What Is This Thing Called EBM

1
What Is This Thing Called EBM?

• Cleo Pappas, MLIS, AHIP
• Maureen Clark, MHS, MLIS

2
Definitions

• Sackett et al define EBM as the integration of
  best research evidence with clinical expertise
  and patient values.
• Sackett D L, Straus S E, Richardson W S,
  Rosenberg W Haynes R B. Evidence-based Medicine
  How to Practice and Teach EBM. Edinburgh
  Churchill Livingstone 2000.

3
Acronyms

• EBM
• EBP
• EBHC
• EBD
• EBS

4
MeSH

• Evidence-Based Medicine is a Medical Subject
  Heading.

5
Modern Environment Demands EBM

• Increase in federal funding for research
• Explosion of medical knowledge and article
  publication
• Technological development of databases capable of
  holding huge datasets
• NLM creation of MedLine

6

• How much effort effort is required and how long
  would it take to translate the research into
  clinical practice?

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Explosion of Medical Knowledge

• A 2004 study estimated it would take 29 hours per
  weekday or 351 hours per month for a physician to
  stay abreast of primary care literature.
• Alper et al. How Much Effort Is Needed to Keep Up
  with the Literature Relevant for Primary Care?
  Journal of the Medical Library Association. 2004
  October 92 (4) 429 37.

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Another definition

• EBM isan evolutionary progression of knowledge
  based on the basic and clinical sciences and
  facilitated by the age of information
  technology.
• Doherty, Steve. Evidence-based medicine
  Arguments for and Against. Emergency Medicine
  Australasia 2005 17 307-13.

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Awakening to the Need For Evidence-Based Practice
In 1972, Dr. Archie Cochrane publishes
Effectiveness and Efficiency random reflections
on health services
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Who Was Dr. Cochrane?
1909 Born in Galashiels, Scotland. 1917
Father killed in the Battle of Gaza 1927-30
King's College Cambridge. Honours Natural
Sciences. 1931 Research student with Dr N.
Wilmerat on tissue cultures 1931-34
Psychoanalysis with Theodor Reik (Vienna,
Berlin) 1934-6 Medical student, University
College Hospital 1936 International
Brigade, Spanish Civil War. 1939-46 Captain,
Royal Army Medical Corps. 1941 PoW medical
officer in Greece and Germany. 1947-48 Studied
tuberculosis epidemiology in the US. 1948-60
Medical Research Council Pneumoconiosis Research.
1960-69 Professor of Tuberculosis and Chest
Diseases, Wales. 1960-74 Dir., Medical Research
Council Epidemiology Research 1972
Effectiveness and Efficiency - Random Reflections
on Health Services. 1974-86 Completed 20
30-year follow-up of Welsh miners.
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What Dr. Cochrane Saw

• The bodys innate healing power
• 1976, Cochrane estimated less than 10 of
  medical interventions objectively demonstrated
  more good than harm
• Laymen had an uncritical belief in medicines
  cure for everything
• Concern the pursuit of a cure at all costs may
  restrict the supply of care
• Solution randomized clinical trials open up a
  new world of evaluation and control which will
  be the key to a rational health service

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Cochrane Collaboration
13
David Sackett

• Why on earth should you take any advice from any
  of us old farts who (through inattention, greed,
  or simple incompetence) got academic medicine
  into the simply awful mess in which you find it
  today?
• BMJ 2004 329294 (31 July)

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Dr. David Sackett

• M.D. (UIC), Doctor of Science (Bern), M.S. in
  Epidemiology (Harvard)
• Professor Emeritus of Clinical Epidemiology and
  Biostatistics at McMaster University.
• Physician-in-chief of medicine at
  Chedoke-McMaster hospitals

15
Dr. David Sackett

• Head of the division of general internal medicine
  at McMaster
• Professor of clinical epidemiology at Oxford
• Founding director of the National Health Service
  RD Centre for Evidence-Based Medicine at Oxford
• Canadian Medical Hall of Fame in 2000

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The Process

• EBM begins and ends with the individual clinician
  treating the individual patient.

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What are we asking?

• Etiology
• Diagnosis
• Therapy
• Prognosis/Harm

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Process

• Formulating the question

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PICO

• Patient
• Intervention
• Comparison
• Outcome

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Patient
21
Intervention
22
Comparison
23
Outcome
24
The Process

• Conducting the search

25
The Process

• Appraising the evidence -

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Validity

• Is there a clearly defined question?
• Was the question focused in terms of the
  population group actually studies, the
  intervention received, and the outcomes
  considered?
• Is there a control group

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Validity

• Were the groups randomized?
• Were all the patients accounted for at the
  conclusion? (Intention to Treat)
• After finding a study that addresses our
  question, the study needs to be analyzed further
  in terms of its statistical quality.

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EBM begins and ends with the individual
clinician treating the individual patient.
29
Tools

• Clinical Queries in PubMed
• Meta-analysis in PubMed
• Online calculators
• Specialized databases Cochrane, Pier

30
Resources

• Studying a Study and Testing a Test (Lippincott
  Williams Wilkins 5th edition (October 1, 2004)
  ISBN0781745764 )
• Evidence-based Medicine Toolkit (Blackwell
  Publishing Limited 2 edition (April 1, 2006)
  ISBN0727918419 )
• Evidence-based Medicine How to Practice and
  Teach EBM (Churchill Livingstone 3 edition
  (April 29, 2005) ISBN 0443074445)