Evidence-Based Veterinary Medicine PDF

EVIDENCE-BASED VETERINARY MEDICINE: AN INTEGRAL TO THE ADVANCEMENT OF THE PRACTICE Emmanuel P. Hernandez, DVM, DVSc WHEN FACED WITH UNCERTAINTY FOR THE BEST AND MOST CURRENT APPROACH TO A CLINICAL PROBLEM 1. Traditional tried and true protocols 2. Personal experience or clinical int...

EVIDENCE-BASED VETERINARY MEDICINE: AN INTEGRAL TO THE ADVANCEMENT OF THE PRACTICE Emmanuel P. Hernandez, DVM, DVSc WHEN FACED WITH UNCERTAINTY FOR THE BEST AND MOST CURRENT APPROACH TO A CLINICAL PROBLEM 1. Traditional tried and true protocols 2. Personal experience or clinical intuition 3. Seek advice from experts in the field 4. Rely on Evidence Based Veterinary Medicine “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. ” -Sacket et al., 2000  Research “Integration of best evidence Evidence with our clinical expertise and our patient’s unique EBM values and Clinical Patient’s circumstances” Expertise Values -Strauss et al  “Its heart is the confidence in the scientific methodology that has been developed over the centuries to enable us to distinguish what is likely to be true from what is likely to be false (or unproven) ” -Cockroft and Holmes  Clinical experience is a valid way in understanding about diagnosis and prognosis of treatment Traditional Methods Pathophysiology rationale is a valid way to guide treatments Common sense and classical COMPARISON OF THE medical training are the only qualities to evaluate medical TRADITIONAL METHODS literature AND EBVM Personal experiences may be misleading Predictions based upon physiology Lorna Alvarado may be wrong EBVM Reading literature requires more than common sense to evaluate the evidence  CLINICAL APPLICATIONS OF EBVM 1. confidence in your own clinical decision-making 2. dealing with information overload 3. developing a structured approach to using reliable evidence-based methods 4. demonstrating Quality Improvement in practice  5As of EVIDENCE BASED PRACTICE (Strauss, et al , 2005) ACCESS APPLY Finding information / best Integrate the appraisal, with evidence to answer the clinical expertise and question ACCESS APPLY client’s values and condition ASK APPRAISE AUDIT ASK APPRAISE AUDIT/ASSESS Translation of a clinical Assessing the evidence for its validity Evaluation of the effectiveness problem into an (closeness to the truth), impact (size and efficiency in executing answerable question of the effect), and applicability previous steps and seek ways (usefulness in practice) to improve them  TOPIC AREAS OF QUESTIONS 1. treatment 2. prognosis and incidence 3. etiology and risk 4. diagnosis 5. prevalence ”ONE CANNOT GET A CLEAR ANSWER TO A VAGUE QUESTION” JOHNSON, 1946 ASK Refine clinical questions so that evidence can be found. Patient In adult female dogs, Intervention does neutering versus non-neutering Comparison decreases the risk of Outcome mammary tumors? ”USE THE BEST EVIDENCE AVAILABLE TO YOU” From: Nielsen et al., 2015  ACCESS www.cabi.org/vetmedresource www.pubmed.ncbi.nlm.nih.gov www.knowledge.rcvs.org.uk www.scopus.com www.webofscience.com www.bestbetsforvets.org ACCESS Patient In adult female dogs, Intervention does neutering versus non-neutering Comparison decreases the risk of Outcome mammary tumors?  dogs, dog, bitches, Patient bitch, canine neutering, spaying, Intervention ovariohysterectomy, ovariectomy, gonadectomy Comparison “not applicable” mammary, breast, tumour, Outcome cancer, neoplasia, neoplasm, mass, lump, carcinoma  APPRAISE SYSTEMATIC REVIEWS LEVEL OF EVIDENCE META-ANALYSES WEBSITE BLINDED RANDOMIZED CONTROL TRIALS COHORT STUDIES CASE CONTROL STUDIES Stronger CASE SERIES Evidence Weaker Evidence SINGLE CASE REPORT IDEAS, EDITORIALS, OPINIONS, CONSENSUS REPORTS COMPARATIVE ANIMAL RESEARCH “IN VITRO” TEST TUBE RESEARCH  Group assignment was randomized and blinded All patients were accounted for Experimental Intent to treat analysis Same baseline characteristics APPRAISE Size of the effect of intervention was QUALITY OF clinically relevant EVIDENCE Clearly defined comparison groups Observational Outcomes measured in same, objective way between groups Sufficient follow up time ”NEGATIVE EVIDENCE IS MORE RELIABLE” -MC KENZIE, 2015 ”STATISTICAL SIGNIFICANCE does not mean BIOLOGICAL SIGNIFICANCE” GET SOMEONE ELSE TO DO IT FOR YOU www.bestbetsforvets.org www.veterinaryevidence.org www.cochranelibrary.com  APPLY Should be performed, I BENEFITS >>> RISK is recommended IIA BENEFITS >> RISK Is reasonable to perform IIB BENEFITS ≥ RISK May be considered III RISK > BENEFITS Should not be performed  “The circumstances of each patient, and the circumstances and values of the owner/carer, must also be considered when making an evidence-based decision” -Centre for Evidence-Based Veterinary Medicine AUDIT “It is vital to assess what we do in order to ensure our practice is responding and adapting to the advances in the profession.”  CHALLENGES OF EBVM TIME ACCESS TO DATA CLIENT ACCESS DEARTH OF EVIDENCE  WHEN YOU GET ZERO RESULTS 1. The evidence does not exist 2. The evidence can’t be found in the database 3. The evidence exist in database, but we are not finding it 4. The evidence exist, but we cannot access it  COLLABORATION and EVIDENCE CREATION PRACTICE RESEARCH