EBM: Whats the Big Deal

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EBM Whats the Big Deal?

• Mark C. Wilson, M.D., M.P.H.
• Wake Forest University School of Medicine

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Todays Road Map

• Evolution of EBM
• Healthy Skepticism
• Blind Men the Elephant
• EBM in Its Place
• Where to From Here?

3
Evidence Based Medicine

• Clinical intuition, unsystematic experience,
  pathophysiologic rationale

Evidence from clinical research
4
Users Guides Series in JAMAEvidence-Based
Medicine Working Group

• Are the Results Valid?
• Are the Results Important?
• Will the Results Help Me Care for My Patients?

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Routine Fears about EBM

• Old Hat
• Ivory Tower Exercise
• Wont Vanquish Uncertainty Thus Paralyzing
• Fixed Cookbook Approach
• A Tool for Cost Cutters
• Just about RCTs Statistics

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EBM A Hierarchy of Evidence

• N-of-1 Trials
• Meta-Analysis of Homogeneous RCTs
• Single RCT
• Cohort Study
• Case-Control Study
• Case Series
• Individual Clinical Experience

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But ...

• Evidence Alone
• Never
• Makes Clinical Decisions

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And ...

• Whenever You Get Confused,
• Start Back with the Patient

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How Would You Treat These Patients With
Pneumococcal Pneumonia?

• 43 y/o smoking construction worker
• 98 y/o bedridden, non-communicative, contracted
  patient in nursing home for 5 years
• 62 y/o with chronic pain and s/p stroke who has
  an advance directive to not be treated with
  antibiotics

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Determinants of Decision-Making

• Evidence
• clinical evidence from patient
• best available external evidence
• systematic research
• pathophysiology
• local experts
• Values
• your patients
• your own

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EBM What it is

• Evidence-Based Medicine is the conscientious,
  explicit, and judicious use of current best
  evidence in making decisions about the care of
  individual patients.
• Practice of evidence-based medicine means
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research.
• EBM What it is and what it isnt. Br Med J
  1996 31271-72

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EBM What it is

• Evidence-Based Medicine is the conscientious,
  explicit, and judicious use of current best
  evidence in making decisions about the care of
  individual patients.
• Practice of evidence-based medicine means
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research.
• EBM What it is and what it isnt. Br Med J
  1996 31271-72

13
EBM What it is

• Evidence-Based Medicine is the conscientious,
  explicit, and judicious use of current best
  evidence in making decisions about the care of
  individual patients.
• Practice of evidence-based medicine means
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research.
• EBM What it is and what it isnt. Br Med J
  1996 31271-72

14
EBM What it is

• Evidence-Based Medicine is the conscientious,
  explicit, and judicious use of current best
  evidence in making decisions about the care of
  individual patients.
• Practice of evidence-based medicine means
  integrating individual clinical expertise with
  the best available external clinical evidence
  from systematic research.
• EBM What it is and what it isnt. Br Med J
  1996 31271-72

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Problems in the Evidence of EBMAm J Med
1997 103529-535

• Major Constraints in Best Available Evidence to
  Help Care for Individual Patients
• Implying that a Specific Collection of Evidence
  is the Best Available Sets Stage for Abuses by
  Guideline Makers and Health Systems
• EBM Places Excess Emphasis on Gathering RCTs and
  Doing Meta-analyses
• EBM Advocates De-emphasize Soft Data

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EBM So Its a Concept with an Imperfect
Name/Label

• Consider the Perspectives of the 3 Blind Men
  Encountering the Elephant of Individualized
  Clinical Decision Making
• No Better Name at Present should just get on
  with the business at hand

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EBM Attempts to

• Inspire Us to Conscientiously Pursue Best
  Available Evidence
• Help Us Explicitly Acknowledge the Strengths
  Limitations of Evidence that Influence Our
  Decisions
• Motivate Us to Tackle the Difficult Judgements
  for Individual Patients that We Must Make
• Empower Us to Keep Up-to-Date and Maintain Our
  Autonomy

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Much Work Still to Do

• EBM is Still in its Infancy
• EBM is Not a Panacea

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Much Work Still to Do

• EBM is Still in its Infancy
• EBM is Not a Panacea
• But the process of EBM is quite appealing on
  multiple levels

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Evidence-Based Medicine

• Essential EBM Skills
• 1) Focus Clinical Questions
• 2) Efficient Information Retrieval
• 3) Appraise Information
• 4) Apply to Patient

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Evidence-Based Health Care
Best Available Evidence
Patient Preferences
Flexible Management Strategies
Establishing Effective Physician-Patient Communica
tion
Patients Clinical Problems
Co-Morbidities
Social Support
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So Where to Now?
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So Where to Now?

• Cultivate Curiosity

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So Where to Now?

• Cultivate Curiosity
• Carefully Select When to Pursue Best Evidence

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So Where to Now?

• Cultivate Curiosity
• Carefully Select When to Pursue Best Evidence
• Hone Your Basic EBM Skills
• Focusing Clinical Questions
• Efficient Searching
• Critical Appraisal
• Make Judgements about Applicability

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So Where to Now?

• Cultivate Curiosity
• Carefully Select When to Pursue Best Evidence
• Hone Your Basic EBM Skills
• Focusing Clinical Questions
• Efficient Searching
• Critical Appraisal
• Make Judgements about Applicability
• Explicitly Wrestle with the Components of
  Clinical Decision-making Think Out Loud

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So Where to Now?

• Cultivate Curiosity
• Carefully Select When to Pursue Best Evidence
• Hone Your Basic EBM Skills
• Focusing Clinical Questions
• Efficient Searching
• Critical Appraisal
• Make Judgements about Applicability
• Explicitly Wrestle with the Components of
  Clinical Decision-making Think Out Loud
• Have FUN!!!

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EBM Will It Really Matter?
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So What Now???