EBMEBMQUESTIONS QUESTIONS

ANYONE ?ANYONE ?Todd D. Tillmanns, MD, FACOGTodd D. Tillmanns, MD, FACOG

Assistant ProfessorAssistant ProfessorDivision of Gynecologic OncologyDivision of Gynecologic Oncology

West Clinic West Clinic & &

University of Tennessee Health Science University of Tennessee Health Science CenterCenter

What is Evidence What is Evidence Based Medicine (EBM)Based Medicine (EBM)

Evidence-based medicine is the Evidence-based medicine is the care of patients using the best care of patients using the best available evidence from the available evidence from the results of research to guide results of research to guide clinical decision making [1-3]clinical decision making [1-3]

1. Sackett, DL, Straus, SE, Richardson, WS, et al. Evidence-based medicine. How to practice and teach EBM, 2nd edition, Churchill Livingstone, Edinburgh 2000.

2. 2. Sackett, DL, Rosenberg, WM, Gray, JA, et al. Evidence-based medicine. What it is and what it isn't. BMJ 1996; 312:71.

3. 3. Geyman, JP, Deyo, RA, Ramsey, SD. Evidence-Based Clinical Practice, Butterworth-Heinemann, Woburn, MA 1999.

What EBM is not!What EBM is not! EminenceEminence VehemenceVehemence EloquenceEloquence Confidence of the sourceConfidence of the source Practicing defensive medicine Practicing defensive medicine The way we do it, you could….. The way we do it, you could…..

Isaacs, D, Fitzgerald, D. Seven alternatives to evidence based medicine. BMJ 1999; 319:1618.

Don’t put the cart Don’t put the cart before the horsebefore the horse

The question must be The question must be defined before the answer defined before the answer to the question can be to the question can be elucidated through a elucidated through a careful searchcareful search

Good Evidence Based Good Evidence Based QuestionsQuestions

Is the finding abnormal?Is the finding abnormal? What is the diagnosis?What is the diagnosis? How often does it occur?How often does it occur? What are the risk factors for the disease?What are the risk factors for the disease? What is the pathogenesis?What is the pathogenesis? What is the natural history?What is the natural history? How effective (harmful) is the How effective (harmful) is the

treatment? treatment? How effective or (harmful) are How effective or (harmful) are

preventative interventions?preventative interventions?

Putting EBM into Putting EBM into practicepractice

What is the incidence and prevalence?What is the incidence and prevalence? What are the signs and symptoms?What are the signs and symptoms? What are the best diagnostic tests with the best What are the best diagnostic tests with the best

clinical findings that confirm the suspected clinical findings that confirm the suspected diagnosis?diagnosis?

What is the best treatment of the disease process?What is the best treatment of the disease process? Once treated what is the best way to maintain Once treated what is the best way to maintain

health for discharge from your care?health for discharge from your care? How would you prevent the disease process?How would you prevent the disease process?

Where do you find the Where do you find the answers?answers?

You must invest your time to become proficient You must invest your time to become proficient searching these sites and otherssearching these sites and others

full text journals (OVID, Medline, Pubmed)full text journals (OVID, Medline, Pubmed) Cochran Data BaseCochran Data Base OrganizationsOrganizations

American College of PhysiciansAmerican College of Physicians American Society of Internal MedicineAmerican Society of Internal Medicine APGO, ACOGAPGO, ACOG Infectious Disease Society of AmericaInfectious Disease Society of America

governmental organizations: governmental organizations: National Institutes of HealthNational Institutes of Health Centers for Disease Control and PreventionCenters for Disease Control and Prevention National Guideline Clearinghouse: National Guideline Clearinghouse: www.guideline.govwww.guideline.gov

Summary of Good Summary of Good Sources for Quick EBM Sources for Quick EBM

Review Review UpToDateUpToDate editors and authors revise the program continually. New information is highlighted in editors and authors revise the program continually. New information is highlighted in each new edition of the CD-ROM and internet versions, and the date when the topic was last updated is each new edition of the CD-ROM and internet versions, and the date when the topic was last updated is noted at the beginning of each topic review. Other textbooks are finding ways to update regularly, but noted at the beginning of each topic review. Other textbooks are finding ways to update regularly, but readers should be aware of how often each part of the information base is updated and when the last readers should be aware of how often each part of the information base is updated and when the last update of each section they are depending on was done. update of each section they are depending on was done.

ACP Journal ClubACP Journal Club is published every two months by the American College of is published every two months by the American College of Physicians/American Society of Internal Medicine. It reviews the world's English-language medical Physicians/American Society of Internal Medicine. It reviews the world's English-language medical journals in internal medicine, selects scientifically strong articles by explicit criteria, and summarizes journals in internal medicine, selects scientifically strong articles by explicit criteria, and summarizes those meeting these criteria as structured abstracts with commentary by an expert, one article per page. those meeting these criteria as structured abstracts with commentary by an expert, one article per page. (ACP Journal Club, ACP-ASIM, 190 North Independence Mall West, Philadelphia, PA 19106-1572, USA; (ACP Journal Club, ACP-ASIM, 190 North Independence Mall West, Philadelphia, PA 19106-1572, USA; 800-523-1546) 800-523-1546)

The Medical LetterThe Medical Letter, a four-page, biweekly, evidence-based review of drugs, including , a four-page, biweekly, evidence-based review of drugs, including effectiveness, mechanism of action, side effects and interactions, and cost – for new drugs in relation to effectiveness, mechanism of action, side effects and interactions, and cost – for new drugs in relation to older alternatives. (The Medical Letter, Inc., 1000 Main Street, New Rochelle, NY 10801; 800-211-2769). older alternatives. (The Medical Letter, Inc., 1000 Main Street, New Rochelle, NY 10801; 800-211-2769).

Evidence-Based MedicineEvidence-Based Medicine is similar to ACP Journal Club but with a wider scope, is similar to ACP Journal Club but with a wider scope, including articles of interest to family medicine, pediatrics, obstetrics and gynecology, surgery, and including articles of interest to family medicine, pediatrics, obstetrics and gynecology, surgery, and psychiatry. (Evidence-Based Medicine, ACP-ASIM, 190 N. Independence Mall West, Philadelphia, PA psychiatry. (Evidence-Based Medicine, ACP-ASIM, 190 N. Independence Mall West, Philadelphia, PA 19106-1572; 800-523-1546) 19106-1572; 800-523-1546)

The Family Practice NewsletterThe Family Practice Newsletter is a four-page, "biweekly update and commentary on is a four-page, "biweekly update and commentary on new and practical clinical information for the primary care practitioner," written by a family physician new and practical clinical information for the primary care practitioner," written by a family physician with public health and law degrees. (Primary Care Press, 5423 Monocracy Drive, Bethlehem, PA 18017; with public health and law degrees. (Primary Care Press, 5423 Monocracy Drive, Bethlehem, PA 18017; 888-399-7442; fax 631-474-5390; cpkerr@nni.com). 888-399-7442; fax 631-474-5390; cpkerr@nni.com).

Evidence-Based PracticeEvidence-Based Practice, "patient-oriented evidence that matters," from the publishers , "patient-oriented evidence that matters," from the publishers of The Journal of Family Practice. (Dowden Health Media, 110 Summitt Ave., Montvale, NJ 07645-9894; of The Journal of Family Practice. (Dowden Health Media, 110 Summitt Ave., Montvale, NJ 07645-9894; 800-707-7040; ebp@dowdenhealth.com) 800-707-7040; ebp@dowdenhealth.com)

Journal WatchJournal Watch is a monthly publication of the Massachusetts Medical Society that summarizes is a monthly publication of the Massachusetts Medical Society that summarizes recent articles with commentary. (Massachusetts Medical Society. 860 Winter St. Waltham, MA recent articles with commentary. (Massachusetts Medical Society. 860 Winter St. Waltham, MA 02451.1411. 781-893-4610). 02451.1411. 781-893-4610).

Credibility of Credibility of ResourcesResources

Internal validityInternal validity: Are the results of : Are the results of clinical research correct for the clinical research correct for the patients in the study? (threatened by patients in the study? (threatened by two processes: bias and chance)two processes: bias and chance)

GeneralizabilityGeneralizability: Do the results of : Do the results of the study apply to my patients the study apply to my patients

Classification of levels of evidence Classification of levels of evidence and recommendationsand recommendations

Level ofEvidence

Type of EvidenceType of Evidence

IaIa Evidence obtained from meta-analysis of randomized Evidence obtained from meta-analysis of randomized controlled trials controlled trials

IbIb Evidence obtained from at least one randomized Evidence obtained from at least one randomized controlled trialcontrolled trial

IIaIIa Evidence obtained from at least one well designed Evidence obtained from at least one well designed controlled study without randomization.controlled study without randomization.

IIbIIb Evidence obtained from at least one other type of well Evidence obtained from at least one other type of well designed quasi-experimental studydesigned quasi-experimental study

IIIIII Evidence obtained from a well designed non-Evidence obtained from a well designed non-experimental descriptive studies, such as comparative experimental descriptive studies, such as comparative studies, correlation studies, and case studies.studies, correlation studies, and case studies.

IVIV Evidence obtained from expert committee reports or Evidence obtained from expert committee reports or opinions or clinical experiences of respected authoritiesopinions or clinical experiences of respected authorities

Grade Grade (Levels)(Levels)

RecommendationRecommendation

A (Ia, Ib)A (Ia, Ib) Requires at least one randomized control trial, adressing Requires at least one randomized control trial, adressing a specific recommendationa specific recommendation

B (IIa, IIb, III)B (IIa, IIb, III) Requires availability of well conducted clinical trialsRequires availability of well conducted clinical trials

C (IV)C (IV) Indicates absence of directly applicable clinical studies of Indicates absence of directly applicable clinical studies of good qualitygood quality

GPP (Good GPP (Good Practice Practice Points)Points)

Recommended best practice based on the clinical Recommended best practice based on the clinical experience of the guideline development groupexperience of the guideline development group

Guidelines for Guidelines for practicing EBMpracticing EBM

Worksheet for EBM presentations by residentsWorksheet for EBM presentations by residents Clinical questionClinical question Reference research articles by level of evidenceReference research articles by level of evidence Identify the incidence and prevalence of disease or Identify the incidence and prevalence of disease or

disorderdisorder Give backgroundGive background Signs and symptoms ( M/C symptom most reliable)Signs and symptoms ( M/C symptom most reliable) Laboratory, studies, findings that confirm diagnosis (and Laboratory, studies, findings that confirm diagnosis (and

exclude others)exclude others) Treatment (Best, most economical and options for second Treatment (Best, most economical and options for second

line)line) Discharge measures and follow up evaluation Discharge measures and follow up evaluation Preventative measuresPreventative measures EBM GuidelinesEBM Guidelines Guidelines for proposing good EBM questions (Sackett)Guidelines for proposing good EBM questions (Sackett)

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