Introduction to the Principles of Evidence-Based Medicine

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Introduction to the Principles of Evidence-Based
Medicine and Evidence-Based Dentistry
Dr. Kannika Chukiatmun DDS., MD. Feb
2002.
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Evidence-Based Medicine
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• ????????? ????????? ????????????????

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?????????? Evidence-based
1. Clinical experience ? ? Evidence
2. Basic pathophysiologic knowledge ? ? new data
3. Intuition ? ? critical appraisal
4. Expert opinion ? ? all
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Previous recommended treatments
Systematic review CPG
??????????? ???????????? ?????
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Searching of evidence Critical appraisal
New regimen of treatments
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Clinical decision making
Patient circumstance
Evidence from research
Preferences Value Right
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Evidence-based policy-making
Value for money in terms of marginal and
opportunity costs
Resources
Values
Evidence
Data about public preferences
Evidence about cost-effectiveness
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Dentistry

• 1. Shifts in health care technology
• molecular biology
• infection control
• material science
• management system
• (Health care improvement / Computer assist)

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Dentistry

• 2. Increasing information
• Dentist / patient
• Research / published data
• Academy
• Company
• (Information Technology)

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Dentistry

• 3. Patients role in treatment plan
• Patients right
• Insurance system
• Health care reform

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Identify clinical problems
Search for evidence
Up date evidence
Discard Store
Make sense of evidence
Act on evidence
(D.Rucgards and A.Lawrence Evidence based
dentistry.BDJ 1995179270-273)
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EBD organizations

• Center for EBD -U.K.
• Cochrane collaboration oral health group
• - U.K., Canada, Australia, New Zealand
• - USA
• - Germany, Denmark, Switzerland
• - Japan etc.

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EBD organizations

• European cochrane centers
• -Aarhus (Denmark)
• K containing tooth paste in
  hypersensitivity
• - Cork (Ireland)
• Endodontics

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EBD organizations

• Scandinavian Society for prosthetic
• Small groups / Individual partners
• - Malta (Surgery)
• - Switzerland (Cost-efficiency)
• - Netherland (Radiography)

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Activity

• Collecting and exchanging information
• Reviewing of evidences
• Quality control of research and publication
• Clinical Practice Guideline
• Evidence-based journals
• EBM Tool/Notes/Hand books
• Training the tutors

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Restorative Dentistry

• Toxic from amalgam filling
• Dental restoration What type of filling?

Preventive Dentistry

• Fluoride gel application

Oral Surgery

• Prophylaxis removal of 3rd molar

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Obstacles

• 1. Lack of information about EBD
• 2. Revision of the quality of dental research
• - Small number of clinical trials
• - Gray zone in dentistry
• - Gap knowledge

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Obstacles

• 3. Training and continuing education
• 4. Application in day-to-day practice
• 5. Community

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EBD

• .. must always be regarded as an adjunct to,
  and not as substitute for, sound clinical
  judgement and patient preferences
• (Asbjorn Jokstad EBD, NOV.1998)

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Evidence-Based Dentistry
Practical Approach Dr.Kannika Chukiatmun
DDS.,MD. Feb 2002
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?????????????

• 1. ?????????????????????
• P Patient Whom is it
  about ? Population
• I Intervention Which manoeuvre ?
  Intervention
• C Comparison
• O Outcome What
  outcome ? Out come - Out put
• - Impact
• Clinical significance

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Asking Clinical Problems

• P - Patient / Situation
• I - Intervention
• (Therapy / Diagnosis / Prevention /
  Management / Economic / Exposures / Causes /
  Prognostic factors)

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Asking Clinical Problems

• C - Comparison
• (Placebo / Standard methods)
• O - Outcome
• (Best result / negative or positive effect)

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Where do clinical questions come from?

• Clinical evidence How to gather clinical
  findings properly and interpret
• them
  soundly?
• 2. Diagnosis How to select
  and interpret diagnostic tests?
• 3. Prognosis How to
  anticipate the patients likely cause?
• 4. Therapy How to select
  treatments that do more good than harm?
• 5. Prevention How to screen and
  reduce the risk of disease?
• Education How to teach yourself,
  the patient, and the family what is
• needed?

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?????????????

• ???????????????
• Libraries
• Specialist information centers
• Information resources / Databases
• Internet sites
• Journals / Books / Gray Literature / Other
  materials
• Experts opinion / Peer Reviews / Colleagues
  etc.

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3 way of finding things on the web

• - Direct tip offs
• - Serendipity
• - A Systematic Search

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• 2. ???????????????
• - ???????????????
• - ??????????????????????? / ????????
• - ????????? EBM / EBD

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???????????????

• 1. ???????????????
• Search Engines
• - Hot Bot - Google - Excite
• - Infoseek - Yahoo
• - Alta Vista - Northern Light
• Meta Search Engine
• - Dogpile - Meta Crawler
• - Cyber 411 - Pre Fusion

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???????????????

• 1. ??????????????? (???)
• Specialty databases
• - The Internet Sleuth
• - Beaucoup
• - Search . com

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• 2. ????????????????????
• ENTREZ Inspec
• BioMedNet MATH SCI etc.
• STN International
• Metadex

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• 3. ????????????????????
• MEDLINE HTA
• OMNI Health STAR
• CINAHL AIDSLINE
• EMBASE CANCERLIT etc.

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• 4. ????????? EBM / EBD
• EB Web sites/ ScHARR (Netting the Evidence)
• The Cochrane Library
• Best Evidence
• TRIP
• CASP etc.

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Search rules and syntax

• Boolean logic - AND, OR, NOT (BUT NOT)
• Proximity operators - ADJACENT
• - NEAR
• - FOLLOWED BY etc.
• Implied boolean - /-,

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Search rules and syntax

• Ctrl - F
• Book mark
• Truncation (, , )
• Wild cards (?)

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Search features

• 1. Phrase searching
• 2. Tresaurus searching
• 3. Field searching

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Field searching

• Term (field / tag) Operator Term (field / tag)

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EBM Search

• Usefulness Relevance x Validity
• Effort

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Seeking the evidence

• 1. Medline search (Vendors, IGM, PubMed)
• 2. Cochrame library and DARE database
• 3. Best evidence CD-ROM
• (Access via TRIP, DARE, IDEA)
• 4. Health star HTA sites (Via IGM)
• 5. NHS Economic Evaluation Database (NEED CRDS)

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Seeking the evidence

• 6. TRIP Database (18 databases of EB linkes)
• 7. Internet Database of EB Abstracts and Articles
  (IDEA)
• 8. Clini web, OMNI Net Medicine Med Finder
• 9. Lists of topic covered by EB Information units
• - ARIF (Aggressive Research Intelligent Unit)
• - NZHTA (NZ Health Technology Assessent Clearing
  House)
• 10. Academic/Institution/Gov. report.

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Where to next?

• - Health related Web
• - Search engines

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?????????????

• 3. ??????????????? (Critical Appraisal)
• - Level of evidence, Type of evidence,
• Study design and the
  pitfalls, Statistics used
• - Users guide to medical literature
• - Others guidelines /
  Modifications etc.

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In vitro (test tube) research
The Evidence Pyramid (Research design hierarchy)
Randomized Controlled Double Blind Studies
Randomized Controlled Studies
Cohort Studies
Case Control Studies
Case Series
Case Reports
Ideas, Editorials, Opinions
Animal research
In vitro (test tube) research
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Type of evidence

• Primary studies
• - Therapy
• - Diagnosis
• - Harm
• - Prognosis

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Type of evidence

• Secondary studies
• - Overview / Systematic review
• - Practice Guidelines
• - Decision Analysis
• - Economic Analysis

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Appropriate study designs
Qualitative Cross Sectional Case-controlled Cohort RCT Systematic review
Diagnosis ? ?? ???
Therapy ? ??
Prognosis ???
Screening ? ? ?? ???
View/beliefs perceptions ???
Prevalence/hypothesis generation ??? ???
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Critical appraisal(The assessment of
methodological quality)

• Evidence ? Quality rating ? Evidence table
• Graded recommendation ? Considered judgment
  
  (Strength of evidence)

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Meta-analysis Systematic reviews
Quality rating
Randomized controlled trials
Quality rating
Evidence table
Observational studies
Quality rating
Graded recommendation
Non-analytic studies
Considered judgment (Strength of evidence)
Expert opinion
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Appraisal StrategyMethods for doing an
assessment of the strength of evidence

• Range from quick scoring system to exhaustive
  analysis of methodology, statistics and
  reporting.
• Anderson 2000

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Quality of Evidence

• Hierarchy of evidence
• The Check List for quality of the evidence
• Validity
• Clinical important
• Relevance

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Quality of Evidence

• The Method for Check Lists construction
• IMRAD format
• Introduction (WHY the author did?)
• Method (HOW they did?)
• Results (WHAT they found?)
• Discussion (WHAT is that means?)
• CONSORT and QUORUM (for RCT and Meta-analysis)

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Evidence table

• I D of the evidence
• Design
• Validity
• Results
• Rating -Yes / No / Not sure / N/A
• - 5 / 4 / 3 / 2 / 1 etc.
• Balancing table / Comparing table

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Meta-analysis Systematic reviews
The Criteria reports
Quality rating
Randomized controlled trials
Quality rating
Evidence table
Observational studies
Quality rating
Graded recommendation
Non-analytic studies
Considered judgment (Strength of evidence)
Expert opinion
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Remarks