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INTRODUCTION TO EVIDENCE-BASED MEDICINE

INTRODUCTION TO EVIDENCE-BASED MEDICINE. Department of Family and Community Medicine UP-Philippine General Hospital. OBJECTIVES. To define Evidence Based-Medicine Family and Community Practice (EBMFCP) To discuss the uses (importance) of EBMFCP

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INTRODUCTION TO EVIDENCE-BASED MEDICINE

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  1. INTRODUCTION TO EVIDENCE-BASED MEDICINE Department of Family and Community Medicine UP-Philippine General Hospital

  2. OBJECTIVES To define Evidence Based-Medicine Family and Community Practice (EBMFCP) To discuss the uses (importance) of EBMFCP To discuss the foundations of a clinical dilemma (clinical question) based on a patient’s case scenario To discuss the different strategies in searching for answers To discuss the steps regarding the critical appraisal of a journal

  3. Introduction Medicine is not an exact science. Medicine is a dynamic field of knowledge.

  4. Therapeutics Diagnostics Differential diagnoses Prognosis Harm

  5. Patients usually serve as the starting point • Good questions are the backbone of EBM • Searching for the right answers is usually the hardest step.

  6. RESOLUTION OF THE CLINICAL DILEMMA

  7. Looking for answers The usual thing………… When asked or in doubt, > we get it from books and journals > ask other: friends, colleagues, mentors, subspecialty experts However,

  8. OUR INFORMATION NEEDS ARE NOT MET!!! our textbooks are out of date by the day they are published our journals are disorganized and inaccessible to us our colleagues may not have the answers that we seek

  9. New Paradigm

  10. WHAT IS EBM? “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." Dr. David Sackett, 1996

  11. EBM is a systematic approach • ACQUISITION • APPRAISAL • APPLICATION of Research to guide decisions in health care

  12. ADVANTAGES OF EBFCP TO DOCTORS: • Lifelong learning • Continuing professional development • Keeping up to date

  13. TO PATIENTS: • Better quality of care • Cost-effective care • Better outcomes

  14. TO THE HEALTH CARE SYSTEM: Better utilization of healthcare resources

  15. The Evidence-Based Family and Community Practitioner Clinical Experience Patient Values Evidence DECISION

  16. Patient dilemma Process of EBP Act & Assess Ask Acquire Principles of evidence-based practice Appraise Hierarchy of evidence Evidence alone does not decide – combine with other knowledge and values Apply

  17. Steps in the EBM Process

  18. CLINICAL SCENARIO Maria, 50/F History of CHF 2o to several Myocardial Infarctions Hospitalized 2x w/n the last 6 months due to worsening of heart failure

  19. Normal sinus rhythm presently Enalapril, aspirin and simvastatin Wants desperately to stay out of the hospital Digoxin (?)

  20. CLINICAL SCENARIO You think she should also be taking digoxin but you arent certain if this will help keep her out of the hospital. You decide to research this question before her next visit.

  21. Background Questions: • Ask for general knowledge about a disease or disease process, tests, treatments, etc. • 2 components: • a. root* + verb “What causes….” • b. condition …. SARS?” • * Who, What, Where, When, How, Why Usually asked because of the need for basic information. Answering the background question.textbooks, handbooks and databases

  22. Foreground Question: • About patient care decisions and actions • 4 (or 3) components: • a. Patient, problem or population • b. intervention, exposure, or manuever • c. comparison (if relevant) • d. clinical outcomes (including time horizon) e.g: in young children with acute otitis media, is short-term antibiotic therapy as effective as long term antibiotic therapy?

  23. Formulating a Focused Question Population (P) – general characteristics of the group of subjects in question Intervention(I) – drug or treatment, diagnostic test, risk factor or anything that is being tested Outcome (O) – endpoint against which a certain intervention is measured Methodology (M) – study design

  24. Translate dilemmas into questions Keep the questions simple, relevant, and manageable Complex questions: FRUSTRATION!!

  25. The question: In elderly patients with congestive heart failure, is digoxin effective in reducing the need for rehospitalization?

  26. THE SEARCH Identify key terms Use the boolean principle (Venn diagram) in combining terms Use OR to broaden search Use AND to narrow down search Use of “Quotation Marks” Use of the MeSH Use of limits Use of truncations

  27. The Key Terms In elderly patients with congestive heart failure, is digoxin effective in reducing the need for rehospitalization? Population – elderly hypertensives with CHF Intervention – digoxin Outcome – rate of hospitalization Methodology – RCT

  28. The Boolean Principle Congestive Heart Failure Digoxin Hospitalization OR to broaden search AND to narrow down search

  29. Meta-Analysis Systematic Review Randomized Controlled Trial Cohort Studies Case-Control Studies Case Series/Case Report Animal Research/Laboratory Studies The Evidence Pyramid

  30. WHAT TO ACCESS? www.nlm.nih.gov www.nejm.com www.bmj.com www.freemedicaljournals.com www.medscape.com www.pubmed.com

  31. What do we do with our output? When you have the article, appraise it using the Evidence-Based Family and Community Practice and Quality Improvement in Health Care Manual (FMRG, 2003) Weigh the evidence afforded by the article

  32. EVIDENCE-BASED FAMILY AND COMMUNITY PRACTICE • Is it relevant? • Is it valid? • What are the results? • Is it applicable to my patient?

  33. JOURNAL REPORT FORMAT • Case Scenario • Research Question • Search • Title • Source • Authors • Appraisal

  34. CRITICAL APPRAISAL OF AN ARTICLE ON THERAPEUTICS

  35. CRITICAL APPRAISAL OF AN ARTICLE ON THERAPEUTICS I. Is it relevant? • Is the objective of the study similar to your clinical dilemma? • population of the study • intervention and comparative interventions • outcome of the study

  36. 2. Was follow-up complete? Methodology and Result Section Look at the number of patients enrolled at the outset and compare this with the number of patients reported in the results table What is the drop-out rate? A drop-out rate of 20% or more is usually declared substantial, if otherwise, check whether an intention to treat analysiswas done.

  37. Secondary Guides: Was the study blinded? What is the definition and importance of blinding? Look at the methodology and results section. Single Blinding? Double Blinding? Triple Blinding?

  38. 2. Were the outcome measurements clearly described and determined in the same way between interventions? whether the outcome measures are those which you and your patient are interested in Surrogate outcome? Clinical outcomes?

  39. Overall, is the study valid?

  40. III. What are the results? A. How large was the treatment effect? Risk in Control (Rc): Risk in Treatment (Rt): No. pxs who did not get well in the control Total no. of pxs in the control group No. who did not get well in the txt group Total no. pxs in the treatment group

  41. Absolute Risk Reduction (ARR) = Rc - Rt Relative Risk (RR) = Rt/Rc RR of 1 : No difference between Treatment and Control RR of >1: Treatment is more harmful RR of <1: Treatment is more effective Relative Risk Reduction (RRR) = 1 – RR

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