Download - Evidence based med
Evidence-Based Medicine
Dr. Marwa RefaatDr. Marwa Refaat
EBMEBMIntroductionIntroduction
HistoryHistory
Definition & ClassificationDefinition & Classification
Elements of EBMElements of EBM
Steps of EBMSteps of EBM
Applying concepts of EBM to Applying concepts of EBM to management of some psychiatric management of some psychiatric disordersdisorders
A dilemmaA dilemma
You are very ill …You are very ill …
Which doctor do you want?Which doctor do you want?
William Osler, 1900 Smart young doctor
Rule 31 – Review the World Literature Fortnightly*Rule 31 – Review the World Literature Fortnightly* *"Kill as Few Patients as Possible" - Oscar London*"Kill as Few Patients as Possible" - Oscar London
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Evidence-based medicine
Evidence-based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence (about therapy, prevention, etiology, harm, prognosis, diagnosis and economic analysis) in making decision about the care of individual patients (Timmermans and Mauck, 2005) and it seeks to assess the quality of evidence of the risks and benefits of treatments (Elstein, 2004).
The practice of evidence-based medicine is a systematic approach to clinical problem solving, which allows the integration of the best available research evidence with clinical expertise
A Cross-Cutting Principle: A Cross-Cutting Principle: Science to Services/Evidence-Based PracticesScience to Services/Evidence-Based Practices
How do we translate research into practice?How do we translate research into practice?
How do we connect services to science?How do we connect services to science?
The history of EBM
Although the formal assessment of medicalinterventions using controlled trials wasalready becoming established in the 1940s,it was not until 1972 that Professor ArchieCochrane, director of the Medical ResearchCouncil Epidemiology Research Unit inCardiff, expressed what later came to beknown as evidence-based medicine (EBM) inhis book Effectiveness and Efficiency: RandomReflections on Health Services.
In 1992, the UK government funded the establishment of the Cochrane Centre in Oxford under Iain Chalmers, with the objective to facilitate the preparation of systematic reviews of randomized controlled trials of healthcare. The following year it expanded into an international collaboration of centers, of which there are now thirteen, whose role is to co-ordinate the activities of 11,500 researchers.
The National Health Service: AService with Ambitions. www.archive.officialdocuments.
co.uk/document/doh/ambition/ambition.htm (last accessed 27 April 2009)
Skills of Evidence-based Skills of Evidence-based MedicineMedicine
Knowledge
Translatio
n KTInformation Mastery
IM
Critical Appraisal
CA
Critical thinking of the content of medical literatureKnowledge applied to patients care
Skills searching the medical literature
Five essential steps of EBM practice: Step 1- converting information needs into an an-
swerable questionStep 2- finding the best evidence to answer the
questionStep 3- critically appraising the evidence for its
validity and usefulnessStep 4- applying the results of the appraisal into
clinical practiceStep 5- evaluating clinical performance
Five essential steps of EBM practice
Step 1 of EBM practice: formulating an answerable clinical question
Good clinical question must be clear, directly focused on the problem, and answerable by searching the medical literature.
1- PICO format P Patient or problem,I Intervention,C Comparison,O Outcome
2- Type of clinical question The most common types of clinical questions is about
intervention, etiology ,risk factors, rate, diagnosis, prognosis , cost-effectiveness, and question about phenomena ((Glasziou P, 2003). 2003).
PICO format
CLASSIFICATION OF EBM:
1. Evidence-based Health Care, also called as the evidence-based guidelines, is the practice of evidence based medicine at the organizational or institutional level. This includes the production of guidelines, policy and regulations (Gray, 1997).
2. Evidence-based Individual Decision Making, is the practice of evidence based medicine by the individual health care provider (Eddy, 2005).
Step 2 of evidence-based medicine practice: finding the evidence
search for relevant evidence that will provide the answer to the question. Some research designs are more powerful than others in their ability to answer research questions.
Levels of evidence and grade of recommendation for ranking the validity of studies about therapy,prevention,etiology and harm,
Oxford Centre for EBMEBM
The “best” evidence depends The “best” evidence depends on the type of questionon the type of question
LevelLevel TreatmentTreatment PrognosisPrognosis DiagnosisDiagnosis
II Systemic Systemic Review of …Review of …
Systemic Systemic Review of …Review of …
Systemic Systemic Review of …Review of …
IIII Randomised Randomised trialtrial
Inception Inception CohortCohort
Cross Cross sectionalsectional
IIIIII
Level of Evidence Level of Evidence
Evidence-based databases
The Cochrane Library (through the Cochrane Collaboration, http://www.cochrane.org
The DARE: includes systematic reviews that have been published outside of the Cochrane collaboration, all quality-assesses and with structured summaries
http://www.crd.york.ac.uk/crdweb
The Cochrane Controlled Trials Register (CEN-TRAL):
PubMed Clinical Queries (http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml)
SUMSearch (http://sumsearch.uthscsa.edu/): a meta-searching service
Step 3 of evidence-based medicine practice: appraising the evidence
There are several tools for appraising a research article. One of them was developed by the Critical Appraisal Skills Programme (CASP), Oxford, UK. CASP aims to help individuals to develop the skills to find and make sense of research evidence, helping them to put knowledge into the practice.
Step 4 of evidence-based medicine model: applying the evidence
The evidence should be fully discussed with the patient. The decision also should take into account the potential side effects of the drug (does side effect outweigh its potential benefits in a particular patient), the cost and availability of that particular treatment in the hospital or practice. The questions that we should ask before the decision to apply the results of the study are
Factors affecting decision in applying EBM:Factors affecting decision in applying EBM:
1- pt. profile1- pt. profile
2- Availability of treatment2- Availability of treatment
3- Alternative modalities3- Alternative modalities
4- Side effects profile4- Side effects profile
5- Appropiate outcomes5- Appropiate outcomes
Step 5 of evidence-based medicine model: evaluating clinical performance
we need to ask whether we formulate answerable questions, find best evidence quickly, effectively appraise the evidence, and integrate clinical expertise and patient preferences and values with the evidence in a way that leads to a rational, acceptable management strategy.
We need to evaluate our approach at frequent intervals and decide whether we need to improve any of the four steps discussed above.
Evidence Based PsychiatryEvidence Based Psychiatry
Applying concepts of EBM to Applying concepts of EBM to management of Psychiatric Disordersmanagement of Psychiatric Disorders
Panic DisorderPanic Disorder
Panic Disorder, With or WithoutPanic Disorder, With or WithoutAgoraphobiaAgoraphobia
Panic disorder is a chronic and recurrent Panic disorder is a chronic and recurrent illness associated with significant illness associated with significant functional impairment.functional impairment.
The estimated lifetime prevalence of The estimated lifetime prevalence of panic attacks is 15%,with a 1-year panic attacks is 15%,with a 1-year prevalence of 7.3%prevalence of 7.3%
About one-third to one-half of patients with About one-third to one-half of patients with PD also have symptoms of agoraphobiaPD also have symptoms of agoraphobia
DSM-IV-TR of Panic AttackDSM-IV-TR of Panic Attack
Treatment of PDTreatment of PD
I- Approach to Psychological I- Approach to Psychological ManagementManagement
CBT is the most consistently efficacious CBT is the most consistently efficacious psychological treatment for PD, according psychological treatment for PD, according to metaanalyses (Level 1) to metaanalyses (Level 1) (Austeralian & New (Austeralian & New Zeland GL, 2003. – Glum GA, metaanalysis 1993)Zeland GL, 2003. – Glum GA, metaanalysis 1993)
Various CBT approaches to the treatment Various CBT approaches to the treatment of panic attacks have been developed of panic attacks have been developed over the years over the years (Landon et al 2004)(Landon et al 2004)
Common components of CBT for Common components of CBT for PDPD
Treatment RecommendationsTreatment Recommendations
II- Approach to II- Approach to Pharmacologic ManagementPharmacologic Management
Strength of evidence of Strength of evidence of pharmacological treatment of PDpharmacological treatment of PD.cont..cont.
III- Combined Psychological and III- Combined Psychological and Pharmacologic TreatmentPharmacologic Treatment
Combined treatment had some advantages Combined treatment had some advantages during the acute and follow-up phases, but, during the acute and follow-up phases, but, when the medication was discontinued when the medication was discontinued after the follow-up phase, there was a after the follow-up phase, there was a considerably lower relapse rate inconsiderably lower relapse rate in
the CBT and CBT-with-placebo groups the CBT and CBT-with-placebo groups (18%), compared with the CBT-plus-(18%), compared with the CBT-plus-imipramine group (48%) and imipramine-imipramine group (48%) and imipramine-alone group (40%) alone group (40%) (Barlow et al. 2000 )(Barlow et al. 2000 )
Diagnosis & Assessment of Diagnosis & Assessment of DeliriumDelirium
Diagnosis & Assessment of Diagnosis & Assessment of DeliriumDelirium
Delirium characterized by :-Delirium characterized by :-
Disturbed level of consciousnessDisturbed level of consciousness
A change of cognition not better explained A change of cognition not better explained by a pre-existing dementiaby a pre-existing dementia
Disturbance develops over a short period Disturbance develops over a short period of timeof time
Evidence from the history, physical, Evidence from the history, physical, examination, or lab. Investigation that examination, or lab. Investigation that disturbance due to medications, medical disturbance due to medications, medical condition ,or substance use.condition ,or substance use.
Assessment of DeliriumAssessment of Delirium
3- Basic laboratory tests3- Basic laboratory tests
Blood chemistries: electrolytes, glucose, Blood chemistries: electrolytes, glucose, calcium, albumin, blood urea nitrogen calcium, albumin, blood urea nitrogen (BUN), creatinine, SGOT, SGPT, bilirubin, (BUN), creatinine, SGOT, SGPT, bilirubin, alkaline phosphatase, magnesium, alkaline phosphatase, magnesium, phosphorusphosphorus
Complete blood count (CBC)Complete blood count (CBC)
Electrocardiogram (ECG)Electrocardiogram (ECG)
Chest X-rayChest X-ray
Arterial blood gases or oxygen saturationArterial blood gases or oxygen saturation
UrinalysisUrinalysis
4- Additional laboratory tests4- Additional laboratory tests
Urine culture and sensitivity Urine culture and sensitivity
Urine drug screenUrine drug screen
Blood tests (e.g., VDRL, heavy metal screen, BBlood tests (e.g., VDRL, heavy metal screen, B1212 and folate and folate levels, antinuclear antibody [ANA], urinary porphyrins, levels, antinuclear antibody [ANA], urinary porphyrins, ammonia level, human immunodeficiency virus [HIV], ammonia level, human immunodeficiency virus [HIV], erythrocyte sedimentation rate [ESR])erythrocyte sedimentation rate [ESR])
Blood culturesBlood cultures
Serum levels of medications (e.g., digoxin, theophylline, Serum levels of medications (e.g., digoxin, theophylline, phenobarbital, cyclosporine)phenobarbital, cyclosporine)
Lumbar punctureLumbar puncture
(CT) or (MRI)(CT) or (MRI)
(EEG)(EEG)
Risk factors in recurrence of major Risk factors in recurrence of major Depressive DisorderDepressive Disorder
APA Guidelines for risk factors in APA Guidelines for risk factors in recurrence of major depressive recurrence of major depressive
DisorderDisorderPrior history of multiple episodesPrior history of multiple episodes
Severity of episodesSeverity of episodes
Earlier age at onsetEarlier age at onset
Presence of an additional non affective psychiatric diagnosisPresence of an additional non affective psychiatric diagnosis
Presence of a chronic general medical disorderPresence of a chronic general medical disorder
Family history of psychiatric illness, particularly mood disorderFamily history of psychiatric illness, particularly mood disorder
Ongoing psychosocial stressors or impairmentOngoing psychosocial stressors or impairment
Negative cognitive styleNegative cognitive style
Persistent sleep disturbancesPersistent sleep disturbances
Key components of effective Key components of effective carecareScreening & Screening &
assessmentassessment
Patient education Patient education and activationand activation
TreatmentTreatment
Care Care managementmanagement
Mental health Mental health consultationconsultation
“Collaborative Care” IAPT
program- NICE guidelines
Integrating Ten Rules for Quality Mental Integrating Ten Rules for Quality Mental Health ServicesHealth Services
1.1. Informed ChoiceInformed Choice2.2. Recovery FocusRecovery Focus3.3. Person CenteredPerson Centered4.4. Do No HarmDo No Harm5.5. Free Access To RecordsFree Access To Records6.6. A System Based on TrustA System Based on Trust7.7. A Focus On Cultural ValuesA Focus On Cultural Values8.8. Knowledge-BasedKnowledge-Based9.9. Partnership Between Consumer & ProviderPartnership Between Consumer & Provider10.10. Access to Services Regardless Of Ability To PayAccess to Services Regardless Of Ability To PayInfusing recovery-based principles into mental health services: A white paper by Infusing recovery-based principles into mental health services: A white paper by
people who are New York state consumers, survivors, patients and ex-people who are New York state consumers, survivors, patients and ex-patients. September, 2004. New York State Office of Mental Healthpatients. September, 2004. New York State Office of Mental Health..
SummarySummaryEBM is a great advance over informal, non-EBM is a great advance over informal, non-quantitative approaches to clinical decisions.quantitative approaches to clinical decisions.EBM should result in more effective, more EBM should result in more effective, more uniform, and more efficient medical care.uniform, and more efficient medical care.EBM is an adjunct, not a substitute for EBM is an adjunct, not a substitute for physicians who can diagnose accurately, access physicians who can diagnose accurately, access evidence efficiently, and think analytically.evidence efficiently, and think analytically.The integration of EBM with cost-benefit analysis The integration of EBM with cost-benefit analysis poses a major challenge for health policy.poses a major challenge for health policy.
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