The Practice of Evidence-Based Medicine (EBM) PDF

PHARMACY INFORMATICS 2. EBM posits a hierarchy of evidence to guide clinical decision-making. THE PRACTICE OF EVIDENCE-BASED MEDICINE (EBM)...

PHARMACY INFORMATICS 2. EBM posits a hierarchy of evidence to guide clinical decision-making. THE PRACTICE OF EVIDENCE-BASED MEDICINE (EBM) 3. Evidence alone is never sufficient to make a clinical decision. - Evidence-based medicine (EBM) combines the practitioner’s clinical expertise and the THE FIVE A’s OF EVIDENCE-BASED PRACTICE patient’s desires and values with the The practice of EBM during patient care is conducted conscientious and judicious use of the by the following steps, described as the five A’s: current best evidence from the clinical literature to improve clinical decision-making. 1. ASSESS the patient of information needed. 2. ASK a focused clinical question. It tests the clinical expertise to identify the 3. ACQUIRE the best available evidence to patient’s diagnosis, risk and benefits, and the answer the question. specific clinical circumstances. Wherein the 4. APPRAISE the quality of the evidence. patient will improve. Thus, EBM is the clinical 5. APPLY the new information to patient care. judgment in order to make the best possible healthcare decision for your patients. 1. ASSESSING THE PATIENT Example case: A 37-year-old female patient is admitted to the hospital with fever, jaundice, and a tender liver after a 1-week alcohol binge. She is diagnosed with alcoholic hepatitis. You are on rounds with the medical team caring for the patient, and they reported that the liver specialist has recommended pentoxifylline therapy for this patient. The physicians have not used this treatment before and want to know whether it will really decrease her risk of mortality. They ask you to research this further and bring information to the team. Assessing the information: Research further Clinical Judgment- this is not only based on and bring information to the team. Gather its own opinion. However, this is based on information regarding pentoxifylline. the expert or condition that is scientific evidence and the patient's values and 2. ASKING FOCUSED CLINICAL preferences. QUESTIONS: The PICO format - A well-formulated clinical question is Patient’s Values and Preferences- refer to important in the practice of EBM. the patient's concern, expectation, and - The important part of EBM. This exercises preferences. us to build our focus question. Relevant Scientific Evidence- the current PICO format: best evidence. This should be high quality P- a word or phrase for the patient or clinical problem and relevant scientific research. I - the intervention C - any comparison intervention being considered (if present) THREE FUNDAMENTAL PRINCIPLES OF EBM O - outcome of concern 1. Optimal clinical decision - making requires “A 37-year-old female patient is admitted to the awareness of the best available evidence. hospital with fever, jaundice, and a tender liver after a Continuous Professional 1-week alcohol binge. She is diagnosed with alcoholic Definitely- make up-to-date hepatitis. You are on rounds with the medical team development. caring for the patient, and they reported that the liver BM & KM 1  PHARMACY INFORMATICS specialist has recommended pentoxifylline therapy for immediately after its release; has a this patient. The physicians have not used this feature to limit results to only systematic treatment before and want to know whether it will reviews or meta-analysis papers. Have really decrease her risk of mortality. They ask you to the most current and comprehensive research this further and bring information to the evidence results. team.” National Maintained by the agency for healthcare In your PICO format, the terms become: Guideline research and quality (AHRQ), this Clearinghous database provides comprehensive P - patient with alcoholic hepatitis e (NGC) evidence-based clinical practice I - pentoxifylline guidelines and alphabetically lists many C - (none for this case) disease states and interventions. Has O - reduced mortality concise information. Formulated clinical question: Does pentoxifylline TRIP Devoted to evidence-based medicine reduce mortality in patients with alcoholic hepatitis? (TurningTurnin only. It has the capacity to be searched g Research by medical images, evidence-based into Practice) medicine, and patient leaflets. Another example: Database A 30-year-old pregnant woman was admitted with severe hypertension. The symptoms get progressively worse and you wonder whether giving Nifedipine Subscription EBM Content might help the woman improve her symptoms and Databases reduce teratogenic effects as compared to Captopril. ACP Journal Club A journal that reviews over 100 P = 30-year-old pregnant woman with severe American College other internal medicine journals in of Physicians order to publish short summaries of hypertension those articles considered by EBM I = Nifedipine experts to be of the highest quality C = Captopril and greatest importance to the field O = Improve the symptoms and reduce teratogenic of internal medicine. effects Formulated clinical question = Does Nifedipine British Medical A database provides a improve the symptoms and reduce the teratogenic Journal (BMJ) comprehensive collection of effects compared to Captopril in 30-year-old pregnant journals from other online databases and assists clinicians in woman with severe hypertension? answering the questions most relevant to clinical practice. 3. ACQUIRING EVIDENCE: DIFFERENT RESOURCES FOR DIFFERENT Cochrane Review Provides very high-quality, INFORMATION NEEDS evidence-based reviews addressing well-researched clinical questions. Essential Evidence A database that was created to Plus assist health care professionals in facilitating evidence-based decision making; gives access to over 13000 topics, guidelines, abstracts and summaries. UpToDate Contains thousands of chapters on basic pathophysiology and current treatment recommendations for Free EBM Content diseases of interest. Weakness: Databases very expensive subscription. PubMed Maintained by the national library of medicine, contains millions of biomedical CONDUCTING THE SEARCH citations from other databases BM & KM 2 PHARMACY INFORMATICS - Once the key words and databases have 4. APPRAISAL: making sure the evidence is been identified, the next thing is to run the good search. At the basic level, an efficient method is to use BOOLEAN SEARCH, - Research the evidence may be appraised which allows user to combine individual with regard to three main areas: validity, words or terms using the Boolean operators importance, and applicability to the patient or “AND”, “OR” and “NOT” to further produce patients of interest. more results. MAKING SURE THE EVIDENCE IS GOOD Examples: - The simplest way to make sure that the evidence has quality is to use evidence from “Alcoholic Hepatitis AND Pentoxifylline AND a trusted resource that has been mortality” prescreened/reviewed by EBM experts. “Pregnant with severe hypertension OR Nifedipine OR Captopril OR improve symptoms” “Alcoholic hepatitis NOT pentoxifylline” 5. APPLYING EVIDENCE TO PATIENT CARE Ask if: - Can it really be applied to the current problem? - Are the treatment benefits worth the potential harms and costs? - Were all clinically important outcomes considered? EVALUATING PERFORMANCE After treatment, follow-ups are made in order to check on the resolution of the disease or disorder and to see if there are complications encountered when applying the intervention. This would then prompt the practicing physician to An evidence pyramid visually depicts the evidential take note of the results and conduct a case study to strength of different research designs. Studies with contribute to the ever-growing reservoir of medical the highest internal validity, characterized by a high information. degree of quantitative analysis, review, analysis and It's important to follow up and evaluate stringent scientific methodology, are at the top of the whether the therapy plan is effective or not. pyramid. Observational research and expert opinion SOAP format - Subjective, Objective, reside at the bottom of the pyramid. Assessment, Plan. Top part of Pyramid- Strong Bottom part of Pyramid- Weak BM & KM 3