EBM

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EBM

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What is systematic review

• A review that include an explicit and detailed
  description of how it was conducted
• Minimize bias, maximize precision
• Include a clear research question, criteria for
  inclusion or exclusion primary studies, the
  process to identify primary studies, and the
  method used to access the methodological quality
  of the selected studies, the methods used to
  extract and summarise the results of primary
  trials on which the conclusion are based

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Categorising evidence

• Summarised evidence can be categorized according
  to study design, and reflects susceptibility to
  bias.
• A comprehensive plan for estimating the strength
  of clinical recommendations can be found on the
  Centre of Evidence-Based Medicines (Oxford)
  homepage evidence-basedmedicine.jr2.ox.ac.uk/,
  and an adaptation of the North of England
  Evidence Based Guidelines Development Project )
  (Table 1) describes the categories in descending
  order of importance.

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How to apply evidence-based medicine to
anaesthesia

• Surrogate or intermediate outcomes such as
  laboratory findings, blood pressure or other
  physiological parameters predominate, and may
  reflect the emphasis given to basic sciences
  during anaesthetic training.
• The disadvantages of using surrogate outcome
  measures have been described in a systematic
  review by Gøtzsche and colleagues in 1996 (30)
  surrogate outcomes impede the search for evidence
  to support clinical decisions.

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The Cochrane Anaesthesia Review Group

• The Cochrane Collaboration is an international
  organisation that aims to help people make
  well-informed decisions about health care by
  preparing, maintaining and promoting the
  accessibility of systematic reviews of the
  effects of health care interventions.
• The group promotes evidence-based anaesthesia
  through the production and maintenance of
  systematic reviews of the effects of
  interventions in anaesthesia, intensive care,
  acute pain treatment, prehospital medicine,
  resuscitation and emergency.

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Evidence-based anaesthesia-related systematic
reviews

• A title of a review that is initially registered
  within the group becomes a protocol, which
  prospectively sets out what is being tested, why,
  and how it will be done.
• The complete systematic review adheres to the
  protocol in order to maintain uniformity and
  minimise bias.
• Systematic reviews performed by the CARG are
  reviews of studies in which evidence has been
  systematically searched for, studied, assessed,
  and summarised according to predetermined
  criteria.

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• Preparation and maintenance of Cochrane reviews
  is the responsibility of international
  collaborative review groups, such as the CARG.
• The members of these groups researchers, health
  care professionals, consumers, and others share
  an interest in generating reliable, up-to-date
  evidence relevant to the prevention, treatment
  and rehabilitation of particular health problems
  or groups of problems.

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The future of evidence-based anaesthesiology

• Anaesthetists are co-operation and teamwork
• Even good evidence can be misapplied in an
  atypical clinical situation
• Evidence-based practice should be incorporated
  into our education, and reinforced in daily
  clinical problem solving

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• Evidence-based medicine provides the best basis
  on which to evaluate those interventions that
  should be abandoned, and those that are
  beneficial and cost-effective.
• It should be a national strategy that the health
  care system be evidence-based, also in
  anaesthesiology

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Conclusions

• There is emerging evidence that, when evidence
  based medicine is practiced, the patient
  benefits.
• Evidence- based medicine requires you not only to
  read articles but to read the right articles and
  then to alter your behaviour.
• Systematic reviews allow some assessment of the
  generalisability of findings, and consistency of
  treatment effect to be explored.

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• An often-cited advantage is increased power.
• The precision of the estimate increases because
  the confidence limits become progressively
  narrower.
• The evidence found through systematic reviews of
  randomised controlled trials should be in
  concordance with the clinicians experience and
  the patients wishes.

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• Clinical experience is invaluable, especially
  when a clinical picture is atypical, or when a
  patient is dissimilar from the population in a
  randomised controlled trial.
• Good knowledge of pathophysiology is also
  advantageous.
• However, experience or pathophysiological
  explanations may be misleading if they are the
  sole reason for arriving at a specific clinical
  decision