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Evidence-Based Medicine Dr. Marwa Refaat Dr. Marwa Refaat

Evidence based med

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Evidence Based Medicine Dr Marwa Refaat 11-3-2012

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Page 1: Evidence based med

Evidence-Based Medicine

Dr. Marwa RefaatDr. Marwa Refaat

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EBMEBMIntroductionIntroduction

HistoryHistory

Definition & ClassificationDefinition & Classification

Elements of EBMElements of EBM

Steps of EBMSteps of EBM

Applying concepts of EBM to Applying concepts of EBM to management of some psychiatric management of some psychiatric disordersdisorders

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A dilemmaA dilemma

You are very ill …You are very ill …

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Which doctor do you want?Which doctor do you want?

William Osler, 1900 Smart young doctor

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Rule 31 – Review the World Literature Fortnightly*Rule 31 – Review the World Literature Fortnightly* *"Kill as Few Patients as Possible" - Oscar London*"Kill as Few Patients as Possible" - Oscar London

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Evidence-based medicine

Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence (about therapy, prevention, etiology, harm, prognosis, diagnosis and economic analysis) in making decision about the care of individual patients (Timmermans and Mauck, 2005) and it seeks to assess the quality of evidence of the risks and benefits of treatments (Elstein, 2004).

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The practice of evidence-based medicine is a systematic approach to clinical problem solving, which allows the integration of the best available research evidence with clinical expertise

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A Cross-Cutting Principle: A Cross-Cutting Principle: Science to Services/Evidence-Based PracticesScience to Services/Evidence-Based Practices

How do we translate research into practice?How do we translate research into practice?

How do we connect services to science?How do we connect services to science?

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The history of EBM

Although the formal assessment of medicalinterventions using controlled trials wasalready becoming established in the 1940s,it was not until 1972 that Professor ArchieCochrane, director of the Medical ResearchCouncil Epidemiology Research Unit inCardiff, expressed what later came to beknown as evidence-based medicine (EBM) inhis book Effectiveness and Efficiency: RandomReflections on Health Services.

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In 1992, the UK government funded the establishment of the Cochrane Centre in Oxford under Iain Chalmers, with the objective to facilitate the preparation of systematic reviews of randomized controlled trials of healthcare. The following year it expanded into an international collaboration of centers, of which there are now thirteen, whose role is to co-ordinate the activities of 11,500 researchers.

The National Health Service: AService with Ambitions. www.archive.officialdocuments.

co.uk/document/doh/ambition/ambition.htm (last accessed 27 April 2009)

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Skills of Evidence-based Skills of Evidence-based MedicineMedicine

Knowledge

Translatio

n KTInformation Mastery

IM

Critical Appraisal

CA

Critical thinking of the content of medical literatureKnowledge applied to patients care

Skills searching the medical literature

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Five essential steps of EBM practice: Step 1- converting information needs into an an-

swerable questionStep 2- finding the best evidence to answer the

questionStep 3- critically appraising the evidence for its

validity and usefulnessStep 4- applying the results of the appraisal into

clinical practiceStep 5- evaluating clinical performance

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Five essential steps of EBM practice

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Step 1 of EBM practice: formulating an answerable clinical question

Good clinical question must be clear, directly focused on the problem, and answerable by searching the medical literature.

1- PICO format P Patient or problem,I Intervention,C Comparison,O Outcome

2- Type of clinical question The most common types of clinical questions is about

intervention, etiology ,risk factors, rate, diagnosis, prognosis , cost-effectiveness, and question about phenomena ((Glasziou P, 2003). 2003).

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PICO format

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CLASSIFICATION OF EBM:

1. Evidence-based Health Care, also called as the evidence-based guidelines, is the practice of evidence based medicine at the organizational or institutional level. This includes the production of guidelines, policy and regulations (Gray, 1997).

2. Evidence-based Individual Decision Making, is the practice of evidence based medicine by the individual health care provider (Eddy, 2005).

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Step 2 of evidence-based medicine practice: finding the evidence

search for relevant evidence that will provide the answer to the question. Some research designs are more powerful than others in their ability to answer research questions.

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Levels of evidence and grade of recommendation for ranking the validity of studies about therapy,prevention,etiology and harm,

Oxford Centre for EBMEBM

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The “best” evidence depends The “best” evidence depends on the type of questionon the type of question

LevelLevel TreatmentTreatment PrognosisPrognosis DiagnosisDiagnosis

II Systemic Systemic Review of …Review of …

Systemic Systemic Review of …Review of …

Systemic Systemic Review of …Review of …

IIII Randomised Randomised trialtrial

Inception Inception CohortCohort

Cross Cross sectionalsectional

IIIIII

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Level of Evidence Level of Evidence

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Evidence-based databases

The Cochrane Library (through the Cochrane Collaboration, http://www.cochrane.org

The DARE: includes systematic reviews that have been published outside of the Cochrane collaboration, all quality-assesses and with structured summaries

http://www.crd.york.ac.uk/crdweb

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The Cochrane Controlled Trials Register (CEN-TRAL):

PubMed Clinical Queries (http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml)

SUMSearch (http://sumsearch.uthscsa.edu/): a meta-searching service

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Step 3 of evidence-based medicine practice: appraising the evidence

There are several tools for appraising a research article. One of them was developed by the Critical Appraisal Skills Programme (CASP), Oxford, UK. CASP aims to help individuals to develop the skills to find and make sense of research evidence, helping them to put knowledge into the practice.

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Step 4 of evidence-based medicine model: applying the evidence

The evidence should be fully discussed with the patient. The decision also should take into account the potential side effects of the drug (does side effect outweigh its potential benefits in a particular patient), the cost and availability of that particular treatment in the hospital or practice. The questions that we should ask before the decision to apply the results of the study are

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Factors affecting decision in applying EBM:Factors affecting decision in applying EBM:

1- pt. profile1- pt. profile

2- Availability of treatment2- Availability of treatment

3- Alternative modalities3- Alternative modalities

4- Side effects profile4- Side effects profile

5- Appropiate outcomes5- Appropiate outcomes

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Step 5 of evidence-based medicine model: evaluating clinical performance

we need to ask whether we formulate answerable questions, find best evidence quickly, effectively appraise the evidence, and integrate clinical expertise and patient preferences and values with the evidence in a way that leads to a rational, acceptable management strategy.

We need to evaluate our approach at frequent intervals and decide whether we need to improve any of the four steps discussed above.

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Evidence Based PsychiatryEvidence Based Psychiatry

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Applying concepts of EBM to Applying concepts of EBM to management of Psychiatric Disordersmanagement of Psychiatric Disorders

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Panic DisorderPanic Disorder

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Panic Disorder, With or WithoutPanic Disorder, With or WithoutAgoraphobiaAgoraphobia

Panic disorder is a chronic and recurrent Panic disorder is a chronic and recurrent illness associated with significant illness associated with significant functional impairment.functional impairment.

The estimated lifetime prevalence of The estimated lifetime prevalence of panic attacks is 15%,with a 1-year panic attacks is 15%,with a 1-year prevalence of 7.3%prevalence of 7.3%

About one-third to one-half of patients with About one-third to one-half of patients with PD also have symptoms of agoraphobiaPD also have symptoms of agoraphobia

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DSM-IV-TR of Panic AttackDSM-IV-TR of Panic Attack

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Treatment of PDTreatment of PD

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I- Approach to Psychological I- Approach to Psychological ManagementManagement

CBT is the most consistently efficacious CBT is the most consistently efficacious psychological treatment for PD, according psychological treatment for PD, according to metaanalyses (Level 1) to metaanalyses (Level 1) (Austeralian & New (Austeralian & New Zeland GL, 2003. – Glum GA, metaanalysis 1993)Zeland GL, 2003. – Glum GA, metaanalysis 1993)

Various CBT approaches to the treatment Various CBT approaches to the treatment of panic attacks have been developed of panic attacks have been developed over the years over the years (Landon et al 2004)(Landon et al 2004)

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Common components of CBT for Common components of CBT for PDPD

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Treatment RecommendationsTreatment Recommendations

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II- Approach to II- Approach to Pharmacologic ManagementPharmacologic Management

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Strength of evidence of Strength of evidence of pharmacological treatment of PDpharmacological treatment of PD.cont..cont.

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III- Combined Psychological and III- Combined Psychological and Pharmacologic TreatmentPharmacologic Treatment

Combined treatment had some advantages Combined treatment had some advantages during the acute and follow-up phases, but, during the acute and follow-up phases, but, when the medication was discontinued when the medication was discontinued after the follow-up phase, there was a after the follow-up phase, there was a considerably lower relapse rate inconsiderably lower relapse rate in

the CBT and CBT-with-placebo groups the CBT and CBT-with-placebo groups (18%), compared with the CBT-plus-(18%), compared with the CBT-plus-imipramine group (48%) and imipramine-imipramine group (48%) and imipramine-alone group (40%) alone group (40%) (Barlow et al. 2000 )(Barlow et al. 2000 )

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Diagnosis & Assessment of Diagnosis & Assessment of DeliriumDelirium

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Diagnosis & Assessment of Diagnosis & Assessment of DeliriumDelirium

Delirium characterized by :-Delirium characterized by :-

Disturbed level of consciousnessDisturbed level of consciousness

A change of cognition not better explained A change of cognition not better explained by a pre-existing dementiaby a pre-existing dementia

Disturbance develops over a short period Disturbance develops over a short period of timeof time

Evidence from the history, physical, Evidence from the history, physical, examination, or lab. Investigation that examination, or lab. Investigation that disturbance due to medications, medical disturbance due to medications, medical condition ,or substance use.condition ,or substance use.

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Assessment of DeliriumAssessment of Delirium

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3- Basic laboratory tests3- Basic laboratory tests

Blood chemistries: electrolytes, glucose, Blood chemistries: electrolytes, glucose, calcium, albumin, blood urea nitrogen calcium, albumin, blood urea nitrogen (BUN), creatinine, SGOT, SGPT, bilirubin, (BUN), creatinine, SGOT, SGPT, bilirubin, alkaline phosphatase, magnesium, alkaline phosphatase, magnesium, phosphorusphosphorus

Complete blood count (CBC)Complete blood count (CBC)

Electrocardiogram (ECG)Electrocardiogram (ECG)

Chest X-rayChest X-ray

Arterial blood gases or oxygen saturationArterial blood gases or oxygen saturation

UrinalysisUrinalysis

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4- Additional laboratory tests4- Additional laboratory tests

Urine culture and sensitivity Urine culture and sensitivity

Urine drug screenUrine drug screen

Blood tests (e.g., VDRL, heavy metal screen, BBlood tests (e.g., VDRL, heavy metal screen, B1212 and folate and folate levels, antinuclear antibody [ANA], urinary porphyrins, levels, antinuclear antibody [ANA], urinary porphyrins, ammonia level, human immunodeficiency virus [HIV], ammonia level, human immunodeficiency virus [HIV], erythrocyte sedimentation rate [ESR])erythrocyte sedimentation rate [ESR])

Blood culturesBlood cultures

Serum levels of medications (e.g., digoxin, theophylline, Serum levels of medications (e.g., digoxin, theophylline, phenobarbital, cyclosporine)phenobarbital, cyclosporine)

Lumbar punctureLumbar puncture

(CT) or (MRI)(CT) or (MRI)

(EEG)(EEG)

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Risk factors in recurrence of major Risk factors in recurrence of major Depressive DisorderDepressive Disorder

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APA Guidelines for risk factors in APA Guidelines for risk factors in recurrence of major depressive recurrence of major depressive

DisorderDisorderPrior history of multiple episodesPrior history of multiple episodes

Severity of episodesSeverity of episodes

Earlier age at onsetEarlier age at onset

Presence of an additional non affective psychiatric diagnosisPresence of an additional non affective psychiatric diagnosis

Presence of a chronic general medical disorderPresence of a chronic general medical disorder

Family history of psychiatric illness, particularly mood disorderFamily history of psychiatric illness, particularly mood disorder

Ongoing psychosocial stressors or impairmentOngoing psychosocial stressors or impairment

Negative cognitive styleNegative cognitive style

Persistent sleep disturbancesPersistent sleep disturbances

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Key components of effective Key components of effective carecareScreening & Screening &

assessmentassessment

Patient education Patient education and activationand activation

TreatmentTreatment

Care Care managementmanagement

Mental health Mental health consultationconsultation

“Collaborative Care” IAPT

program- NICE guidelines

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Integrating Ten Rules for Quality Mental Integrating Ten Rules for Quality Mental Health ServicesHealth Services

1.1. Informed ChoiceInformed Choice2.2. Recovery FocusRecovery Focus3.3. Person CenteredPerson Centered4.4. Do No HarmDo No Harm5.5. Free Access To RecordsFree Access To Records6.6. A System Based on TrustA System Based on Trust7.7. A Focus On Cultural ValuesA Focus On Cultural Values8.8. Knowledge-BasedKnowledge-Based9.9. Partnership Between Consumer & ProviderPartnership Between Consumer & Provider10.10. Access to Services Regardless Of Ability To PayAccess to Services Regardless Of Ability To PayInfusing recovery-based principles into mental health services: A white paper by Infusing recovery-based principles into mental health services: A white paper by

people who are New York state consumers, survivors, patients and ex-people who are New York state consumers, survivors, patients and ex-patients. September, 2004. New York State Office of Mental Healthpatients. September, 2004. New York State Office of Mental Health..

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SummarySummaryEBM is a great advance over informal, non-EBM is a great advance over informal, non-quantitative approaches to clinical decisions.quantitative approaches to clinical decisions.EBM should result in more effective, more EBM should result in more effective, more uniform, and more efficient medical care.uniform, and more efficient medical care.EBM is an adjunct, not a substitute for EBM is an adjunct, not a substitute for physicians who can diagnose accurately, access physicians who can diagnose accurately, access evidence efficiently, and think analytically.evidence efficiently, and think analytically.The integration of EBM with cost-benefit analysis The integration of EBM with cost-benefit analysis poses a major challenge for health policy.poses a major challenge for health policy.

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