Intro to EBM Flashcards
What are the goals of EBM?
To develop a set of evidence supported practice tools to further lifelong, self-directed learning
Guide informed clinical decisions in caring for patients
What is EBM?
“…the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”
--D Sackett, BMJ, 1996
Integrating individual clinical expertise with the best available external clinical evidence from systematic research (Sackett et al., 2000)
How do some “older” clinicians see EBM?
“EBM is the increasingly fashionable tendency of a group of young, confident and highly numerate medical academics to belittle the performance of experienced clinicians using a combination of epidemiological jargon and statistical sleight-of-hand”
What does EBM serve to do?
Standardize practice while maintaining patient centered care
Promotes life-long learning
Response to practice variability
Provide granularity on complex questions and gray areas
What is the number 1 reason we need EBM?
We have A LOT of questions-
2 questions generated per 3 outpatient encounters
5 questions generated per inpatient admission
What is the number 2 reason we need EBM?
Traditional sources of information are inadequate
Textbooks are outdated from day 1
Experts often are wrong
Passively listening to CME does not improve skills and knowledge
Medicine is constantly evolving
What percent of questions do primary care physicians try to answer?
20-57%
What is the number 3 reason we need EBM?
Disparity between increasing diagnostic skills and clinical judgment and decreasing current knowledge and clinical performance.
What did the studies of the 1980s focus on and what did they find?
Looked at practice variations
Surgeons were found to be using heterogeneous standards
Showed the need for PROVEN therapies for patients
What things will we confront daily that will utilize EBM?
Interpretation of tests
Harms due to exposures
Disease prognostication
Effectiveness of preventative & therapeutic intervention
Costs
What are the two types of EBM questions?
Background & Foreground
What are background questions?
Ask for general knowledge about a disorder.
What are foreground questions?
Ask for specific knowledge about managing patients with a disorder.
i.e, You know how to treat Trichomonas. What about when the patient states she cannot take Flagyl! What do you do?
What are the 3 main skills of EBM?
Information Mastery – efficient searching
Critical Appraisal = critical thinking
Application to the patient
-Inclusive of: Best evidence, Clinical experience, Specific clinical situation, and Patient values
How does EBM make us good providers?
Competence
Providing highest quality care
Providing individualized care
Respecting the choices and decisions of the patient
Communicating risk and options to patients effectively
Utilization of best practices
How much care in the 1970’s was evidence based?
10-20%
In 1990’s what percentage of healthcare was evidence based?
21%
What does effective care “equal”?
Evidence based care.
What are the two alternates to effective care?
Preference-sensitive care & Supply-sensitive care
What is preference-sensitive care?
Wide variations in provider preference lead to wide variation in health care utilization
‘Surgical signature’
‘Medical signature’
Example: Implementation of shared decision tool reduced prostatectomy 40%
What is supply-sensitive care?
The more inpatients beds and specialists the more utilization
Increased utilization DOES NOT equal better care
Physicians moving from low to high supply adapt practice to use excess supply
What is the three-pronged approach to EBM?
Clinical Problem Solving
Medical Informatics
Critical Appraisal of Medical Literature
What is clinical problem solving?
Lots of Good Questions
A Little Epidemiology
A Little Statistics
What are medical informatics?
Clinicians with computer medical databases such as PubMed, Cochrine Library, TRIP, DynaMed, National Guidelines Clearinghouse, etc.
How do we clinically appraise medical literature?
Some statisitics, some epidemiology
Some notion of study design and levels of evidence
Using JAMA based worksheets
What does the three pronged approach serve to do?
What Evidence-Based Medicine is and is not important?
Importance of “spreading the word”
An attitude switch from an Authority in medicine (“This is the way I do it”) to Evidence indicates this is the best practice
An active, practical approach for “informed consumers”
Why do we use evidence-based care?
Too many patients
Too many problems
Too many journals
Information overload
Reimbursement
Core Measures
Foster Understanding
Quality Improvement
Average time clinician’s spend reading per week
< ½ hour - 3% 1 hour - 46% 1 ½ hours - 23% 2 hours - 20% > 3 hours - 8%
How do you create an EBM prescription?
The Pathway to the Truth (the 5 A’s)
Step1: Formulate and Ask a question.
Step 2: Access the evidence
Step 3: Critically Appraise the evidence.
Step 4: Apply the evidence.
Step 5: Assess the use of information in practice.
What are the 5 A’s?
Ask a question.
Access the evidence.
Critically appraise the evidence.
Apply the evidence.
Assess the use of information in practice.
What is POE?
Patient-Oriented Evidence
What are examples of patient-oriented evidence?
Mortality, Morbidity, quality of life
What are examples of disease-oriented evidence?
Pathophysiology, pharmacology, etiology
Which type of evidence is almost always “best”?
Patient-Oriented Evidence
Do POE and DOE always agree?
No
What is DOE?
Disease-Oriented Evidence
What are the 4 kinds of clinical questions?
Etiology
Diagnosis
Therapy
Prognosis
What does PICO stand for?
Patient
Intervention
Comparison Intervention
Outcome
What are Hill’s guidelines for determining causation?
Strength of the association
Consistency
Specificity – cause should lead to a single effect
Temporality
Biological gradient (i.e dose response)
Biological Plausibility
Coherence with other data
Analogy – similar relationships with other processes
