An Introduction to Evidence Based Medicine EBM and The Cochrane Library

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An Introduction to Evidence Based Medicine (EBM)
and The Cochrane Library

• February 8, 2007
• Charles Wood

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Session Outline

• Part 1 Principles of EBM
• Part 2 Formulating Questions
• Part 3 Finding Evidence

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Part 1 - Principles of EBM
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EBM - Background

• A Canadian connection!
• The term "evidence based medicine" was coined at
  McMaster Universitys Medical School in the
  1980's to label a clinical learning strategy
  people at this school had been developing for
  over a decade. (BMJ 1995. 3101122 MeSH, NLM,
  2004)
• The term EBM now encompasses
• A philosophy
• A clinical strategy
• An application

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EBM - Philosophy

• Evidence-Based Medicine is the conscientious,
  explicit and judicious use of current best
  evidence in making decisions about the care of
  individual patients. In practice, this means
  integrating individual clinical experience with
  the best available external evidence from
  systematic research.
• (Sackett et al., 1996. Evidence based medicine
  what it is and what it isn't.BMJ, 312 71-2)

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EBM Clinical Strategy

• EBM is the process of systematically finding,
  appraising, and using contemporaneous research
  findings as the basis for clinical decisions.
• EBM encourages health professionals to ask
  questions, find and appraise relevant data, and
  then apply that information to their everyday
  clinical practice.
• (MeSH, NLM, 2004)

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EBM Clinical Strategy

• EBM ? EBHC
• Evidence-Based Health Care (EBHC) extends the
  application of the principles of EBM to all
  professions associated with health care. (CEBM,
  Oxford, 2004)
• Large scale adoption and adaptation across
  several practice areas/fields/disciplines Why?
• EB Nursing, EB Mental Health, EB Pediatrics, EB
  Public Health, EB Clinical Practice, EB
  Health Administration, etc.

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EBM Clinical Application

• How to practice EBM
• Five steps
• Question - Take your need for information about a
  patient problem and formulate a clear, concise,
  clinical question (3 Cs)
• Search the literature for best evidence to help
  you answer that question
• Critically appraise the evidence for its validity
  and applicability
• Integrate this critical appraisal with clinical
  expertise and patient information, such as
  values, unique biology, current health status,
  etc.
• Evaluate your effectiveness and efficiency in
  executing Steps 1-4 and seek ways to improve them
  both for next time
• Sackett DL et al. (2000). Evidence-based
  Medicine How to Practise and Teach EBM

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Principles of EBM

• So what is best evidence?
• Highest quality ?
• Lowest quality ?

• Clinical research

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What is a systematic review?

• Systematic reviews are concise summaries of the
  best available evidence that address clear,
  concise, clinical questions (3 Cs). They
  represent the explicit and rigorous use of
  methods to identify, critically appraise, and
  synthesize relevant studies.
• (Mulrow, Cook, Davidoff, 1998).

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Part 2 Formulating Questions
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Constructing a Question

• Construct a question using the PICO model
• Population
• How would you describe a group of patients
  similar to yours?
• Intervention
• Which main intervention, prognostic factor or
  exposure are you considering?
• Comparison
• What is the main alternative to your
  intervention?
• Outcome
• What are you trying to do for the patient
• Relieve or eliminate symptoms?
• Reduce the number of adverse effects?
• Improve function or test scores?

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Case Study

• George
• active 83 year old male.
• swims 3 times a week for 45 minutes.
• still drives a car.
• has developed pain in his left knee.
• The physicians diagnosis is osteoarthritis. She
  suggests that a course
• of physical therapy would be beneficial.
• George has had physical therapy before for his
  back, and is very
• sceptical of this suggestion. He wants to know is
  there any proof
• that physical therapy does any good for this
  problem. He is also curious whether
• drug therapy would be effective.

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Forming a question

• Population osteoarthritis of the knee, elderly
• Intervention Physical therapy
• Comparison Drug therapy
• Outcome comfort
• Can physical therapy for osteoarthritis of the
  knee improve comfort and mobility in elderly
  patients?

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Part 3 Finding Evidence
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Where do I look for the best evidence?

• Databases
• The Cochrane Library
• PEDro for physical therapy, OTseeker for
  occupational therapy
• OVID Databases MEDLINE, CINAHL, PsycINFO,
  HealthSTAR, etc.
• Important Note When using the OVID resources,
  you need to apply limits under publication
  type/format such as, reviews, systematic reviews,
  and/or randomized control trials in order to
  isolate the type of evidence you are looking for.

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Cochrane Collaboration

• Produce The Cochrane Library
• Established in 1992
• Named after Dr. Archie Cochrane, who in the
  1970s, championed the idea that up-to-date,
  systematic reviews of medical research must be
  readily available in order to make informed
  healthcare decisions.

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Cochrane Collaboration

• Who is involved?
• Volunteer health professionals, researchers,
  translators, and health care consumers from
  around the world
• These people are organized into topic focused
  groups called Collaborative Groups

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Cochrane Collaboration

• What is their objective?
• Aim to help people make well informed decisions
  about health care by preparing, maintaining, and
  ensuring the accessibility of systematic reviews
  on the effects of health care interventions. (The
  Cochrane Collaboration)

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Cochrane Collaboration

• How do they accomplish this?
• Identify specific topics
• Evaluate and compare all medical research studies
  relevant to that topic
• Analyze the results of these studies
• Report their findings in a Systematic Review and
  make it available through The Cochrane Library

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The Cochrane Library

• A resource for identifying systematic reviews and
  high quality studies on a topic, and those
  currently in progress (Reviews, RCT, Protocols)
• Aimed at health professionals who are looking for
  in depth information on types of treatment, such
  as effectiveness, economic evaluation, outcomes,
  etc.

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The Cochrane Library

• Q When should I use The Cochrane Library?
• A For treatment and intervention questions
• Examples
• Is treatment R more effective than treatment S
  for treating condition T?
• What is the most effective treatment for
  condition D?
• Which treatment of F and G leads to improved
  patient care outcomes for condition H?
• Does treatment J impact length of stay?, etc.

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The Cochrane Library

• Dont use the Cochrane Library for
• General health care questions causal, prognosis,
  etiology, etc.
• Background information on diseases/types of
  treatment
• Clinical Practice Guidelines (CPGs)
• Statistics (prevalence incidence)
• Primary research other than Randomized Control
  Trials (RCTs)

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The Cochrane Library

• Access provided by Health Quality Council (HQC)
  to the entire province!
• From within SHR
• http//www.thecochranelibrary.com
• From Home
• Go to the Saskatoon public library website.
  http//www.saskatoonlibrary.ca/ Then, click
  databases, then health, then Cochrane
  library, then click here to access the Cochrane
  Library from home. You will be prompted for your
  last name and barcode (the code is on the front
  of your public library card).

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The Cochrane Library

• Now lets take a look at the Cochrane Library to
  find information that will help us in Georges
  case.
• http//www.thecochranelibrary.com