* المرحلة الرابعة طب مجتمع د.مؤيد العدد10 19\2\2018
تسلسل 3* Methodology in EBM The practice of EBM requires access to evidence and a change in the way medical decisions are made. Health care practitioners, who have in the past primarily relied on their individual experience, medical textbooks and expert opinion, will be expected to integrate the results of recent, valid and relevant research into their individual patient decisions. Several sources of clinical evidence are available, and using information technology significantly facilitates the search process.
Access to current clinical evidence ranges from: 1. Journal subscriptions (paper or electronic), to 2. Electronic information systems that include collections of books, journals and databases. 3. Systematic reviews, such as those from the Cochrane Collaboration, are also available. 4. Specialized or general evidence-based databases, such as Ovid's Evidence Based Medicine Reviews can also be searched to obtain abstracts of articles that have been appraised for merit and relevance.
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Practicing EBM involves using the best clinical evidence, obtained using an exact (precise and accurate) methodology, to make decisions for an individual patient or population.The exact EBM methodology entails the use of a “problem solving algorithm” [involving]:(1) Formulating answerable questions, (2) Gathering evidence, (3) Evaluating the evidence, (4) Putting evidence into practice, and (5) Evaluating the results of putting evidence into practice. *
Ask
Acquire
Appraise
Apply
Act & Assess
Patient dilemma
Principles of evidence-based practice
Evidence alone does not decide – combine with otherknowledge and values Hierarchy of evidence
Process of EBP
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1. Formulating answerable questions: The first step in EBM is by converting a clinical situation into a searchable, (and hopefully answerable) question using PICO: 1. PATIENT. 2. INTERVENTION. 3. COMPARISON. 4. OUTCOME.
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PICO(P): “Patient” refers to the person presenting with the problem, or more simply, to the “problem” itself. Both concepts are important in searching.(I): “Intervention” refers to the action taken in response to the problem. This is often a drug or surgical procedure, but it can take many forms.(C): “Comparison” refers to the benchmark against which the intervention is measured. Often it refers to another treatment, no treatment, or a placebo.(O): “Outcome” refers to the anticipated result of the intervention. *
Clinical Scenario You are seeing a 60 years old lady with knee OA not responding to NSAIDs, you know that IA steroid may improve her condition, but it is safety measure or not NOW PICO will be: P (patient): Knee OA I (intervention): IA steroids C (comparison): NSAIDs O (outcome): Safety The query will be a network searchable and hopefully an answerable one as the following Knee OA IA steroids Vs NSAIDs Safety
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(2) gathering evidence:
*Systematic review and meta-analysis: (systematic review) by identifying all valid published information in a given clinical area (with the same study design) and pooling the results in a statistically valid fashion (meta-analysis), thus, it is possible to arrive at a more precise estimate of treatment effect. This approach is very attractive, as it allows all evidence in the field of interest to be taken into account.
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Study
RR (95% CI)0.23 (0.03,1.75)
Fletcher
0.57 (0.20,1.66)
Dewar
1.35 (0.74,2.45)
1st European
1.22 (0.67,2.24)
Heikinheimo
1.01 (0.55,1.85)
Italian
0.70 (0.53,0.92)
2nd European
0.46 (0.25,0.83)
2nd Frankfurt
0.78 (0.48,1.27)
1st Australian
2.38 (0.65,8.71)
NHLBI SMIT
1.05 (0.48,2.28)
Valere
0.96 (0.33,2.80)
Frank
0.90 (0.63,1.28)
UK Collab
2.57 (0.34,19.48)
Klein
0.61 (0.42,0.89)
Austrian
0.28 (0.03,2.34)
Lasierra
1.16 (0.84,1.60)
N German
0.81 (0.26,2.51)
Witchitz
0.85 (0.54,1.34)
2nd Australian
0.51 (0.33,0.78)
3rd European
0.88 (0.62,1.25)
ISAM
0.83 (0.75,0.91)
GISSI-1
0.77 (0.70,0.84)
ISIS-2
0.80 (0.75,0.85)
Overall (95% CI)
Risk ratio
0.1
1
10
Streptokinase for Myocardial Infarction
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SIGN classification for grading evidence:1++ High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias1– Meta-analyses, systematic reviews, or RCTs with a high risk of bias2++ High-quality systematic reviews of case-control or cohort studiesHigh-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal2+ Well-conducted case-control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal2– Case-control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal3 Non-analytic studies; for example, case reports, case series4 Expert opinion SIGN: Scottish Intercollegiate Guidelines Network *
Searching Tools:MEDLINE: Include both;1. PubMed (clinical queries)2. Ovid (Cochrane’s data Base & Best Evidence)Thus the question here could be as:If you directly go to Yahoo or Google search engine Knee OA IA steroids Vs NSAIDs Safety PubMed orKnee OA IA steroids Vs NSAIDs Safety Best Evidence orKnee OA IA steroids Vs NSAIDs Safety EBM *
To be more focused, the search question will be: Knee OA IA steroids Vs NSAIDs Safety Best Evidence Meta-analysis or Knee OA IA steroids Vs NSAIDs Safety Best Evidence Systematic reviews or Knee OA IA steroids Vs NSAIDs Safety EBM Meta-analysis or Knee OA IA steroids Vs NSAIDs Safety EBM Systematic reviews
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Or, by entering to the EBM website directly and here you can choose with many different qualities of options such as the following:
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Does a normal ECG rule out a serious elevation of potassium?
*Diagnosis button
* Means any letters
“OR” synonyms PubMed via Google
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Diagnosis button
*Sensitivity of 62% or 55%
*Databases included in The Cochrane Library: 1. The Cochrane Database of Systematic Reviews. 2. The Database of Abstracts of Reviews of Effects (DARE). 3. The Cochrane Central Register of Controlled Trials. 4. The Health Technology Assessment Database. 5. The NHS Economic Evaluation Database.
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Cochrane Systematic Reviews (522; another 500 in preparation) Database of Abstracts of Reviews of Effectiveness (1895) Registry of Randomised Controlled Trials (218,355)
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Can we get evidence to the bedside?
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Internet access is required to incorporate EBM into the medical environment. Bringing EBM to the bedside using wireless devices, however, is more complex. Although it seems reasonable that practicing EBM at the bedside using mobile devices would increase efficiency, several barriers to bedside implementation have been identified. These include privacy and security concerns, time constraints, negative patient perceptions, and ease of use challenges.
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Now Why bother with Evidence-Based Practice?
*With EBM you will be: 1. Scientific professional physician. 2. Master in your specialty. 3. Quickly lifetime. 4. Your experience will be > 10 000 hours forward and > 10 years.
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At the end, we should remember that EBM is not cook-book medicine Because EBM is the integration of: best available evidence with clinical expertise and patient preference
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http://bmjupdates.mcmaster.ca
*What you need more??????????1. Users sign up according to discipline.2. Users control relevance and flow.3. Users can change disciplines at any time, and can sign up for as many as they wish.4. Users can search according to discipline – or not.5. Users can access PubMed Clinical Queries.(can monitor individual use, if agreed) *
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Dear Dr. Haynes, We want to alert you to NEW articles in the PLUS system. These articles that have received very high relevancy and newsworthiness scores:
1. Brazg R, et al. Effect of adding sitagliptin, a dipeptidyl peptidase-4 inhibitor, to metformin on 24-h glycaemic control and beta-cell function in patients with type 2 diabetes. Diabetes Obes Metab. 2007;9:186-93.
Rated by: IM/General (patients referred from Primary Care)
Relevance: 5 of 7Newsworthiness: 5 of 7
We hope that you will find these articles of value in your clinical practice. Best wishes from the PLUS Team
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