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Evidence based medicine Riga 2012-05-07

  • 1. Evidence based medicine Professor Janko Kersnik, MD, MSc, PhD Family doctor in a branch office Kranjska Gora, Slovenia Head of Family Medicine Department, Medical School Maribor Head of Research Department, Department of Family Medicine, Medical School Ljubljana President of Slovenian Family Medicine Society President of EURACT
  • 2. Structure of the presentation 1. Principles of EBM 2. Demonstration in searching evidence 3. Assessment of the evidence (paper) 4. Information for group work: Exercise in assessment of evidence 7. 5. 2012 EBM 2
  • 3. Variation to the theme s Evidence based medicine s Scientific medicine s Evidence based practice s ... 7. 5. 2012 EBM 3
  • 4. Read thread of EBM s Patient dilemma s Ask clinical question s Acquire (search) evidence s Apprise (assess) evidence s Apply in everyday practice s Act (monitor change) 7. 5. 2012 EBM 4
  • 5. Aim of the first part s To demonstrate how by using IT we can get answers to clinical questions. 7. 5. 2012 EBM 5
  • 6. Literature s http:// www.hsl.unc.edu/services/tutorials/ebm/w s http://medlib.bu.edu/tutorials/ebm/ 7. 5. 2012 EBM 6
  • 7. By the end of the first part you will s Know how to set clinical question s Know key electronic databases (Medline, Cochrane, Clinical Evidence) s Know how to get them (Internet, CD, book) s Understand and value evidence for safe work s Be able to use evidence for your everyday practice 7. 5. 2012 EBM 7
  • 8. What do we know on EBM? s Buzz groups – discuss in groups of three 7. 5. 2012 EBM 8
  • 9. What is EBM? s Evidence instead experience and eminence s Use of IT in everyday practice s An answer to patient demands s “New religion” which is changing our practice 7. 5. 2012 EBM 9
  • 10. What is EBM practice? s EBM is defined as an application of best research evidence in everyday patient care. s EBM is defined as clinical decision which is based on systematic search, assessment and application of evidence. 7. 5. 2012 EBM 10
  • 12. Four steps in searching evidence 1 2 3 4 7. 5. 2012 EBM 12
  • 13. 1 Clinical question s To begin the EBM search process start with a well-developed and answerable question. A good clinical question will: – Save time when researching – Keep the focus directly on the patient's need – Suggest the appropriate form that a useful answer may take s The clinical question will impact the entire EBM literature searching process. 7. 5. 2012 EBM 13
  • 14. Typical questions s Therapy s Diagnostics s Prognosis s Prevention s Health promotion …. s What should I do for this patient? 7. 5. 2012 EBM 14
  • 15. PICO 7. 5. 2012 EBM 15
  • 16. Questions s Who is your patient? s What is the intervention? s What is the comparison? s What is the outcome? 7. 5. 2012 EBM 16
  • 17. Your patient s In your 83-year old patient, who is 25 years treated for high blood pressure, which is well organized with the average blood pressure values below 140/90 mmHg, you have found at a regular check up an irregular heart rhythm, which is on the ECG proved atrial fibrillation. Does not have any other diseases, he is in good physical and mental condition. Since you do not have data on the beginning of this disorder, you have referred him to a cardiologist. He returns with the result, from which you read, that he has undergone unsuccessful cardio conversion. The patient prefers aspirin, which does not require any monitoring, over proposed warfarin. 7. 5. 2012 EBM 17
  • 18. Patient dilemma s Shall we follow the guidelines or is there evidence that we can take into account patient preferences? 7. 5. 2012 EBM 18
  • 19. In small groups... ...define clinical question from your practice, …or define clinical question from the case of our 83- years old patient. 7. 5. 2012 EBM 19
  • 20. Clinical question in our case s Is treatment with aspirin (I) in the 83- year old patient with chronic atrial fibrillation (P) as effective as warfarin (C) in terms of prevention of stroke and total mortality and complications of treatment (O)? 7. 5. 2012 EBM 20
  • 21. Searching evidence s Where do you search information? 7. 5. 2012 EBM 21
  • 22. Hierarchy of evidence s Systematic reviews s Meta-analyses s RCT s Prospective studies s Retrospective studies s Case reports 7. 5. 2012 EBM 22
  • 23. Types of studies (iz: Silagy and Haines, Evidence Based Practice in Primary Care, BMJ Books, 1998) O b s e rv a tio n a l E x p e r im e n ta l D e s c r ip tiv e A n a ly t i c a l U n c o n t r o lle d C o n tr o lle d C o h o rt C a s e -c o n tro l N o n - r a n d o m is e d R a n d o m is e d 7. 5. 2012 EBM 23
  • 24. Sources s Medline s Cochrane s Clinical Evidence 7. 5. 2012 EBM 24
  • 25. MEDLINE s From 1966 s Internet based s Search; PubMed - http:// www.ncbi.nlm.nih.gov/pubmed/ (http:// www.ncbi.nlm.nih.gov/sites/entrez ) s Usual terms s Option “find related data; PubMed; related articles” s Option “Also try” s Options to copy in a file (Send to; File) or in own data base (Reference manager) 7. 5. 2012 EBM 25
  • 26. Strategy s Search; MeSH (Medical Subject Headings) s English terms s Operators (and, not, or) s Limits (author, title, abstract, language) s “Find related articles” 7. 5. 2012 EBM 26
  • 28. 7. 5. 2012 EBM 28
  • 29. COCHRANE s Systematic reviews, RCT s Internet s Rigorous inclusion criteria s Regular update 7. 5. 2012 EBM 29
  • 30. 7. 5. 2012 EBM 30
  • 31. 7. 5. 2012 EBM 31
  • 32. CLINICAL EVIDENCE s Book twice a year s Relevant clinical questions 7. 5. 2012 EBM 32
  • 33. 7. 5. 2012 EBM 33
  • 34. Find in Internet relevant papers for the subject you are interested! Select one you want to apprise. 7. 5. 2012 EBM 34
  • 35. Search for our patient s MeSH: warfarin aspirin stroke prevention not dabigatran s Limits – RCT or systematic reviews, – Not older than 5 years, – Human, – Male, older than 80 years, – English, – Free papers. 7. 5. 2012 EBM 35
  • 36. Search results for our patient s We got 7 hits. s After reading titles and abstracts we were left with two of them: – Williams JE, Chimowitz MI, Cotsonis GA, Lynn MJ, Waddy SP; WASID Investigators.Gender differences in outcomes among patients with symptomatic intracranial arterial stenosis. Stroke. 2007 Jul;38(7):2055-62. Epub 2007 May 31. – Rash A, Downes T, Portner R, Yeo WW, Morgan N, Channer KS. A randomised controlled trial of warfarin versus aspirin for stroke prevention in octogenarians with atrial fibrillation (WASPO). Age Ageing. 2007 Mar;36(2):151-6. Epub 2006 Dec 15. 7. 5. 2012 EBM 36
  • 37. Conclusions for the first part s Searching can make fun s There are simple tools available s Practice make expert 7. 5. 2012 EBM 37
  • 39. Aims of the second part s What is medical literature? s What types of documents/papers do we know? s Sources of primary documents s Criteria for papers, guidelines, meta- analyses. Systematic reviews 7. 5. 2012 EBM 39
  • 40. Medical literature s Primary documents – primary (research) paper – diploma, masters, doctoral thesis s Secondary documents – review paper – meta-analysis – seminar work – guidelines s Tertiary documents – textbook – handbook – congress proceedings 7. 5. 2012 EBM 40
  • 41. Sources of primary documents s Specialist theses s Graduate theses s Maister theses s Doctoral tehses s Medical journals 7. 5. 2012 EBM 41
  • 42. Strengths and weaknesses of primary documents Strengths Weaknesses s Original, s Large number of unpublished work papers s Source of new s Evidence is mainly knowledge scattered over s Basis of scientific several journals development 7. 5. 2012 EBM 42
  • 43. Structure of primary document s Title s Results s Abstract – Sample description – Key results s Introduction – Additional analyses – “What was the problem?” “Why is this s Discussion problem interesting for – On methods a reader?” – On results s Aims, hypothesis s Conclusions s Methods and patients s Acknowledgement – Methods s Financial disclosure – Patients - sampling – Study description s “Conflict of interest” – Data analysis s References s Appendices 7. 5. 2012 EBM 43
  • 44. External grading of “reliability” of the source – medical journal s External reviewers s Indexed s On Medline s SCI: science citation index, SSCI: social science citation index s IF: impact factor 7. 5. 2012 EBM 44
  • 45. Appraisal of “usefulness” of the paper s Check in aims and Hypotheses, – If they agree with your need for information; s In methods check, – If the paper studies same population as yours; – If the study subject complies with your need – If sample size and study power are given; – If appropriate statistical methods were used; s In results check, – For ev. biases and flaws; – If the results are valid for your practice; – If the statistical significance has also any clinical meaning. EBM 45 7. 5. 2012
  • 46. IMRAD s Introduction (why the authors decided to do this research), s Methods (how they did it, and how they analysed their results), s Results (what they found), and s Discussion (what the results mean). 7. 5. 2012 EBM 46
  • 47. Paper quality criteria – introduction and methods s Is the purpose clear? s What is the measure of the study succes? s Is the methodology understandable? s Where are the patients from? s What is the selection of patients? s Methods of data collection s What is the percentage of responses? s Is the number of observations sufficient? 7. 5. 2012 EBM 47
  • 48. Paper quality criteria – results and conclusions s Whether they used appropriate statistical methods? s Are the results shown appropriately or misleading? s Are there confidence intervals shown? s Are the conclusions based on the study results? s Are the authors aware of limitations and potential biases? s Recommendations for further study? 7. 5. 2012 EBM 48
  • 49. Methods s Random allocation of study participants s Researchers were blinded for the initial allocation s The groups did not differ at the beginning of the study s Researchers were blinded for actual allocation s Was analysis performed on all included participants? 7. 5. 2012 EBM 49
  • 50. Appraisal of recomendations in the guidelines (GRADE, BMJ 2004, 328: 1490-8) s A: The opinion supports more quality studies - there is no major change in knowledge expected. s B: Opinion supported by one or more major study weaker or incomplete study - we can expect changes in knowledge. s C: Opinion support some studies, but not always quality ones - future research is likely to result in significant changes in knowledge. s D: No reliable conclusion is possible. 7. 5. 2012 EBM 50
  • 51. Appraisal of meta-analysis (Cochrane) s Described protocol of meta-analysis s Description systematic literature search s Criteria for inclusion or exclusion of studies, research, and that all the reasons why they were excluded s The homogeneity of the results shown by tests s Appropriate statistical analysis were used s In the case of statistically significant differences the possibility of biases due to variability of studies explained s Conclusions shown with regard to treatment decisions EBM 7. 5. 2012 51
  • 52. Conclusions s Knowledge becomes quickly obsolete, or new replaces old dogmas. s Physicians must follow new findings. s Information is unlimited, our ability is limited. s Reliance on the eminence does not suit any more. s We urgently need to know how to find and use appropriate sources of new knowledge. 7. 5. 2012 EBM 52
  • 53. Thank you very much for your attention!
  • 54. Group work: Evaluate papers! 7. 5. 2012 EBM 54