EBM Flashcards
What is the aim of EBM
apply the best available evidence gained from the scientific method to clinical decision making, or
integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances
What are the four things that are integrated in EBM
Best research evidence
Clinical expertise
Patient values
Patient circumstances
What was the coldfx controversy
Was an over the counter cold remedy that purposefully misled consumers into believing it worked even though it was shown to be inneffective
Traces of EBm origin can be found where
ancient Greece
Who is Avicenna? What did they create
Avicenna (c. 980 - 1037), also known as Ibn Sina, was a Persian philosopher and physician.
He was the first to recognize the concept of infectious diseases and introduced quarantine
to control their spread. He introduced clinical pharmacology and experimental medicine
Created the Canon of Medicine, which was used for centuries afterwards
Who is Dr. Archie Cochran? What was his book?
Through his book “Effectiveness and Efficiency: Random Reflections on
Health Services” (1972) and subsequent advocacy, caused increasing awareness and
acceptance of the concepts behind evidence-based practice
First to used EBM
The methodologies used to determine “best evidence” were largely established by
the McMaster University research group led by
David Sackett and Gordon Guyatt
Guyatt coined the term “evidence based”
5 reasons why EMB is gaining popularity
1- Need for valid and quantitative information in variety of medical practice aspects
* 2- The shortcomings and inadequacy of traditional references such as text books, medical journals
* 3- The gap and disparity between our diagnostic skills and clinical judgment.
* 4- We are too busy and not having enough time per patient for finding and adopting this evidence
* 5-The gap between evidence and practice (Knowledge-to-practice gap) lead to variations in practice and quality of care
How do we practice EBM
Step 1- Formulate a question (converting the need for information into an answerable question).
* Step 2- Search for answer (tracking down the best evidence with which to answer the question).
* Step 3- Critically appraise (critically appraising that evidence for its validity (closeness to the truth), impact (size of the effect), and applicability (usefulness in our clinical practice).
* Step 4- Adopt and integrate (integrating the critical appraisal with our clinical expertise and with our patient’s unique biology, values and circumstances).
* Step 5- Evaluate the end results and yourself (evaluating your effectiveness and efficiency in executing steps 1-4 and seeking ways to improve them).
Which steps are “using mode”, “doing mode”, and “replicating mode”
What are background questions? What are the two essential components?
What are foreground questions? What are the four essential components?
As you gain experience how are background and foreground questions balanced
As you gain experience, foreground questions increase
Cognitive resonance
The knowledge we already have about our patient predicament leads to mental reinforcing and emotional responses
Cognitive Dissonance
Our patient’s condition brings us to a point that we confront
what we do not know and we need to know (knowledge gap
awareness). Powerful motivators of learning. Turning the “
negative space” of knowledge gap to the “ positive space” of
well-structured clinical Q
We do not know what we don’t know leads to an _______ _________
undisturbed ignorance
Central issues in clinical work, where clinical questions often arise (10 things)
How can EBM be practiced in real time
Capturing or saving: using shorthand
Scheduling: by when we need to have our Qs answered
Selecting: which one or few of the many Qs should be pursued
How many questions do you usually need
one or two
7 ways well-formulated questions can help
- They help us focus our scarce learning time on evidence that is directly relevant to our patients’ clinical needs.
- They help us focus our scarce learning time on evidence that directly addresses our particular knowledge needs.
- They can suggest high-yield search strategies.
- They suggest the forms that useful answers might take.
- they can help us to communicate more clearly with our colleagues.
- When teaching, they can help our learners to better understand the content of what we teach
- When our questions get answered, our knowledge grows, our curiosity is reinforced, our cognitive resonance is restored, and we can become better, faster, and happier clinicians
What is an educational prescription
Specifies the clinical problem that generated the questions
States the question in all its key elements
It specifies who is responsible for answering it.
It reminds everyone of the deadline for answering it
reminds everyone of the steps of searching, critically appraising, and relating the answer back to the patient
How to find
current best evidence and have current best
evidence find us
Should sort evidence into pre-appraised and non-pre-appraised
2 step screening test for whether a text is likely to be evidence based and up-to-date. Should it be used if it fails these screens
1-A text that provides recommendations for patient care must have “in line” references to evidence that supports each of its key recommendations about the diagnosis, treatment, or prognosis of patients.
2-If the text does indicate exact references for its
recommendations, check the date of publication of the references; if the most recent is more than 2–3 years old, you will need to check whether more recent studies require a change in recommendation. Texts that fail these two screens should be used for background reading only, no matter how eminent their authors
No
What is the 6S hierarchy of organization of pre-appraised evidence
What is systems
Computerized decision support
The ideal one
A perfect evidence-based clinical information system would integrate and concisely summarize all relevant and important research evidence about a clinical problem and would automatically link, through an electronic medical record, a specific patient’s circumstances to the relevant information.
It is published and then reliably and promptly updated whenever important new, high-quality, confirmatory or discordant research evidence becomes available
What is Summaries
Evidence based textbooks
Excellent, less-developed, readily available
It is limited to coverage of therapy topics
High scientific standards
* Posts newly published evidence in an update table for each topic.
* Retrieves not only its own content but pre-appraised references for other topics as well
What is synopses of syntheses?
Evidence-based journal abstracts
carefully edited, typically one-page, structured
descriptions of pre-appraised articles that report sound research
with clinically relevant and
newsworthy findings
The perfect synopsis would provide only, and
exactly, enough
information to support a
clinical action.
Syntheses
Systematic reviews
If more detail is needed or no synopsis is at hand, then databases of systematic reviews (syntheses) are available
Based on exhaustive searches for evidence, explicit scientific reviews of the studies uncovered in the search, and systematic assembly of the evidence
Synopses of studies
Evidence-based journal abstract
Reports of individual studies
If the higher “S” levels fails, then synopses of studies will be checked
Studies
Original journal articles
If every other “S” fails, the original articles or studied should be checked
Example of Summaries, synopses of syntheses, syntheses, synopses of studies, studies
Summaries: CE, Dynamed
synopses of syntheses: ACP medicine
Syntheses: Cochrane collaboration
Synopses of studies: ACPJN, EBN
Studies: ACPJC+
Quality of databases such as PubMed and EMBASE
Typically lower quality but more productive
When to use search engines
If you do not know which database to loo for your question
You must do your own appraisal
How to access evidence-based information services in countries with high resources, low resources, if you are on your own with no resources
countries with high resources: Clinical evidence
Countries with low resources: HINARI offers journals at no cost or low cost
If you are on your own with no resources: free access to high-quality evidence-based information, pre-appraised evidence
What do you search for to solve patient problems
Key question
Best answer to the clinical problem
Evidence resources
Three levels of studies in descending order of clinical usefulness:
Retrivied via clinical queries from medline
Pre-appraised for quality and relevance
Retrieved via PubMed
(1) pre-appraised for quality
and relevance (e.g., via ACPJC+ and
EvidenceUpdates); (2) retrieved via clinical queries
from MEDLINE; and (3) retrieved via PubMed using
just our search terms, “type 2 diabetes and
cardiovascular risk”.
Does evidence make decisions
No
Have to balance other circumstances and her wishes, carefully negotiate priorities with the patient to best match between the evidence and her wishes
Common features for appraisal of most studies (2 features and 3 points for each)
A- Race analogy: Was there a fair start, was the race fair, was it a fair finish
B- The PICO format when we consider validity: What is the population, What was the intervention, were the outcomes measured in an objective fashion
Common validity concerns for systematic reviews
Was the literature search comprehensive
Was the quality of the individual studies assessed
How to appraise evidence
After examining the validity of the studies we consider whether its results are important, this disuccsion will include precision and magnitude
For systematic reviews: consider heterogeneity
