaching and Practices Pisake Lumbiganon, MD, MS (Penn) Professor of Ob & Gyn President, Royal Thai College of Obstetricians and Gynecologists Convenor, Cochrane Thailand Director, WHO Collaborating Centre on Research Synthesis in Reproductive Health Faculty of Medicine Khon Kaen University, Thailand 11/8/2017 Professor Pisake Lumbiganon 1
Conflict of Interest None 11/8/2017 Professor Pisake Lumbiganon 2
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08/11/60 Professor Pisake Lumbiganon Faculty of Medicine, KKU 4
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Clinical question PICO P = Population I = Intervention C = Comparison O = Outcomes 11/8/2017 Professor Pisake Lumbiganon 6
Clinical question Is rapid negative pressure application as effective and safe as stepwise method? 11/8/2017 Professor Pisake Lumbiganon 7
How can we get evidences? Asking teachers Reading textbook Finding guidelines Attending scientific conferences Attending workshops Searching and reviewing papers Conducting research 08/11/60 Professor Pisake Lumbiganon Faculty of Medicine, KKU 8
Quality of Evidence Ia. Research synthesis of RCT Ib. At least one properly designed RCT IIa. At least one well designed controlled trial without randomization IIb. At least one well-designed cohort study III. Evidence obtained from case control or descriptive studies IV. Opinion of respected authorities. [National Institute for Health and Care Excellence (NICE), 2004] 11/8/2017 Professor Pisake Lumbiganon 9
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What is Cochrane evidence and how can it help you? For 20 years, Cochrane has produced systematic reviews of primary research in human health care and health policy, These are internationally recognized as the highest standard in evidence-based health care resources. 11/8/2017 Professor Pisake Lumbiganon 12
What are Cochrane Systematic reviews? They investigate the effects of interventions for prevention, treatment, and rehabilitation. They also assess the accuracy of a diagnostic test for a given condition in a specific patient group and setting. They are published online in the Cochrane Library. 11/8/2017 Professor Pisake Lumbiganon 13
What are Cochrane Systematic reviews? Each systematic review addresses a clearly formulated question; for example: Can antibiotics help in alleviating the symptoms of a sore throat? 11/8/2017 Professor Pisake Lumbiganon 14
To answer this question We search for and collate all the existing primary research on a topic that meets certain criteria; Then we assess it using stringent guidelines, to establish whether or not there is conclusive evidence about a specific treatment. 11/8/2017 Professor Pisake Lumbiganon 15
What are Cochrane Systematic reviews? Cochrane Reviews are peer reviewed and dynamic; We update them regularly to incorporate new research. This ensures that you can base treatment decisions on the most up-to-date and reliable evidence. 11/8/2017 Professor Pisake Lumbiganon 16
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Steps of a Cochrane systematic review STEP 1: formulate the question STEP 2: put together a team and register the title STEP 3: write a protocol STEP 4: locate and select studies STEP 5: assess studies for risk of bias STEP 6: retrieve data STEP 7: analyse and present results STEP 8: interpret results and write review STEP 9: improve and update review 11/8/2017 The Thai Cochrane Network 32
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Systematic review Included one trial involving 94 women. Duration of vacuum procedure was reduced in rapid application group - 6.10 minutes ( 95% confidence interval -8.83 to -3.37) There were no significant differences in Maternal and fetal morbidity Not enough evidence to recommend (Suwannachat B 2008) 11/8/2017 Professor Pisake Lumbiganon 34
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What should we do next? Randomized controlled trial Sample size : 660 Multi-centre 11/8/2017 Professor Pisake Lumbiganon 36
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What is evidence based? The process of systemically: finding, appraising, and using research findings as the basis for clinical decisions. [National Institute for Health and Care Excellence (NICE), 2004] 11/8/2017 Professor Pisake Lumbiganon 50
What is Evidence-based clinical practice? Evidence-based clinical practice therefore involves integrating: individual clinical practice and the best available evidence from research with patient preferences [National Institute for Health and Care Excellence (NICE), 2004] 11/8/2017 Professor Pisake Lumbiganon 51
Archie Cochrane 1979 It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomized controlled trials. 08/11/60 Professor Pisake Lumbiganon Faculty of Medicine, KKU 52
Quality of Evidence I. Evidence obtained from at least one properly designed randomized controlled trial II-1. Evidence obtained from well designed controlled trial without randomization II-2. Evidence obtained from well-designed cohort or case control studies, preferably from more than one center or research group II-3. Evidence obtained from multiple time series with or without intervention III. Opinion of respected authorities. 08/11/60 Professor Pisake Lumbiganon Faculty of Medicine, KKU 53
Randomized controlled trials New intervention Yes No Population at risk R Outcomes Yes Standard intervention No 08/11/60 Professor Pisake Lumbiganon Faculty of Medicine, KKU 54
The problems Health personnel need updated information Textbooks are out of date sooner Journals are disorganized and limited Too much information ( good and bad ) Time limitation Knowledge and performance deteriorates 08/11/60 Professor Pisake Lumbiganon Faculty of Medicine, KKU 55
The Slippery Slope Knowledge of current best care............... r = -0.54 p<0.001.............. CEBM web site: http://cebm.jr2.ox.ac.uk/ years since graduation 08/11/60 Professor Pisake Lumbiganon Faculty of Medicine, KKU 56
Research findings Research synthesis Clinical practice guideline Audit 08/11/60 Professor Pisake Lumbiganon Faculty of Medicine, KKU 57
Research synthesis The results of a particular research study cannot be interpreted with any confidence unless they have been considered together with the results of other studies addressing the same or similar questions Research synthesis is the process through which two or more research studies are assessed with the objective of summarizing the evidence relating to a particular question. 08/11/60 Professor Pisake Lumbiganon Faculty of Medicine, KKU 58
Research synthesis is needed not only to reflect the cumulative nature of science, but also because: the volume of research is overwhelming the quality of research is very variable access to reports of research is haphazard, and often biased # most studies are too small 08/11/60 Professor Pisake Lumbiganon Faculty of Medicine, KKU 59
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Life-long learning Routine to Research Clinical question (PICO) Literature search Systematic (Cochrane review) Comprehensive search Risk of bias assessment Data synthesis and interpretation Evidence generation Appropriate study design Collaboration (multicentre study) Update evidence Implementation Role model of teachers Take home message 11/8/2017 Professor Pisake Lumbiganon 61