Upload
liana
View
27
Download
5
Tags:
Embed Size (px)
DESCRIPTION
Evidence Based Medicine… The Road ahead: Bridging the gap from theory to Practice. Amr Nadim, MD. Professor of Obstetrics & Gynecology Ain Shams Faculty of Medicine The QAInc. Advisory Board. What happened …?. - PowerPoint PPT Presentation
Citation preview
Evidence Based Medicine…Evidence Based Medicine…The Road ahead: Bridging the gap The Road ahead: Bridging the gap
from theory to Practicefrom theory to Practice
Amr Nadim, MD.Professor of Obstetrics & Gynecology Ain Shams Faculty of MedicineThe QAInc. Advisory Board
What happened …?
• Over the past decade, the term
"evidence-based medicine" (or EBM) has
gained considerable currency.
• EBM has been described as a "paradigm
shift" that will "change medical practice in
the years ahead."
The medical practice so far…
• Based experience gained from clinical practice
• Information essentially driven from– The basic science research– Observational studies that are NOT necessarily
controlled– Expert opinion– Advocacy
So, when faced with a problem, Doctors may…
• Reflect on their own clinical experience,
• Reflect on the underlying biology,
• Go to a textbook,
• Ask a local / international expert.
• Believe in what they are told by pharmaceutical
companies
What is the problem any way…?
• Bias, bias and bias…
The Founding Father
Prof. Archibald Leman Cochrane a British medical epidemiologist whose book Effectiveness and Efficiency:
Random Reflections on Health Services (1972) and subsequent
advocacy caused increasing acceptance of the concept of
Evidence Based Medicine
(January 12, 1909 - June 18, 1988)
The People at McMaster Universityas early as 1992
…introduced Evidence Based Medicine
as a Shift of Paradigm
What is EBM…?
• “The conscientious, explicit and judicious use
of current best evidence in making decisions
about the care of individual patients"
• It is about the WISE use of the EVIDENCE to
achieve a QUALITY OF PATIENT CARE
Evidence-based medicine is:
the SYSTEMATICSYSTEMATIC, SCIENTIFICSCIENTIFIC and EXPLICITEXPLICIT
use of current best evidence in making decisions
about the care of individual patients.
EBM: The Theory
Patient Values…?
• The unique preferences, concerns, The unique preferences, concerns,
and expectations each patient brings and expectations each patient brings
to a clinical encounter.to a clinical encounter.
• They may differ from phase to phase.. They may differ from phase to phase..
from one encounter to another.from one encounter to another.
• These must be integrated into clinical These must be integrated into clinical
decisions if they are to serve the decisions if they are to serve the
patient.patient.
Clinical Expertise…?
Ability to use The clinical skills & past experience Ability to use The clinical skills & past experience
to rapidly identify to rapidly identify Each patient’sEach patient’s::
– Unique health state.Unique health state.
– Individual risks/benefits of interventions Individual risks/benefits of interventions
(Diagnostic or therapeutic).(Diagnostic or therapeutic).
– Personal values and expectations.Personal values and expectations.
What is The Best Research Evidence ?What is The Best Research Evidence ?
Clinically relevant, Clinically relevant, Patient-centeredPatient-centered research research
about:about:
– Diagnostic tests: Diagnostic tests: To detect the diseaseTo detect the disease
– Prognostic markers: Prognostic markers: To follow up the diseaseTo follow up the disease
– Therapeutic / preventive regimens: Therapeutic / preventive regimens: To treatTo treat
– Harm: Harm: That treatments/diagnostic tools may cause.That treatments/diagnostic tools may cause.
EBM: The Theory
A Paradigm Shift…?
Paradigm..?
• “An entire constellation of beliefs, concepts, values, techniques, and so on shared by the members of a given community"
Paradigm Shift…?
EBM: The Theory
• A Paradigm shift:The medical community is shifting gears
Advocacy Inquiry
Opinion Evidence
Disease-oriented
Patient-oriented
Intermediate results
Final outcomes
And in doing so, one should…
• Define the problem in the form of an
answerable clinical question.
• Perform an elaborate search for the best
available evidence.
• Appraise this evidence for relevance
&validity.
• Incorporate it in his practice
• Become a life-long learner.
I have no particular talent…I am merely inquisitive
What we used to do…
Time spent reading around one’s patients is slim:
Self-reports from Oxford :
• House Officers: none
• S.H.O.’s: 10 minutes
• Registrars: 90 minutes
• Senior Registrars: 45 minutes
• Consultants:
– Post 1975: 60 minutes
– Pre 1975: 30 minutes
What EBM originally advocated…
Ask a Focused Clinical Question
Appraise itFor validity
Incorporate it in your practice
Go to the medline and search for the
Best available evidence
Become a life-long learner
While you are formulating your question…
•Alendronate improvesBMD
•Alendronate reduces fracture Risk
•HRT Lowers LDL and Increases HDL
• HRT reduces incidence of Cardiovascular events
DOE POEM
DOE (intermediate outcomes)– Disease-Oriented Evidence
A test result / A physiological number
POEM (final outcomes))– Patient-Oriented Evidence that Matters to
the Patient Will I die? Will I suffer? My quality of life?
POEMPPatient-Oriented
EEvidence
that MMatters…
To whom?
To you …and To your patient
And While Doing So You Should Respect The EVIDENCE Hierarchy
What we used to do…
And in many instances we find ourselves lost in a maze…
What EBM is now proposing…
Information Mastery
Everything is based on the usefulness equation:
Usefulness = Relevance x Validity
Work
Cochrane Library
Specialty-specificPOEMs
Best Evidence
Clinical Evidence
Textbooks, Up-to-Date, 5-Minute Clinical Consult
Usefu
lness
Journals/ Medline
Drilling for the evidence
Levels of Evidence and Grades of Recommendations
Grade of recommendation
Level of evidence
Interventions
1a Systematic review of randomized controlled trials A
1b Individual randomized controlled trial
2a Systematic review of cohort studies
2b Individual cohort study
3a Systematic review of case-control studies B
3b Individual case-control study
C 4 Case series
D 5 Expert opinion without explicit critical appraisal or based on physiology or bench research
EBP has changed the world
• Source of knowledge is expert opinion
• Clinical skills are seen as semi-mystical
• Research is marginal to practice
Source of knowledge is systematic review of evidence
Clinical skills can be audited and managed
Research and evidence go together
• Most of what doctors need to know is in their heads.
• Most medical care is assumed to be beneficial
Doctors must use information tools constantly/ they must constantly be updated and learn new skills.
Widespread recognition that the balance between doing good and harm is fine
EBP has changed the world
• Clinical performance is not systematically audited
• Doctor patient relationship is essentially master/pupil
Clinical performance is regularly reviewed and managed
Patient partnership is often thought.
EBP has changed the world
• Patients do not have easy access to the knowledge base of doctors
• The doctor is smartest
Patients have as much access to the evidence base of medicine as doctors
Often the patient is smarter
EBP has changed the world
The Pre-internet Patient..
The Clinician of the Future
– Learn how to say “I do NOT know” with ease and confidence
– Knows then how to find the best available evidence.
– Listen to the patient, appreciate his preferences, determine which tests and treatment will do more good than harm by tailoring the best available evidence to the individual’s condition.
– Discuss the options with the patient and help him make an informed choice depending on his values and preferences
Ahmad Nadim
In few words, EBM changed the medical practice….
A Doctor
• More resourceful
• Aware of the concept of Information Mastery
• Following Evidence Based Guidelines.
• Publishing and Appraising Evidence Based Researches and Literature
A Patient
• More Resourceful
• Aware of his writes
• Able and willing to take part
in the Decision Making
process concerning his life
• Not bluffed by DOEs but
essentially with POEMs
However…
Many Leaks From Research To Practice
Paul Glasziou, CEBM, Oxford UniversityThe 3rd Asia Pacific Congress on EBM, November 2004
Paul Glasziou, CEBM, Oxford University
Practicing Evidence Based Medicine
Linking evidence to practice
Get
the
evid
ence
stra
ightG
et th
e
evid
ence
stra
ight
1
Set p
olicy
(guid
elin
e)
based
on th
e
evid
enceSet
polic
y
(guid
elin
e)
based
on th
e
evid
ence2
Cha
ngin
g
Pract
ice
thru
the
polic
y
(gui
delin
e)
Cha
ngin
g
Pract
ice
thru
the
polic
y
(gui
delin
e)
3
What EBM Did Bring To Our Medical Practice Over The Past Decade?
• WHO Medical Eligibility Criteria• WHO Cire • WHO Reproductive Health library• RCOG green top guidelines• The Cochrane Library• Fostering the concept of life-long learning.• CAT Banks• Putting an emphasis on the importance of
controlled clinical trials.
And so, we are left with…
Peer reviewing: detecting errors
• 60% response rate
• Median number of errors detected 2
• Maximum number detected 5
• Percentage not detecting any 20%
600 word study with 8 errors …Sent to 400 reviewers
Problems with peer reviewing
• Slow
• Expensive
• A lottery
• Ineffective
• Biased
• Easily abused
• Can’t detect fraud
The power of peer review
• Reviewer A “I found this paper an
extremely muddled paper with a large
number of deficits.”
• Reviewer B “It is written in a clear
style and would be understood by any
reader.”
An EBM New Vision of peer review
• “Peer review is changed from being an arbitrary decision made in a closed box to an open scientific discourse.”
• The Critical Appraisal Process has generated Post-publication peer reviewers
A word on patients
• The impact of medical journals on patients and the
public is mainly via the mass media
• Most mass media coverage is reasonable, but
some can be way off beam, sometimes causing
major problems
• The public are often very confused by conflicting
reports from scientific journals
• That’s why Evidence Based Medicine will be a
way of avoiding such confusion.
A word on patients
• Patients increasingly have access to the same
information as doctors, including journals
• The BMJ has just appointed a patient editor
• Ten years from now journals might be for
doctors and patients
What will survive as the world changes completely
• Clear ethical values• Being clear about our mission• Putting patients first• Constantly trying to improve• Basing what we do on evidence• Leadership• Become Lifelong learners and Mastering the
information
• EBM paved the way for accreditation
processes
• It provided a rational
• In this respect Evidence Based Medicine has
been the Bible for setting principles and
guidelines for peer reviewers in their ultimate
search for completion of Accreditation
Process
??? In Practice
Performance
In Practice Competence
Guidelines
Information
The Doctor
Data
Th
e P
atie
nt
Know
ledge
The Evidence
Wise Use
EB
M
“Knowing is not enough; we must apply
Willing is not enough; we must do…”
Goethe
Do you want to start Practicing EBM…?
Reflect on your practice on regular basis.
Inquire …DO NOT advocate
Feel good about NOT knowing everything
Learn to ask a focused clinical question
Let someone else DO the heavy lifting
Learn to use a computer
A New Role for EBM
• If all practitioners had the skill to:
– Do a rapid literature search on one or two search engines
– Rapidly critically assess the media’s study of the week
– Be able to judge the quality of critically appraised
information provided by a third party,
… then the gap between evidence and practice
would quickly narrow.
A New Role for EBM
• Presence of an internet connection in every practitioner’s office will signal a revolution in the practice of Medicine.
• Basic information about any problem or symptom, no matter how rare or unusual, can be obtained within a few minutes by the clinician.
• Best available evidence, recently updated is there for any patient within the time constraints of a visit to a busy practice.
A New Role for EBM
• CAPRE stands for “Critically Appraised Practice Reflection Program” – which includes identifying a patient with a specific
problem, – providing the patient with EBM information
answering their questions and then determining if they did or did not follow the advice.
A New Role for EBM
• The final step, all on line, is to feed back to the program a description as to whether the patient adopted the recommendations or not, and for the physician to self assess to determine if he or she might have presented the information more effectively.
• The new role of EBM is in assisting the physician in diagnosing and managing their patients and being educated on line
InfoRetriever 4.1Windows 95/98/NT/ME/2000/XP, PocketPC and Web
650 critical reviewsof recent research from the Journal of Family Practice POEMs section
Bayesian diagnostic test / H&P calculator
Basic drug info by class and cost for 1200 drugs
Key evidence-basedtreatment guidelines
Cochrane Databaseof Systematic Reviews:over 1200 abstracts
102 clinical predictionrules
www.MedicalInforetriever.com
1500 short research synopses (400 added per year)
5 Minute Clinical Consult
What EBM originally advocated…
Ask a Focused Clinical Question
Appraise itFor validity
Incorporate it in your practice
Go to the medline and search for the
Best available evidence
Become a life-long learner
What EBM Is now Able to Provide…
Ask a Focused Clinical Question
Appraise The Evidence
For validity
•Incorporate it in your practice
•Create a partenaria with your patient
Go to the Evidence Based sites
maintained by a third party
Become a life-long learner
Access them at point of care
…and after all, is EBM a “Paradigm Shift”…?
• This may involve lot of philosophy that is exceeding
the scope of this presentation.
• To shortly answer the question: The answer is
“NO”.
• Instead let us better consider EBM and traditionally
practiced medicine as a continuum that will help you
to better practice medicine by
– Providing a quality care to your clients and
– Remaining up to date.
“When a steamroller comes through, you should choose to become either part of the roller or part of the road.”
Thank you…