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Evidence-Based Medicine By Dr. Nelly Hegazy Lecturer of Public Health & Community Medicine Research Methodology 1 INTENDED LEA...

Evidence-Based Medicine By Dr. Nelly Hegazy Lecturer of Public Health & Community Medicine Research Methodology 1 INTENDED LEARNING OBJECTIVES (ILO) By the end of this session the candidate will be able to: 1. Define Evidence-Based Medicine 2. Identify the need for EBM 3. Illustrate the 3 components of EBM 4. Demonstrate THE FIVE BASIC STEPS OF EBM 2 Research Methodology The origin of EBM, can be traced back to the late 1980s, or even earlier when in 1970 a committee of physicians and administrators tried to evaluate literature to understand how health professionals learn and keep up-to-date after they graduate. However, It first appeared in medical literature in 1991, when it was proposed by a group of academic physicians as a new way of teaching the practice of medicine. It was based on the belief that a paradigm shift was occurring, from “intuition, unsystematic clinical experience and pathophysiological rationale” to an emphasis on evidence collected from research.. Research Methodology 3  The new approach was consolidated and named EBM in 1992 by a group led by Gordon Guyatt from the Department of Clinical Epidemiology and biostatistics at McMaster University in Ontario, Canada EBM It is a change in the way physicians practice medicine, teach and learn, and handle research Research Methodology 4  Medical knowledge grows every day, Medical research is continually discovering improved treatment methods and therapies. Not all studies are equally well-designed, conducted or interpreted Practitioners must keep up to date with current research The doctor should spend most of its work hours only to review all published articles and studies. On the other side, even if the doctors find the time to read all of them, they would be lack the time to evaluate the value of the study, its methodology, outcome and transparency. That is why a need occurs that the doctor, with his limited time, read selectively, make effective selection of what he reads, and what not 5 Research Methodology  What is Evidence-Based Medicine? Evidence-based practice is the conscientious explicit and judicious use of current best evidence in helping individual patients make decisions about their care in the light of their personal values and beliefs Conscientious: being careful, and thorough, in what you do Explicit: being up-front, open, clear and transparent Judicious: using good judgement and common sense The aim of EBM is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management. Research Methodology 6  It is a change in the way physicians practice medicine, teach and learn, and handle research. Clinical practice: Based on the best current evidence (not necessarily on how it’s always been done) Patient Care: Compassionate, patient-oriented Learning & Teaching: Problem-based, problem-solving more investigative, less know-it-all-by-yesterday Research: More stringent approach, better proof criteria Research Methodology 7 oWhat are the 3 PATIENT components of EBM? Question or Problem PHYSICIAN INFORMATION Research Methodology 8 THE ADDED DETAILS PATIENT Values, Concerns Preferences, Expectations Life predicament EBM PHYSICIAN INFORMATION Training & Experience Clinically relevant Current Expertise Proven by research Continued learning Best up-to-date evidence Demand for proof Research Methodology 9  THE FIVE BASIC STEPS OF EBM 5 As Technique 1- Clinical Question ( ASK) Patient-focused, problem-oriented 2- Find Best Evidence ( Acquire) Literature Search 3- Critical Appraisal (APPRAISE) Evaluate evidence for quality and usefulness 4- Apply the Evidence (Apply) Implement useful findings in clinical practice 5- Evaluate (Assess) The information, intervention, and EBM process Research Methodology 10  Step 1: Clinical Question ( ASK) The FIRST step The HARDEST step The MOST IMPORTANT stepearned In every consultation decisions need to be made. Many of these are done almost subconsciously, with little or no formal critical evaluation. Questions frequently arise, such as the pros and cons of using a particular form of therapy, the value of having a particular diagnostic test or screening procedure, the risk or prognosis of a particular disease, or the cost (and cost-effectiveness) of a potential intervention. Research Methodology 11  Step 1: Clinical Question ( ASK) WHEN PRACTICING EBM, a good question must also: Be specific Identify the problem, clarify the clinical issue Asking good Be answerable questions is through the literature a skill to be Contain multiple aspects learned (patient, options, comparisons, etc) It should NOT involve a question of Personal Preference or Local Concern. Research Methodology 12  Step 1: Clinical Question ( ASK) FRAMING THE QUESTION (Example: PICO/PECO) P PATIENT type of patient or population Ex: 47 years male with DM2 and cellulitis toe, 25 years old female with DVT and chest pain I INTERVENTION Clinical intervention Ex: Medication, Procedure, test, surgery, radiation, drug, vaccine.( E :EXPOSURE Environmental, personal, biological (PECO) Ex: TB, tobacco, drug, diet, pregnancy or menopause, MRSA, allergy) C COMPARISON compare alternative treatment Ex: Other prior, new or existing therapy. O OUTCOME: clinical outcome of interest Ex: Reduced death rate in 5 yrs., decreased infections, fewer hospitalizations. Research Methodology 13 Step 1: Clinical Question ( ASK) Research Methodology 14 Step 1: Clinical Question ( ASK) Research Methodology 15 Research Methodology 16  THE FIVE BASIC STEPS OF EBM 1- Clinical Question ( ASK) 5 As Technique Patient-focused, problem-oriented 2- Find Best Evidence ( Acquire) Literature Search 3- Critical Appraisal (APPRAISE) Evaluate evidence for quality and usefulness 4- Apply the Evidence (Apply) Implement useful findings in clinical practice 5- Evaluate (Assess) The information, intervention, and EBM process Research Methodology 17  Step 2: Find Best Evidence ( Acquire) EBM Resources :EBM Resources can be divided into three major categories Research Methodology 18  Step 2: Find Best Evidence ( Acquire) Background Information Resources They provide broad overviews of medical topics, which helps increase the understanding of the topics and acquaint you with the related evidence- based literature. Examples of Background Information Resources: Evidence-Based Topic Overviews Broadly summarize the available evidence-based literature on topics without specifically focusing on a particular clinical question. Evidence-Based Practice Guidelines and Consensus Statements Considered treatment guidelines, often published and updated by government or professional associations, represent the gold standard treatment strategies for common diseases. Research Methodology 19 Step 2: Find Best Evidence ( Acquire) Filtered Information Resources Once you have a solid understanding of your topic, next investigate Filtered Information Resources. These resources, called “synthesized” resources, are structured to save you time and effort by providing varying levels of analysis. Examples of Filtered Information Resources: ❖ Cochrane Systematic Reviews Utilize explicit methods to collect, critically appraise, and summarize the best available medical literature. Cochrane Systematic Reviews answer a specific clinical question. Reviews are among the studies of highest scientific evidence.Minimum Bias: Evidence is included/excluded on the basis of explicit quality criteria ❖ Non-Cochrane Systematic Reviews A Systematic Review in general is “an overview of primary studies that used explicit and reproducible methods”. Example : Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews ❖ Critically Appraised Articles Critically Appraised Articles analyse a single research article, judge its validity, and publish an enhanced abstract of the article. Example : ACP journal club Research Methodology 20  Step 2: Find Best Evidence ( Acquire) Unfiltered Information Resources If there is no filtered information on your topic ,you will need to access individual journal articles and studies. However, because generally journal articles and studies are not evaluated you will need to analyse your found articles and studies to determine their quality. Examples of Unfiltered Information Resources: Journal Articles Research articles found in journals often investigate one topic in detail and require critical evaluation on the reader’s part. MEDLINE is the premier source for biomedical journal articles. MEDLINE is available through PubMed. Research Methodology 21 Research Methodology 22 Research Methodology 23 Research Methodology 24  Research Methodology 25  THE FIVE BASIC STEPS OF EBM 5 As Technique 1- Clinical Question ( ASK) Patient-focused, problem-oriented 2- Find Best Evidence ( Acquire) Literature Search 3- Critical Appraisal (APPRAISE) Evaluate evidence for quality and usefulness 4- Apply the Evidence (Apply) Implement useful findings in clinical practice 5- Evaluate (Assess) The information, intervention, and EBM process Research Methodology 26  Step 3: critically appraising the information (APPRAISE) ❖Critical appraisal of articles is a process which involves carefully reading an article and analysing its methodology, content, and conclusions. Appraisal principles (primary and secondary research) ❑What is the PICO of the study? Does it match my question? ❑How well was the study done? Is it biased? ❑What do the results mean? Are they real and relevant? (The key question to keep in mind is: “Do I believe these results sufficiently that I would be prepared to adopt a similar approach, or reach a similar conclusion, with my own patients?”) ❖There are a range of different approaches to critical appraisal, depending on the type of question being asked. The skill of being able to critically appraise articles needs to be learned and practised like any other clinical skill Research Methodology 27  THE FIVE BASIC STEPS OF EBM 1- Clinical Question ( ASK) 5 As Technique Patient-focused, problem-oriented 2- Find Best Evidence ( Acquire) Literature Search 3- Critical Appraisal (APPRAISE) Evaluate evidence for quality and usefulness 4- Apply the Evidence (Apply) Implement useful findings in clinical practice 5- Evaluate (Assess) The information, intervention, and EBM process Research Methodology 28  Step 4: applying the evidence Integrate appraised evidence with own clinical expertise and patient’s preferences Question to ask: Is the intervention feasible in my settings? What alternatives are available? Is my patient so different then those in the study that the results cannot apply ? Will the potential benefits outweigh the potential harms of treatment ? What does my patient think? What are his cultural beliefs? Research Methodology 29  THE FIVE BASIC STEPS OF EBM 1- Clinical Question ( ASK) 5 As Technique Patient-focused, problem-oriented 2- Find Best Evidence ( Acquire) Literature Search 3- Critical Appraisal (APPRAISE) Evaluate evidence for quality and usefulness 4- Apply the Evidence (Apply) Implement useful findings in clinical practice 5- Evaluate (Assess) The information, intervention, and EBM process Research Methodology 30  Step 5: Evaluating (Assess) ❑The final step in using an EBM approach is Evaluating our effectiveness and efficiency in executing Steps 1-4 and seeking ways to improve them both for next time ❑ As we incorporate EBM into routine clinical practice, we need to evaluate our approach at frequent intervals and to decide whether we need to improve on any of the four steps discussed above. ❑we need to ask whether we are formulating answerable questions, finding good evidence quickly, effectively appraising the evidence, and integrating clinical expertise and patient’s values with the evidence in a way that leads to a rational, acceptable management strategy. Research Methodology 31 ❑There is nothing particularly conceptually difficult about these five steps; they can be readily taught at an undergraduate level and then reinforced at a postgraduate level. ❑The practical problem in the “real world” facing busy general practitioners is having sufficient time to apply these steps routinely in their daily practice. Research Methodology 32  Email: [email protected]  SUGGESTED REFERENCES & REQUIRED READINGS 1. http://www.bumc.bu.edu/medlib/resources/tutorials/introduction-to evidence-based-medicine/ebm-intro-p6/ 2. https://www.asha.org/research/ebp/ 3. Sackett DL, Strauss SE, Richardson WS,et al.Evidence-based medicine: how to practice and teach EBM. London: Research Methodology Churchill-Livingstone,2000. 34