Thewarug Werawatganon , MD Anesthesiology, Chulalongkorn University

1. EBM Introduction to Evidence Based Medicine ThewarugWerawatganon, MD Anesthesiology, Chulalongkorn University

2. EBM • Evidence Based Medicine • Use of research information in clinical decision: David Eddy • Experience Based Medicine • Experience, Explanation

3. Evidence-Based Medicine:Definition Conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. (Sackett, DL et al Evidence-based medicine: what it is and what it isn’t, BMJ 1996)

4. Evidence-Based Practice

5. Clinical problem • High cholesterol • Aspirin

6. EBM process • 1. Translation of uncertainty to a question • 2. Systematic retrieval of the best evidence • 3. Critical appraisal of evidence for validity • 4. Application in practice • 5. Evaluation of performance

8. Clinical Question • Diagnosis • Therapy • Prognosis • Etiology

9. Type of Question: type of study

10. Hierarchy of Study Design Meta-Analysis Systematic Review Randomized Controlled Trial Cohort study Case Control study Case Report Animal study

11. Question • P Patient • I Intervention • C Comparison • O Outcome

12. Clinical trial Phase I healthy volunteers for dose-ranging Phase II efficacy and safety Phase III efficacy, effectiveness and safety Phase IV postmarketing surveillance

13. Systematic retrieval • Pubmed • Embase • Cochrane

14. EBM • Create • Use

15. Use EBM for patient management Critical Appraisal Valid Result Application

16. EBM • Application • Clinical decision • Clinical practice guideline • Policy – technology assessment

17. EBM • Randomized Controlled Trial (RCT) • Systematic Review • Clinical Practice Guideline (CPG) • Health Policy

18. EBM • Randomized Controlled Trial (RCT) • Systematic Review: Cochrane • Clinical Practice Guideline (CPG) • Health Policy • Agency for Healthcare Research and Quality's (AHRQ) • National Institute for Clinical Excellence (NICE)

19. Strength of Evidence Clinical Practice Guideline (CPG) Evidence level Ia - Evidence from Meta-analysis of RCTs Ib - Evidence from at least one RCT IIa - Evidence from at least one well designed controlled trial which is not randomized IIb - Evidence from at least one well designed experimental trial III - Evidence from case, correlation, and comparative studies. IV - Evidence from a panel of experts

20. Categories of recommendations Level A: Good evidence suggests that the benefits substantially outweigh the risks. Should discuss the service with eligible patients. Level B: At least fair evidence suggests that the benefits outweighs the risks. Clinicians should discuss the service with eligible patients. Level C: At least fair evidence suggests that there are benefits, but the balance between benefits and risks are too close for making general recommendations. Clinicians need not offer it unless there are individual considerations. Level D: At least fair evidence suggests that the risks outweighs potential benefits. Not routinely offer the service to asymptomatic patients. Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty

21. Limitation • Bias • Sponsor's interests. • Lag • Population segments under-researched • Published and unpublished • EBM from groups of people but applies to treat each patient

22. Clinical problem • Aspirin 39,876 initially healthy women 45+ yrs Receive aspirin 100 mg or placebo monitored 10 years for major cardiovascular events

23. Nonfatal 198 244 0.81 (0.67–0.97) 0.02 198 193 1.02 (0.84–1.25) Fatal 14 12 1.16 (0.54–2.51) 0.70 Nonfatal 184 181 1.01 (0.83–1.24) 0.90 Death from cardiovascular causes 120 126 0.95 (0.74–1.22) 0.68

24. EBM Study course

25. Objective Good Research Interim Analysis

26. Formulation of Research Question ThewarugWerawatganon, MD Anesthesiology, Chulalongkorn University

27. Question

28. careful study to find and report new knowledge

29. Previous knowledge Test hypothesis Reject / accept New knowledge What is research?

30. ประโยชน์ • Position • Honor • Promotion • Money • Skill • Knowledge • Graduate • Improvement

31. Research>>>…. Development>>>…. Outcome Improvement

32. Example Nasotracheal intubation in ICU • Oral hygeine care • Less misplacement • Comfortable

33. Nosocomial maxillary sinusitis during mechanical ventilation: a prospective comparison of orotracheal versus the nasotracheal route Intensive Care Med. 1990;16(6):390-3. Salord F, Gaussorgues P, Marti-Flich J, Sirodot M, Allimant C, Lyonnet D, Robert D.

34. A randomized study assessing the systematic search for maxillary sinusitis in nasotracheally mechanically ventilated patients. Influence of nosocomial maxillary sinusitis on the occurrence of ventilator-associated pneumonia. Am J RespirCrit Care Med. 1999 Mar;159(3):695-701. Holzapfel L, Chastang C, Demingeon G, Bohe J, Piralla B, Coupry A.

35. Starting Point? Problem

36. Problem …Data DataQuestion

37. Starting Point? Problem >> Research Question

38. Research Question • Work • Read • Think

39. Research Question

40. Research Question See Look Intelligence

41. Scope of Anesthesia • General & Regional anesthesia • Critical care • Respiratory care • Pain service • Cardiopulmonary resuscitation

42. Aspect • Basic science • Clinical • Health Service System • Economic Analysis

43. Finding • Advisor • Friend • Previous Study • Pondering

44. Finding • Topic of interest • Explore Textbook & Journal • The most specific thought

45. Write Down The Research Question • Define research boundary clearly • Suitable method to do

46. Evaluate The Research Question • Exist • No clear answer • Innovate • Narrow focus • Feasible • Benefit • Creating Not Destroying anyone • Answerable by research

47. Example: Ventilator Associated Pneumonia • What is the incidence of VAP?

48. Example: Ventilator Associated Pneumonia • What is the incidence of VAP? • What are the significant Risk factors for VAP?

49. Example: Ventilator Associated Pneumonia • What is the incidence of VAP? • What are the significant Risk factors for VAP? • Is orotracheal is better than nasotracheal tube?

50. Example: Ventilator Associated Pneumonia • What is the incidence of VAP? • What are the significant Risk factors for VAP? • Is orotracheal is better than nasotracheal tube? • Can new mode ventilation prevent VAP?