Intro to EBM

Question 1

What are the goals of EBM?

Answer 1

To develop a set of evidence supported practice tools to further lifelong, self-directed learning

Guide informed clinical decisions in caring for patients

Question 2

What is EBM?

Answer 2

“…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)

Question 3

How do some “older” clinicians see EBM?

Answer 3

“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”

Question 4

What does EBM serve to do?

Answer 4

Standardize practice while maintaining patient centered care

Promotes life-long learning

Response to practice variability

Provide granularity on complex questions and gray areas

Question 5

What is the number 1 reason we need EBM?

Answer 5

We have A LOT of questions-

2 questions generated per 3 outpatient encounters
5 questions generated per inpatient admission

Question 6

What is the number 2 reason we need EBM?

Answer 6

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Textbooks are outdated from day 1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

Question 7

What percent of questions do primary care physicians try to answer?

Answer 7

20-57%

Question 8

What is the number 3 reason we need EBM?

Answer 8

Disparity between increasing diagnostic skills and clinical judgment and decreasing current knowledge and clinical performance.

Question 9

What did the studies of the 1980s focus on and what did they find?

Answer 9

Looked at practice variations

Surgeons were found to be using heterogeneous standards

Showed the need for PROVEN therapies for patients

Question 10

What things will we confront daily that will utilize EBM?

Answer 10

Interpretation of tests

Harms due to exposures

Disease prognostication

Effectiveness of preventative & therapeutic intervention

Costs

Question 11

What are the two types of EBM questions?

Answer 11

Background & Foreground

Question 12

What are background questions?

Answer 12

Ask for general knowledge about a disorder.

Question 13

What are foreground questions?

Answer 13

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?

Question 14

What are the 3 main skills of EBM?

Answer 14

Information Mastery – efficient searching

Critical Appraisal = critical thinking

Application to the patient
-Inclusive of: Best evidence, Clinical experience, Specific clinical situation, and Patient values

Question 15

How does EBM make us good providers?

Answer 15

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

Question 16

How much care in the 1970’s was evidence based?

Answer 16

10-20%

Question 17

In 1990’s what percentage of healthcare was evidence based?

Answer 17

21%

Question 18

What does effective care “equal”?

Answer 18

Evidence based care.

Question 19

What are the two alternates to effective care?

Answer 19

Preference-sensitive care & Supply-sensitive care

Question 20

What is preference-sensitive care?

Answer 20

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%

Question 21

What is supply-sensitive care?

Answer 21

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

Question 22

What is the three-pronged approach to EBM?

Answer 22

Clinical Problem Solving

Medical Informatics

Critical Appraisal of Medical Literature

Question 23

What is clinical problem solving?

Answer 23

Lots of Good Questions

A Little Epidemiology

A Little Statistics

Question 24

What are medical informatics?

Answer 24

Clinicians with computer medical databases such as PubMed, Cochrine Library, TRIP, DynaMed, National Guidelines Clearinghouse, etc.

Question 25

How do we clinically appraise medical literature?

Answer 25

Some statisitics, some epidemiology Some notion of study design and levels of evidence Using JAMA based worksheets

Question 26

What does the three pronged approach serve to do?

Answer 26

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”

Question 27

Why do we use evidence-based care?

Answer 27

Too many patients Too many problems Too many journals Information overload Reimbursement Core Measures Foster Understanding Quality Improvement

Question 28

Average time clinician's spend reading per week

Answer 28

``` < ½ hour - 3% 1 hour - 46% 1 ½ hours - 23% 2 hours - 20% > 3 hours - 8% ```

Question 29

How do you create an EBM prescription?

Answer 29

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.

Question 30

What are the 5 A's?

Answer 30

Ask a question. Access the evidence. Critically appraise the evidence. Apply the evidence. Assess the use of information in practice.

Question 31

What is POE?

Answer 31

Patient-Oriented Evidence

Question 32

What are examples of patient-oriented evidence?

Answer 32

Mortality, Morbidity, quality of life

Question 33

What are examples of disease-oriented evidence?

Answer 33

Pathophysiology, pharmacology, etiology

Question 34

Which type of evidence is almost always "best"?

Answer 34

Patient-Oriented Evidence

Question 35

Do POE and DOE always agree?

Answer 35

No

Question 36

What is DOE?

Answer 36

Disease-Oriented Evidence

Question 37

What are the 4 kinds of clinical questions?

Answer 37

Etiology Diagnosis Therapy Prognosis

Question 38

What does PICO stand for?

Answer 38

Patient Intervention Comparison Intervention Outcome

Question 39

What are Hill's guidelines for determining causation?

Answer 39

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