Uma Devalapalli

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Uma Devalapalli
Evidence Based Medicine Process - An Introduction
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Aims Objectives
To know about

• What is Evidence Based Medicine (EBM)?
• Why is EBM Important?
• The steps in EBM process

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Learning Outcomes
By the end of this session you will be able to

• Formulate a clinical question
• Apply PICO model to identify key concepts

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What is EBM ?
EBM is the Conscientious, explicit and judicious
use of current best evidence in making decisions
about the care of the individual patient.
-Sackett D. et al., 1996
Thus, the practice of EBM means Integrating
individual clinical expertise with the best
available external clinical evidence from
systematic research.

• Evidence Based Clinical practice is an approach
  to decision making in which the clinician uses
  the best evidence available, in consultation with
  the patient, to decide upon the option which
  suits that patient best
• -Muir Gray JA., 1997

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Why is EBM Important ?

• Studies on information seeking habits of
  physicians
• Practice generated 2 questions for every 3
  patients.
• Only 30 of physicians' information needs were
  met during the patient visit, usually by a
  colleague.
• Reasons for not using printed resources included
• office textbook collections too old,
• lack of knowledge of appropriate resources, and
• lack of time to find the needed information.
• (Covell, DG. Uman, CG. Manning, PR. Information
  needs in office practice
• are they being met? Annals of Internal Medicine
  103(4)596-599, Oct 1995.)

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Why is EBM Important ?

• When actually observed
• About 5 questions for each patient.
• 52 of these question could be answered
• by the medical record or hospital information
  system.
• 25 could have been answered by published
  information resources such as textbooks or
  MEDLINE.
• (Osheroff JA. Forsythe DE. Buchanan BG. Bankowitz
  RA. Blumenfeld BH.
• Miller RA. Physicians' information needs
  analysis of questions posed during
• clinical teaching. Annals of Internal Medicine
  114(7)576-81, 1991 Apr 1.)

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Why is EBM Important ?
When Clinicians have access to information, it
changes their patient care management
decisions. (Sackett D, 1998 Crowley S, 2003)
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The Steps in the EBM Process

• The patient
• The question
• The resource
• The evaluation
• The patient

• The patient
• The question
• The resource
• The evaluation
• The patient

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Step 1 The Patient

• Starts with the patient
• a clinical problem/ question arises out of the
  care of the patient.

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Step 2 The Question

• Construct a well-built question derived from
  the case.

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Clinical Scenario

• You are assessing a 65-year-old man who is due to
  have coronary grafting.

Anaesthetist suggests thoracic epidural, where
as Surgeon says that epidurals can be dangerous
with full heparinisation
Now the the team wants to know whether the
thoracic epidural prior to induction reduce the
post -operative complications
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Anatomy of good Clinical Question
Does epidural anesthesia reduce post operative
complications ?

• Ask focussed and answerable questions !!!

In elderly male patient undergoing cardiac
surgery, does epidural anaesthesia reduce the
post operative complications?
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PICO - Finding the evidence

• P - Patient, Problem or Population
• I - Intervention
• C - Comparison (not always relevant)
• O - Outcome

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PICO - Finding the evidence

• P Patient, Population or Problem
• I Intervention or Exposure
• C Comparison
• (not always relevant)
• O Outcome

• What patient group, population or problem are you
  interested in?
• elderly coronary patient
• What intervention or exposure are you examining?
• epidural anaesthesia
• Do you want to make a comparison?
• general anaesthesia
• What outcome were you looking for?
• reduce the post operative complications

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PICO in practice

• P In elderly coronary artery graft
  patients
• I does epidural anaesthesia
• C compared with general anaesthesia
• O reduce postoperative complications?

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Step 3 The Resource

• Select the appropriate resource(s)
• and conduct a search

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Resources available from the library

• Databases (subscribed free)
• Cochrane Library, TRIP, Medline, Embase etc
• Journals (print electronic)
• Books
• Web based resources
• - (reports, statistics, guidelines)

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Step 4 The Evaluation

• Appraise the evidence for its
• validity (closeness to the truth) and
• applicability (usefulness in clinical practice)

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Common Questions

• Are the results of the study valid ?
• What are the results ?
• Will the results help in caring for my patient ?

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The Hierarchy of Research Evidence
Systematic Review
A review in which all available evidence on a
particular subject is systematically identified,
appraised and summarised.
A group of patients are randomly allocated to
receive different interventions. Outcomes are
then compared.
Randomised Controlled Trials
Groups of people are selected on the basis of
their exposure to a particular agent and followed
up.
Cohort Study
Survey or interview of a sample of the population
of interest at one point in time.
Cross Sectional Survey
A report based on a single subject or patient.
Case Report
A consensus of experience amongst professionals.
Expert opinion
Anecdotal
Something a bloke told you after a meeting or in
the bar.
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Step 5 - The Patient
Return to the patient

• - integrate the evidence with clinical
  expertise, patient preferences
• and
• - apply it to practice

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The EBM cycle

• Identify Define the problem
• Formulate a focused clinical question
• Identify the appropriate resources
• Search for valid and relevant information
• Critically appraise/review this information
• Implement in practice
• Clinical audit ...

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