Evidence based medicine: misconception, myths and facts

1. Prof. Aboubakr Elnashar
Benha university, Egypt
Email: elnashar53@hotmail.com

2.  Benefits of EBM
 Misconceptions
 Myths
 Conclusion
Aboubakr Elnashar

3. Yes

4. EBM:
Way of critical thinking
Appropriate tool for sound clinical decisions
Problem solving approach
Life-long self-directed learning

6. Use:
more effective intervention
proven therapies and diagnostic tests
only
Result in:
Better management of patients
Better patient outcomes.
Less harm or side-effects
Better communication with patients about the
rationale behind the management decisions.Aboubakr Elnashar

7. More efficient use of resources
Improve resource utilization
Reduced cost per patient.
Aboubakr Elnashar

8. Using the best available evidence :
Appropriate funding decisions.
More effective and efficient care
Aboubakr Elnashar

9. Upgrade knowledge routinely.
Up-to-date, Keeping up knowledge
explosion &med literature based on valid
evidence.
Improve clinicians’ understanding of research
methods & make them more critical in using
data.
Improves confidence in management
decisions. Relieve anxiety about uncertainty
Improves reading habits.
Aboubakr Elnashar

10. Gives team a framework for group
problem solving & for teaching
Enables juniors to contribute fully to
the team.
VI. The graduates:
EBM curricula
Self-directed
Problem-based
Aboubakr Elnashar

11. •There is a significant gap between
EBM & application of this to clinical
practices

12. Clinical
Practice
Research
Haynes calls this the “evidence transfer gap”. EBM seeks to close the gap
between completed research activity and the practice of medicine.
The “Evidence Transfer Gap”
EBM
Aboubakr Elnashar

13. •A mistaken thought, idea, or notion; a misunderstanding.
•Can happen anywhere, in any situation: not understanding a
topic; not knowing the full story; hearing the wrong story… there’s
many reasons how one can misunderstand something.

14. The clinically-important knowledge of
physicians deteriorates rapidly after we
complete our training.
Aboubakr Elnashar

15. 2. Expert opinion is the best evidence.
•Experience: “I always did it this way”
 Clinical experience is crucial.
 Clinical guideline should be based on
critical appraisal of medical literature
Aboubakr Elnashar

16. Traditional CME is completely ineffective in
changing our behavior.
A great deal of research reported in journals
is poorly done, poorly analyzed: not valid &
irrelevant to our patients and practices.
Only 20% of health care is EB (Kerr White, 2002)
Aboubakr Elnashar

17. Setting Type I Type II No Evid.
Cancer center (USA) 24% 21% 55%
Tertiary surgical center (USA) 14% 64% 22%
Primary care centers (Spain) 38% 4% 58%
General medicine hospital (UK) 53% 29% 18%
General psychiatric ward (UK) 65% 35%
Anesthesia (Australia) 32% 65% 3%
Aboubakr Elnashar

18. Decision based on pathophysiologic
principles may be incorrect
Aboubakr Elnashar

19. Certain rules of evidence are
necessary.
Systematic unbiased observation
increases the confidence of the
physician knowledge.
Aboubakr Elnashar

20. CAT = Critical appraisal of topic is
necessary
Critical appraisal: assessment of evidence
by systematically reviewing its relevance,
validity, results and applicability (RVRA)
Aboubakr Elnashar

21. 1. Relevance:
Common to our practice &
patient-oriented outcome (POEM) not DOE
2. Validity: Free from bias (Truth)
 Randomization.
 Follow up complete.
 Intention to treat.
 Blindness.
 Similar groups at start.
 Both groups treated equally.
3. Results:
Clinically important (magnitude and precession)
4. Applicability:
Applicable at my setting &
useful for my patients
Aboubakr Elnashar

22. •Derived from the Greek word mythos, which means "word of mouth."
•Something that is widely thought to be false
•Holy story

23. EBM focus on:
patient preference
clinical judgment of the
practitioner
best available evidence to
produce the best patient
outcomes
EBM takes into account the
circumstances of the patient
Aboubakr Elnashar

24. Three (Es) - EBM Components
Aboubakr Elnashar

25. EBP is a patient-centered approach &
is highly individualized
Begin & end with the patient in mind
Any practice that fails to take into
account of the individual patient is not
EBP
Clinical evidence can never replace
individual clinical expertise because this
expertise decides whether the external
evidence applies to the patient (Sackett,
1998)
Aboubakr Elnashar

26. The traditional medical paradigm is based on
authority.
EBM is dependent on the use of RCT, systematic
reviews & meta-analysis, although it is not restricted
to these.
 RCT is
 the epitome of all research designs because its
design provides the strongest validity
 It provides the best assurance that the result was
due to the intervention
Aboubakr Elnashar

27. RCT:
a group of patients is randomised into
study group & control group. These
groups are followed up for the
variables/outcomes of interest.
If the sample size is large enough, this
study design avoids problems of bias
and confounding variables
Aboubakr Elnashar

28. Randomized Controlled study
Aboubakr Elnashar

29.  SR
A review of a clearly formulated question that
uses systematic & explicit methods to
1. identify, select and critically appraise relevant
research
2. collect & analyse data from the studies that are
included in the review
 Meta-Analysis
The use of statistical techniques in a SR to
integrate the results of included studies.
Aboubakr Elnashar

30. Aboubakr Elnashar

31. Why SR on the top:
Rigorous methodology
Peer reviewed
Relatively large sample size
Ensures the highest quality evidenceAboubakr Elnashar

32. There are now many advocates of a more
inclusive approach to evidence:
Qualitative research is as valid a form of
evidence as quantitative research
There are now methodologies to systematic
review both numerical and textual findings of
research
 EBP insists that each client is treated with
the best available evidence, that practitioners
make a genuine effort to find the best solution
given their resources.
Aboubakr Elnashar

33. It is not disputed that practice should be
grounded in theory, however it should be
predicated on the best available evidence
This is addressed by systematic reviews
Aboubakr Elnashar

34. Disease-Oriented
Evidence
DOE (intermediate
outcomes)
▪ Pathophysiology,
pharmacology,
etiology, test result
▪ using drug x
decreases the
level of serum
Lipid
Patient-Oriented
Evidence that Matters
to the Patient
POEM (final outcomes)
 Mortality
Morbidity
quality of life
 using drug x
decreases morbidity
& mortality
Aboubakr Elnashar

35. This indicates a fundamental
misunderstanding of the financial
consequences
Physicians identify & implement the
most efficacious treatments to maximize
the outcomes for patients, this may
increase costs
EBP does not reduce the need for
treatments, it attempts to ensure that
each patient gets the best treatment
appropriate for his/her condition.
Aboubakr Elnashar

36. EBP incorporates the more
extensive processes of
SECONDARY & TERTIARY
RESEARCH
searching,
appraisal,
synthesis and
incorporation of the best available
evidence into practice
Aboubakr Elnashar

37. Aboubakr Elnashar

38. Refuted by audits from
within clinical care where at
least some inpatient clinical
teams have provided EB
care to patients
Busy clinicians who can
devote their scarce time can
practice EBM
Aboubakr Elnashar

39. EBP critically examines all
clinical procedures, critically
evaluating their appropriateness
for the specific situation.
Text books: Fail to recommend
Rx up to 10 ys after it’s been
shown to be efficacious.
Continue to recommend therapy
up to 10 ys after it’s been shown to
be useless.
Aboubakr Elnashar

40. The use of evidence is only one piece of
the clinical decision-making process.
Patient situations, preferences & values
are a key component in the process.
Aboubakr Elnashar

41. It is impossible for any practitioner
to keep up with the entire health care
literature {2 million articles published
annually, 6000 articles published
daily].
To keep up to date, physician should
read 19 articles/d.
 Lag time from time of “knowing” to
time of implementation:
13 ys for thrombolytic therapy.
10 ys for corticosteroids to enhance
fetal lung maturity.Aboubakr Elnashar

42. Do not need skills in biomathematics or
statistics
Physicians can gain skills to make
independence decisions & can evaluate
expert opinions.
EBP does not mean continous running to
the library, but that clinicians should
remember to search for evidence to support or
refute their practice methods.
EBM reduces reading by quality filters
Aboubakr Elnashar

43. Aboubakr Elnashar

44. Search Cascade
Aboubakr Elnashar

45. EBM approach depends on high-quality
literature, which is lacking in many areas of
medicine
There are more RCT each year
There are many other types of evidence to
make good decisions.
Aboubakr Elnashar

46.  Many myths & misconceptions exist in
health care practice
 Myths & misconceptions must be overcome
to implement EBM
 EBM:
Aboubakr Elnashar

47. Aboubakr Elnashar

48. Life is short &
the evidence is too
hard to find???
Thank you
Questions?
Aboubakr Elnashar