If you teach him how to fish, If you teach him how to fish, he will eat today … If you give...

If you teach him how to fish,If you teach him how to fish,

he will eat today …

If you give someone a fish,

he will eat every day…

Evidence –Based Medicine Evidence –Based Medicine Journal Club Journal Club

Prof. EIAD AL-FARISProf. EIAD AL-FARIS

Chairman, Department of Family and Community MedicineChairman, Department of Family and Community Medicine College of Medicine,King Saud UniversityCollege of Medicine,King Saud University

ContentsContents

1.1. Aims and ObjectivesAims and Objectives2.2. IntroductionIntroduction3.3. Definition of EBM.Definition of EBM.4.4. Steps For EBM Practice.Steps For EBM Practice.5.5. Well Built Clinical Questions.Well Built Clinical Questions.6.6. Identifying The EvidenceIdentifying The Evidence7.7. Search Strategy. Search Strategy. 8.8. ConclusionConclusion

Aims and ObjectivesAims and Objectives

What is EBM ?What is EBM ?

Integration of best research evidence with Integration of best research evidence with clinical experience & patient values.clinical experience & patient values.

Which database you are prescribed Which database you are prescribed to?to?

Pubmed Pubmed Cochrane LibraryCochrane Library Clinical EvidenceClinical Evidence Best EvidenceBest Evidence Bandolier Bandolier Therapeutic InitiativeTherapeutic Initiative Trip databaseTrip database GoogleGoogle

WHAT IS EBM ?WHAT IS EBM ?

The conscientious, explicit and The conscientious, explicit and judicious use of current judicious use of current best best evidenceevidence in making decisions about in making decisions about the care of individual patients.the care of individual patients.

DAVID SACKETT

Five steps process ?Five steps process ? Asking the right question.Asking the right question. Searching for information.Searching for information. Evaluating the evidence forEvaluating the evidence for

validity and usefulness. validity and usefulness.

Implement useful findings inImplement useful findings in clinical practiceclinical practice

Evaluate the whole processEvaluate the whole process

Step I.Step I.

Converting the need for Converting the need for information into a answerable information into a answerable question.question.

To answer a clinical question effectively, To answer a clinical question effectively, First, turn your scenarios into First, turn your scenarios into 'well-built' 'well-built' clinical Q.clinical Q.

Four domains:Four domains: PICOPICO

1) the 1) the ppatient (atient (pproblem)roblem)

2) the 2) the iintervention or exposure ntervention or exposure

3) the 3) the ccomparison (intervention)omparison (intervention)

4) the clinical 4) the clinical ooutcomesutcomes

For healthy adults is it For healthy adults is it worthwhile to give aspirin as worthwhile to give aspirin as

prophylaxis to reduce MI prophylaxis to reduce MI and or stroke ?and or stroke ?

Aspirin and Primary PreventionAspirin and Primary Prevention

1. 1. PPatient population.atient population.

2. 2. IIntervention.ntervention.

3. 3. CComparison omparison intervention.intervention.

4. 4. OOutcomes. utcomes.

Asymptomatic adults with no Asymptomatic adults with no risk factors risk factors

Aspirin Aspirin

PlaceboPlacebo

Incidence of CV eventsIncidence of CV events

““In asymptomatic adults no risk factors, would the In asymptomatic adults no risk factors, would the use of aspirin reduce the incidence of cardiovascular use of aspirin reduce the incidence of cardiovascular events?events?

Information management Information management PrinciplesPrinciples

Clinical ScenarioClinical Scenario

Ibrahim is a 30 years old teacher, he is known Ibrahim is a 30 years old teacher, he is known case of allergic rhinitis. He presented to your case of allergic rhinitis. He presented to your clinic for follow up, he is having a flare up of clinic for follow up, he is having a flare up of rhinitis symptoms, and he wants to get refills rhinitis symptoms, and he wants to get refills of the antihistamine pills that he used to get of the antihistamine pills that he used to get from his physician. from his physician.

You wonder should you prescribe intranasal You wonder should you prescribe intranasal steroids or refill the antihistamines?!steroids or refill the antihistamines?!

Step 1Step 1Formulating an answerable Formulating an answerable

questionquestion

Formulating clinical questionsFormulating clinical questions

PPatient/ Population : Patients with Allergic atient/ Population : Patients with Allergic Rhinitis Rhinitis

IInterventionntervention : Intranasal steroids : Intranasal steroids CComparisonomparison : Antihistamines : Antihistamines OOutcomeutcome : Control of symptoms : Control of symptoms

In patients with Allergic Rhinitis, is Intranasal In patients with Allergic Rhinitis, is Intranasal steroids more effective than antihistamines in steroids more effective than antihistamines in the management of Allergic Rhinitis the management of Allergic Rhinitis symptoms?symptoms?

Step II.Step II.

Searching best evidence to answer the Searching best evidence to answer the question.question.

Identifying The EvidenceIdentifying The Evidence

• Primary Sources

• Secondary Sources

MedlineEmbase

Systematic Reviews

Clinical Guidelines

Where to Find the Best Where to Find the Best Evidence ?Evidence ?

Invest in evidence databasesInvest in evidence databases• Using Prefiltered sources

• Using Unfiltered sources

Best Evidence 5.lnk

Search strategySearch strategy

Disease and intervention well understood & Disease and intervention well understood & fully fully evaluated Textbookevaluated Textbook

Common problem Clinical evidence Common problem Clinical evidence ACP ACP Journal ClubJournal Club

New intervention Medline PubMed New intervention Medline PubMed clinical clinical queries.queries.

Broad questions System review Broad questions System review articles e.g articles e.g Cochrane libraryCochrane library

Internet googleInternet google

Q1. For healthy adults is it worthwhile Q1. For healthy adults is it worthwhile to give aspirin as prophylaxis to reduce to give aspirin as prophylaxis to reduce MI and or stroke.MI and or stroke.

Scenario and Questions (Cont’d)Scenario and Questions (Cont’d)

PRIMARY SOURCES PRIMARY SOURCES

Primary Sources of evidencePrimary Sources of evidence

MEDLINEMEDLINE

EMBASEEMBASE

Other Search EnginesOther Search Engines

EMBASEEMBASE CANCERLITCANCERLIT CINAHLCINAHL HealthSTARHealthSTAR

Secondary sources of Secondary sources of EvidenceEvidence

SECONDARY SOURCESSECONDARY SOURCES A Unique Source…A Unique Source…

Its contents are Its contents are driven by driven by questionsquestions rather than rather than by the availability of by the availability of research evidence.research evidence.

It is It is updated every 6 months.updated every 6 months.

Clinical EvidenceClinical Evidence

Produced by the BMJ Publishing GroupProduced by the BMJ Publishing Group Updated every six monthsUpdated every six months www.clinicalevidence.orgwww.clinicalevidence.org

1. 1. PPatient population.atient population.

2. 2. IIntervention.ntervention.

3. 3. CComparison omparison

4. 4. OOutcomes. utcomes.

Asymptomatic adults with no Asymptomatic adults with no risk factors risk factors

Aspirin Aspirin

PlaceboPlacebo

Incidence of CV eventsIncidence of CV events

““In asymptomatic adults no risk factors, would the In asymptomatic adults no risk factors, would the use of aspirin reduce the incidence of cardiovascular use of aspirin reduce the incidence of cardiovascular events?events?

BenefitBenefit

CER=4.8%CER=4.8% EER=4.2%EER=4.2% ARR=4.8-4.2=0.6%ARR=4.8-4.2=0.6% NNT=167NNT=167

HarmsHarms

IC bleeds: IC bleeds: NSNS

EC bleeds:EC bleeds: ARI=0.8-0.5=0.3%ARI=0.8-0.5=0.3% NNH=333NNH=333

The Cochrane LibraryThe Cochrane Library

http://www.thecochranelibrary.comhttp://www.thecochranelibrary.com

Clinical ScenarioClinical Scenario

Khalid is a 40 years old smoker, would like to quit Khalid is a 40 years old smoker, would like to quit smoking, he tried to do that, by himself, several times smoking, he tried to do that, by himself, several times over the last two years, but he could not tolerate the over the last two years, but he could not tolerate the withdrawal symptoms. Recently he read an article in withdrawal symptoms. Recently he read an article in the newspaper reporting that anti-depression the newspaper reporting that anti-depression medications can be used to help smoker to quit, he medications can be used to help smoker to quit, he would like your advise about this issue!would like your advise about this issue!

You wonder what is the role of antidepressants in You wonder what is the role of antidepressants in smoking cessation?! smoking cessation?!

PPatient/ Population : Smoking Cessationatient/ Population : Smoking Cessation IInterventionntervention : Antidepressants : Antidepressants

therapy therapy CComparisonomparison : Placebo : Placebo OOutcomeutcome : Rate of smoking : Rate of smoking

Cessation Cessation

The Cochrane Database of Systematic The Cochrane Database of Systematic ReviewsReviews

Live Demonstration Live Demonstration

“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 randomised controlled trials.”

Archie CochraneArchie Cochrane

The Cochrane Database of The Cochrane Database of Systematic Reviews (CDSR)Systematic Reviews (CDSR)

Include more than 50 review groups.Include more than 50 review groups.

ContainsContains over 3541over 3541 completed reviews and completed reviews and review protocols.review protocols.

The CDSR abstracts are free The CDSR abstracts are free The CDSR impact factor is 4.654 ranking The CDSR impact factor is 4.654 ranking

number 14number 14 The collection is updated quarterly.The collection is updated quarterly. Reviews are updated every 2 years.Reviews are updated every 2 years.

Review GroupsReview Groups

Acute respiratory infectionsAcute respiratory infections AirwaysAirways AnaesthesiaAnaesthesia BackBack Breast cancerBreast cancer Colorectal cancerColorectal cancer Consumers and communicationConsumers and communication Cystic fibrosis and genetic Cystic fibrosis and genetic

disordersdisorders Dementia & cognitive Dementia & cognitive

improvementimprovement Depression, anxiety & neurosisDepression, anxiety & neurosis

Developmental, psychosocial Developmental, psychosocial and learning problemsand learning problems

Drugs and alcoholDrugs and alcohol Ear, nose and throat disordersEar, nose and throat disorders Effective practice and Effective practice and

organisation of careorganisation of care EpilepsyEpilepsy Eyes and visionEyes and vision Fertility regulationFertility regulation Gynaecological cancerGynaecological cancer HeartHeart Hepato-biliaryHepato-biliary

Database Of Abstracts Of Database Of Abstracts Of Reviews Of Effectiveness Reviews Of Effectiveness

(DARE(DARE)) DARE is a collection of abstracts of DARE is a collection of abstracts of

well-conducted and quality-assessed well-conducted and quality-assessed research reviews about the effectiveness research reviews about the effectiveness of health care interventions.of health care interventions.

http://nhscrd.york.ac.uk/darehp.htmhttp://nhscrd.york.ac.uk/darehp.htm

ACP Journal ClubACP Journal Club

Selects articles from the Selects articles from the literature that are original literature that are original commented on by clinical commented on by clinical experts.experts.

More than 2000 reviews More than 2000 reviews currently available.currently available.

http://www.acpjc.org/http://www.acpjc.org/

ACP Journal Club ACP Journal Club

Selects articles from the literature that are Selects articles from the literature that are original commented on by clinical experts.original commented on by clinical experts.

More than 2000 reviews currently available.More than 2000 reviews currently available. http://www.acpjc.org/http://www.acpjc.org/

Q2. One of my healthy patients Q2. One of my healthy patients

asked whether to take folicasked whether to take folic

acid or not ?acid or not ?

Scenario and Questions (cont’d)Scenario and Questions (cont’d)

BandolierBandolier Search for systematic reviews and abstract Search for systematic reviews and abstract

themthem Include NNT tables Include NNT tables http://www.jr2.ox.ac.uk/Bandolier/http://www.jr2.ox.ac.uk/Bandolier/

Bandolier is an Oxford based Bandolier is an Oxford based appraisal site with lots of good appraisal site with lots of good material. material. http://www.jr2.ox.ac.uk/bandolier/bformHJ.hthttp://www.jr2.ox.ac.uk/bandolier/bformHJ.htmlml

SECONDARY SOURCESSECONDARY SOURCES

Q3. One of your residents asked Q3. One of your residents asked you you should we stop prescribing traditional should we stop prescribing traditional NSAID, and shift to the selective C0X2NSAID, and shift to the selective C0X2

inhibitors? inhibitors?

Scenario and Questions (cont’d)Scenario and Questions (cont’d)

SECONDARY SOURCESSECONDARY SOURCES

Evidence Based Therapeutics Initiative Evidence Based Therapeutics Initiative from UBC, Canadafrom UBC, Canada http://www.ti.ubc.ca/index.html

Q4.Q4.A.A. For type I diabetic patient with For type I diabetic patient with

microalbuminurea, which is the best ACEI or microalbuminurea, which is the best ACEI or ARB that will protect the kidney?ARB that will protect the kidney?

B.B. In diabetic and HTN patients, which is more In diabetic and HTN patients, which is more effective in preventing stroke, captopril or effective in preventing stroke, captopril or enalapril?enalapril?

Scenario and Questions (Cont’d)Scenario and Questions (Cont’d)

TRIP DatabaseTRIP Database

The TRIP Database searches 70 sites of high-The TRIP Database searches 70 sites of high-quality medical information.quality medical information.

The site is updated monthly.The site is updated monthly. http://www.tripdatabase.com/http://www.tripdatabase.com/

Step (3): Critical Appraisal of the Step (3): Critical Appraisal of the EvidenceEvidence

Is the evidence from this article valid? METHODIs the evidence from this article valid? METHOD If valid, are the RESULTS important?If valid, are the RESULTS important? If valid and important, can you apply the If valid and important, can you apply the

evidence in the caring for the patients in the local evidence in the caring for the patients in the local contexts?contexts?

ConclusionConclusion

Conclusion Cont.Conclusion Cont.

The main thing is toThe main thing is to

keep asking questions.keep asking questions.

Thank YouThank Youeiad@ksu.edu.saeiad@ksu.edu.sa

King Saud Khazindar Free Journals King Saud Khazindar Free Journals http://www.alkhazindar.com.sa/onlinejournals/first.asp

Literature Review

Training Medical Students in Evidence-based Training Medical Students in Evidence-based Medicine: A Community Campus Approach.Medicine: A Community Campus Approach. Family Med 1999, 31 (10): 703-8.Family Med 1999, 31 (10): 703-8.

Michigan State University (MSU)Michigan State University (MSU) A nine-session 20 hours curriculum A nine-session 20 hours curriculum Third year medical students Third year medical students It compared this group with the AAMC It compared this group with the AAMC graduates and the 1994 class who were not graduates and the 1994 class who were not taught this course taught this course

AAMC Comparison of AAMC Comparison of Literature Analysis SkillsLiterature Analysis Skills

1994 1995 1996 1997

AAMC Comparison of AAMC Comparison of Research Research Technique SkillsTechnique Skills

1994 1995 1996 1997

CONCLUSIONCONCLUSION

If you teach him how to fishIf you teach him how to fish,,

he will eat today …

If you give someone a fish,

he will eat every day…

Be open to Be open to questions; questions; never avoid never avoid or ignore a or ignore a question.question.

Show Show interest in interest in the patient’s the patient’s story; never story; never act bored.act bored.

Do not give Do not give the patient the patient falsefalse

reassurance.reassurance.

1900 1990 2000

10,000

100,000

?250,000INFORMATION EXPLOSION

MEDICAL JOURNALS

DOE POEMDOE POEM Disease Oriented Evidence Disease Oriented Evidence

(DOE)(DOE) Patient Oriented Evidence that Patient Oriented Evidence that

Matters (POEM)Matters (POEM) the outcomes that matter the outcomes that matter most to our patients.most to our patients.

POEMs POEMs Decreased symptoms, Decreased symptoms,

mortality, morbidity, cost mortality, morbidity, cost Increased QOL.Increased QOL.

Doe Doe

pathophysiological pathophysiological point of viewpoint of view

RELEVANCE RELEVANCE XX VALIDITY VALIDITY

WORK WORK

Shaughnessy et. al. JFP 1994.Shaughnessy et. al. JFP 1994.

USEFULNESS OF USEFULNESS OF

INFORMATIONINFORMATION ==

Relevance Relevance Applicability to practice.Applicability to practice.

DOE DOE VSVS POEMs POEMs

Frequency of the Frequency of the ProblemProblem

DOE makes sense DOE makes sense Can we apply it to our Can we apply it to our

patients before POEM?patients before POEM?

EBM encourages a healthy EBM encourages a healthy skepticism skepticism

Example from the history Example from the history Antiarrhytharic ??Antiarrhytharic ?? ββ -blockers -blockers

Clofibrate Clofibrate decreases decreases

cholesterol cholesterol

Clofibrate decreases CV Clofibrate decreases CV mortality/mortality/

MorbidityMorbidity

Clofibrate Increases Clofibrate Increases overall mortalityoverall mortality

ββ ––blockers are blockers are contraindicated for contraindicated for heart failure patientsheart failure patients

ββ ––blockers decrease blockers decrease mortality in heart mortality in heart failure patientsfailure patients

Antiarrhythmic A Antiarrhythmic A decreases PVCsdecreases PVCs

Antiarrhythmic A Antiarrhythmic A decreases symptomsdecreases symptoms

Antiarrhythmic A Antiarrhythmic A increases mortalityincreases mortality

DOE POEM

The cardiac arrhythmia suppression trial. N Engl J Med 1991.

Step 1Step 1Formulating an Formulating an

answerable answerable questionquestion

To answer a clinical question effectively, To answer a clinical question effectively, First, turn your scenarios into First, turn your scenarios into 'well-built' 'well-built' clinical Q.clinical Q.

Four domains:Four domains: PICOPICO

1) the 1) the ppatient (atient (pproblem)roblem)

2) the 2) the iintervention or exposure ntervention or exposure

3) the 3) the ccomparison (intervention)omparison (intervention)

4) the clinical 4) the clinical ooutcomesutcomes

Clinical ScenarioClinical Scenario Ibrahim is a 30 years old teacher, he is known case Ibrahim is a 30 years old teacher, he is known case

of allergic rhinitis. of allergic rhinitis. He presented to your clinic for He presented to your clinic for follow up, he is having a flare up of rhinitis follow up, he is having a flare up of rhinitis symptoms, and he wants to get refills of the symptoms, and he wants to get refills of the antihistamine pills that he used to get from his antihistamine pills that he used to get from his physician. physician.

You wonder should you prescribe You wonder should you prescribe intranasal steroids or refill the intranasal steroids or refill the antihistamines?!antihistamines?!

PPatient atient : Patients with : Patients with Allergic Rhinitis Allergic Rhinitis

IInterventionntervention : Intranasal : Intranasal steroids steroids

CComparisonomparison : Antihistamines : Antihistamines

OOutcomeutcome : Symptoms Control : Symptoms Control

Step 2Step 2

SEARCHING FOR THE SEARCHING FOR THE Best EVIDENCEBest EVIDENCE

Identifying The EvidenceIdentifying The Evidence

• Primary Sources

• Secondary Sources

MedlineEmbase

Systematic Reviews

Clinical Guidelines

Medline search

Secondary Secondary sources of sources of EvidenceEvidence

Where to Find the Best Evidence ?Where to Find the Best Evidence ?

Invest in evidence Invest in evidence databasesdatabases

• Using Prefiltered sources

They do steps 3 and 4 They do steps 3 and 4 Focus on relevantFocus on relevant

information information Evaluate its validity.Evaluate its validity.

Aspirin and Primary PreventionAspirin and Primary PreventionBenefitBenefit

CER=4.8%CER=4.8% EER=4.2%EER=4.2% ARR=4.8-4.2=0.6%ARR=4.8-4.2=0.6% NNTNNT=167=167

HarmsHarms

IC bleeds: IC bleeds: NSNS

EC bleeds:EC bleeds: ARI=0.8-0.5=0.3%ARI=0.8-0.5=0.3% NNHNNH=333=333

3rd session:

Boolean Operators Boolean Operators

A A ANDAND B B

Boolean OperatorsBoolean Operators

A A OROR B B

SPECIALIST (MEDICINE SPECIALIST (MEDICINE SPECIFIC) SEARCH ENGINESPECIFIC) SEARCH ENGINE

e.g. e.g. i-TRIP Database i-TRIP Database

ii- OMNI ii- OMNI (Organization Medical Network Information)(Organization Medical Network Information)

Agency for Health Care Agency for Health Care Research & Quality (AHRQ)Research & Quality (AHRQ)

Include a comprehensive guidelines for 19 separate Include a comprehensive guidelines for 19 separate conditions.conditions.

http://www.ahrq.gov/clinic/cpgarchv.htm.http://www.ahrq.gov/clinic/cpgarchv.htm. Include recommendations on a wide range of Include recommendations on a wide range of

clinical preventive services.clinical preventive services. Evidence-based Practice Centers (EPC) Reports:Evidence-based Practice Centers (EPC) Reports: http://www.ahrq.gov/clinic/epcindex.htmhttp://www.ahrq.gov/clinic/epcindex.htm

Other sources of systematic Other sources of systematic reviewsreviews

CFP Critical Appraisal Index CFP Critical Appraisal Index The Therapeutics InitiativeThe Therapeutics Initiative

Canadian Practice GuidelinesCanadian Practice GuidelinesInfobaseInfobase

The most up-to-date Canadian based The most up-to-date Canadian based guidelines site.guidelines site.

Most of the guidelines are evidence-based.Most of the guidelines are evidence-based. http://mdm.ca/cpgsnew/cpgs/index.asphttp://mdm.ca/cpgsnew/cpgs/index.asp

National Guideline ClearinghouseNational Guideline Clearinghouse

Include structured abstracts of guidelines with Include structured abstracts of guidelines with links to full-text guidelines.links to full-text guidelines.

Not all guidelines are evidence-based.Not all guidelines are evidence-based. http://www.guidelines.govhttp://www.guidelines.gov

Guideline Advisory CommitteeGuideline Advisory Committee

Gives quick access to recommended Gives quick access to recommended guidelines for common medical conditions.guidelines for common medical conditions.

Include summaries and ratings of the Include summaries and ratings of the guidelines with full text links to guidelines.guidelines with full text links to guidelines.

http://www.gacguidelines.ca/http://www.gacguidelines.ca/

Other sources of Evidence-based Other sources of Evidence-based GuidelinesGuidelines

The Scottish Intercollegiate Guidelines The Scottish Intercollegiate Guidelines Network (SIGN)Network (SIGN)

http://pc47.cee.hw.ac.uk/sign/clinical.htm.http://pc47.cee.hw.ac.uk/sign/clinical.htm. The New Zealand Guidelines Group The New Zealand Guidelines Group http://www.nzgg.org.nz/index.cfm.http://www.nzgg.org.nz/index.cfm. The NHS and department of Health The NHS and department of Health

Technology assessment programme.Technology assessment programme. http://www.hta.nhsweb.nhs.uk/htapubs.htmhttp://www.hta.nhsweb.nhs.uk/htapubs.htm

The Canadian Task Force on The Canadian Task Force on Preventive Health CarePreventive Health Care

A practical guide for a wide variety of A practical guide for a wide variety of preventive health interventions using EBM preventive health interventions using EBM recommendations.recommendations.

Include age and sex specific recommendation Include age and sex specific recommendation tables.tables.

http://www.ctfphc.org/http://www.ctfphc.org/