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Life long learning with EBM

Life long learning with EBM. Prof Eiad Al-Faris MD, MSc, MRCGP, MMEd, Prof. and Consultant of Family Medicine King Saud University Supervisor -King Saud University chair for medical education. Outline. Introduction Definition of EBM Steps of EBM Practical search Conclusion Closure.

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Life long learning with EBM

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  1. Life long learning with EBM Prof Eiad Al-Faris MD, MSc, MRCGP, MMEd, Prof. and Consultant of Family Medicine King Saud University Supervisor -King Saud University chair for medical education

  2. Outline • Introduction • Definition of EBM • Steps of EBM • Practical search • Conclusion • Closure

  3. INFORMATION EXPLOSION 850,000 500,000 100,000 10,000 MEDICAL JOURNALS 1900 1990 2000 2014

  4. Rule 31 – Review the World Literature Fortnightly* 8,500 per day 2,142 per day 94 per day

  5. Clinical Scenario • Ibrahim is a 30 years old teacher, he is known case of allergic rhinitis. He presented with a flare up of rhinitis symptoms, and he wants to get refills of the antihistamine pills. • You wonder should you prescribe intranasal steroids or refill the antihistamines?!

  6. Clinical Scenario Ibrahim is a 60 years old teacher, he is known to have hypertension. He presented to the ED with severe chest pain for the last two hours. • In addition to history / exam and ECG, you wonder should you request for the timely diagnosis: troponin or creatine kinase- MB or both?

  7. When confronted with a clinical question, whom usually you consult?

  8. Colleagues- experts • A great source of information. • Quick, affordable and accessible. • But potentially very biased: Variability Not updated

  9. Textbooks • Rapidly out-of-date (2-4y). • A good source of background information (pathophysiology), • but a poor source of information for most foreground questions (clinical).

  10. Burn your traditional textbooks

  11. What is EBM?

  12. EBM is The integration of the current best evidence (from research) with our clinical expertise and patient’s values.

  13. Three (Es)- EBM Components

  14. Rules of Evidence All evidence is not created equal. Evidence alone never makesclinical decisions.

  15. Hierarchy of Evidence Meta-analysis of RCTs Multi-centric large RCTs Single Centre RCT Observational studies Patient-important outcomes Clinical experience Basic research test tube, animal, human physiology

  16. 6 As to practice EBM Assess your patient Ask clinical questions Acquire the Evidence(s) Appraise the evidence(s) Apply The best evidence to patient Assess Yourself

  17. Assess Your Patient History Physical examination Objective data – labs, x-rays • Formulate differential diagnosis • Pretest probability of disease

  18. To answer a clinical question effectively First, turn your scenarios into 'well-built' clinical Q. Four domains:PICO 1) the patient (problem) 2) the intervention or exposure 3) the comparison (intervention) 4) the clinical outcomes

  19. 1.Patient population. 2. Intervention. 3. Comparison intervention. 4. Outcomes. Patients attending the ED with chest pain Treponine or creatine kinase-MB Troponine creatine kinase-MB Accuracy of diagnosis of IHD “In Patients attending the ED with chest pain, is troponine as compared to creatine kinase-MB more valid for the diagnosis of ischemic heart disease?

  20. For healthy adults is it worthwhile to give aspirin as a prophylaxis to reduce MI and or stroke ?

  21. 1. Patient population. 2. Intervention. 3. Comparison intervention. 4. Outcomes. Asymptomatic adults with no risk factors Aspirin and Primary Prevention Aspirin Placebo Incidence of CV events

  22. “In asymptomatic adults no risk factors, would the use of aspirin reduce the incidence of cardiovascular events?

  23. Ask Clinical Questions (PICO) Patient/ Population Outcome Intervention/ Exposure Comparison does early treat- ment with a statin decrease cardio- vascular mortality? In patients with acute MI compared to placebo what is the accuracy of exercise ECHO In women with suspected coronary disease compared to exercise ECG for diagnosing significant CAD? In post- menopausal women does hormone replacement therapy compared toNo HRT increase the risk of breast cancer? Components of Clinical Questions (PICO)

  24. Types of clinical questions • Therapy and harm: how to select treatments to offer patients that do more good than harm • Diagnostic tests: how to select and interpret diagnostic tests, in order to confirm or exclude a diagnosis • Prognosis: how to estimate the patient's likely clinical course over time

  25. Prefiltered Sources: UpToDate Clinical Evidence Dynamed Physicians Information and Education Resource (PIER) Clinical Practice Guidelines Cochrane Library Ovid MD Consult Medscape Unfiltered Sources MEDLINE (www.pubmed.gov) Google scholar (www.google.com Acquire the Best Evidence We need to focus and familiarize ourselves with few of them

  26. Systems Summaries Synopsis of Syntheses Syntheses Synopsis of Studies Studies

  27. Summaries • Clinical Evidence www.clinicalevidence.com • Dynamed • Physicians Information and Education Resource (PIER) pier.acponline.org • UpToDate www.uptodate.com • Clinical Practice Guidelines • National Guidelines Clearinghouse www.guideline.gov

  28. Synopses of Syntheses • ACP Journal Club www.acpjc.org • The database of abstracts of reviews of effects (DARE) www.crd.york.ac.uk • Evidence Based Medicine ebm.bmj.com • Evidence Based mental health ebmh.bmj.com

  29. A comparison of answer retrieval. Ahmadi SF Med Teach - 2011

  30. Syntheses • ACPJC plus (plus.mcmaster.ca/acpjc) • The Cochrane Library www.thecochranelibrary.com

  31. Synopsis of Studies • Evidence-Based Abstraction Journals • EvidenceAlerts https://plus.mcmaster.ca/EvidenceAlerts/

  32. Studies • www.pubmed.gov • Clinical queries • Mesh search • Special queries: for health services and qualitative research www.nlm.nih.gov/bsd/special_queries.html

  33. Federated Search Engines • TRIP Turning Research Into Practice www.tripdatabase.com • SUMSearch sumsearch.uthsca.edu

  34. EBM can reduce reading need How much is valid AND relevant? Number Needed to Read is 20+ PROCESS • 120+ journals scanned • 50,000 articles • Is it valid? (<5%) • Intervention: RCT • Prognosis: inception cohort • Etc • Is it relevant? • 6-12 GPs & specialists asked:Relevant? Newsworthy? • < 0.5% selected Number Needed to Read is 200+ www.evidence-basedmedicine.com

  35. Controlled trials The “Evidence Transfer Gap” Clinical Practice

  36. The Challenge – Bridging the gap! • New EBM teaching models • Deals with barriers • EBM Environment

  37. Appraise the EvidenceFour Pillars RV-RA system Relevance: It focuses on medical problems common to our practice. patient-oriented evidence Validity: Correctness (likely to be true)- bias- Results: Clinically important Magnitude and Precision (MP) Can we apply the results to our patient? Applicable in and useful for my patients

  38. Relevance Consider three questions to determine Relevance • From your practice • Require change of practice • Patient-oriented outcome (POEM)

  39. POEM Vs. DOE POEM: Patient-oriented evidence that matter mortality, morbidity, quality of life DOE: Disease-oriented evidence pathophysiology, pharmacology, etiology

  40. Comparing DOE and POEM

  41. DOE POEM The cardiac arrhythmia suppression trial. N Engl J Med 1991.

  42. DOE POEM The cardiac arrhythmia suppression trial. N Engl J Med 1991.

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