EBM
EVIDENCE BASED MEDICINE
RESOURCES
Lobna Al Juffali, Msc
Spring 2010
A DRUG INFORMATION QUESTION
“ My 8 month baby has a severe earache for 2 days
Should I treat him with Antibiotics?”
ON WHAT BASES SHOULD I ANSWER THE
QUESTION?
1.
2.
3.
On my current knowledge depending on my
practice
By experts opinion
By the well structured studies that justifies the
use or non use of antibiotics
COMMONSENCE

I shook the tree, and a coconut fell on my head.
Hmm....maybe shaking the tree caused the
coconut to fall on my head! Better not shake
trees without first watching for falling coconuts...
EBM
I gave my patient who has had bronchitis for 4 or 5
days an antibiotic, and 3 days later she felt
better.
Hmm...maybe giving the patient the
antibiotic caused her to feel better! I better give
all of my patients with bronchitis an antibiotic...
EBM
ON WHAT BASES SHOULD I ANSWER THE
QUESTION?
1.
2.
3.
On my current knowledge depending on my
practice
By experts opinion
By the well structured studies that justifies the
use or non use of antibiotics
INTRODUCTION
1990s, a group of clinicians and early In the
epidemiologists at McMaster University in Ontario, Canada,
officially lead by Dr. David Sackett which coined the term
"evidence-based medicine.”
The concept faced mixed reviews: excitement from those in
the academic and research worlds and suspicion from
those in the "real world," who found EBM impractical in a
busy medical office.
EBM
DR. SACKETT DEFINES EBM AS :
“Evidence-based medicine is the integration of
best research evidence with clinical expertise
and patient values”
EBM
Patient
Values
Clinical
Expertise
Research
Evidence
WHY DO WE NEED EVIDENCE BASED
MEDICINE?

Clinical examples that we practice without the
best evidence which lead to harm for our
patients.

Failure of common sense .

The wide variation in current clinical practice
among practitioners.


The difficulty of managing medical information,
when results conflict and thousands of articles
are published every month .
The knowledge declines over time, and
traditional CME doesn't work
EBM
WHAT WERE THEY
PRACTICING IN THE PAST
EBM
50 YEARS ?
EB
Opinion Based Medicine
EBM
EBM VS TBM
EBM
Demands better evidence
 external clinical evidence
 Guidelines.
 systematic reviews
 meta-analyses
 own experience
 Patients preference
 evidence that matters
Focuses on outcomes that matter
to the patient

TBM





opinion based medicine
own experience
asking relatively few
colleagues
Guidelines, but they were
consensus-based. opinions not
backed up by science."
"BOGSATs,"
SO they fail to search for
evidence which might cause
them to reach a different
conclusion or allow them to
come to a more balanced
decision
EBM
EBM
HOW DO WE PRACTICE
EVIDENCE BASED MEDICINE
5 STEPS IN PRACTICING EBM
critically appraising
that evidence for its
validity ,impact and
applicability
tracking down the
best evidence with
which to answer
that question
Formatting
An answerable
question
(well built
clinical
question)
integrating the
critical appraisal with
our clinical expertise
and with our patient’s
evaluating our
effectiveness and
efficiency in
executing steps 1–4
TRACKING DOWN THE BEST
EVIDENCE
 To
be useful, medical information should be
relevant to everyday practice, correct (valid)
and easy to obtain.
Usefulness equation
Relevance x Validity
Work
EB
VALIDITY


The hard part of Information Mastery
The “Truth”-Probability statement that what we
do does more good than harm.
EBM
RELEVANCE
Frequency
 Type of evidence presented
 Evidence that can change my practice

EBM
RELEVANCE: TYPE OF EVIDENCE

POE: Patient-oriented evidence


mortality, morbidity, quality of life
DOE: Disease-oriented evidence

pathophysiology, pharmacology, etiology
EBM
Type of Evidence
Example
DiseaseOriented
Evidence
PatientOriented
Evidence
that Matters
Comment
Antiarrhythmic
therapy
Antiarrhythmic
drug X
decreases
PVCs on
ECGs
Antiarrhythmic
drug X
increases
mortality
The results of the
POEM study are
contrary to what
the DOE study
would suggest
Antihypertensive
therapy
Antihypertensive
drug
treatment
lowers BP
Antihypertensive
drug
treatment
decreases
mortality
The results of the
POEM study are
in concordance
with DOEs
EB
WORK

Basic law of human behavior: lowest amount of
work you can get away with
EBM
Information source
Relevance
Validity Work
Usefulness
Evidenced based textbook
High
High
Low
High
Standard textbook
High
Low
Low
Mod
Drug reference book ( PDR)
High
Mod
Low
High- Mod
Systematic review EB
High
High
Low
High
Practice Guidelines EB
Mod
High
Low
Mod-High
Practice guidelines
consensus
Mod
Mod
Low
Mod
Drug advertising
Mod
Low
Low
Low
Drug company
representatives
High
Low
Low
Low
Colleagues
High
Mod
Low
High- Mod
Internet in 10 years
High
High
Low
High
Internet now
Low
Low
High
Low
EBM
IS ALL EVIDENCE CREATED EQUALLY?
HOW DO WE SEARCH
LITERATURE RESOURCES
FILTERED RESOURCES

appraise the quality of studies and often make
recommendations for practice
Systematic Reviews
Authors of a systematic review ask a specific
clinical question, perform a comprehensive
literature search, eliminate the poorly done
studies and attempt to make practice
recommendations based on the well-done studies.


A meta-analysis is a systematic review that
combines all the results of all the studies into a
single statistical analysis of results.
EXAMPLES OF SYSTEMIC REVIEWS/
METAANYLSIS
The Cochrane Database of Systematic Reviews
 The Database of Abstracts of Reviews of Effects (DARE)
 Ovid MEDLINE: Enter your search query. Click on "More
Limits"; select “Systematic Reviews” under “Subject
Subsets.”
 PubMed: Click on “Clinical Queries” on the left side of the
screen; select “Find Systematic Reviews” and enter your
search query.

FILTERED RESOURCES
Critically-Appraised Topics
evaluate and synthesize multiple research studies
 Clinical evidence
 National Guideline Clearinghouse
 Critically-Appraised Individual
ArticlesAuthors of critically-appraised
individual articles evaluate and summarize
individual research studies.
 The ACP Journal club
 Daily POEMS
 Evidence updates

FILTERED RESOURCES

“Evidence-Based…” Journal series
 (e.g., Evidence-Based Medicine, EvidenceBased Mental Health, Evidence-Based
Nursing)
UNFILTERED RESOURCES

Evidence is not always available via filtered
resources. Searching the primary literature may
be required. It is possible to use specific search
strategies in MEDLINE and other databases to
achieve the highest possible level of evidence
PubMed
 Ovid Medline

BACKGROUND INFORMATION/EXPERT OPINION
Evidence in these resources may vary from expert
opinion to high levels of evidence.
UpToDate
 e-Medicine
 E-Books at Galter
 ACP Medicine

5S APPROACH TO EVIDENCE BASED
INFORMATION ACCESS
Systems
Summaries
synopses
Synthesis
Studies
Computerized decision
support system (CDSS)
Evidence basedtextbooks
Evidence based-journal
abstracts
Cochrane reviews
Original published
articles from journals
Systems
Summaries
SYSTEMS
synopses
Synthesis
Studies






Decision support tools.
They 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.
updated whenever important new research evidence
becomes available.
would not tell decision-makers what to do.
to ensure that the cumulative research evidence
concerning the patient’s problem is immediately at
hand.
to maximize speed of use
Systems
Summaries
SUMMERIES
synopses
Synthesis
Studies
These are critically appraised topics
 Summaries that integrate best available evidence
to provide a full range of evidence concerning
management options for a given health problem
(eg, acute coronary syndromes [ACS]).




Clinical Evidence
PIER (Physicians' Information and
Education Resources)
DynaMed
DYNAMED
is updated daily
 monitors the content of over 500 medical journals
and systematic evidence review databases
 clinically-organized summaries for more than
3,000 topics,

PIER (PHYSICIANS' INFORMATION AND
EDUCATION RESOURCES)
Link: http://online.statref.com/UserLogin.aspx
 Is an American College of Physician product
 summarizes and evaluates current evidence for
patient care.
 It grades clinical recommendations based on the
strength of the evidence available.

Systems
Summaries
SYNOPSES
synopses
Synthesis
Studies
Critically appraised journal article/study
 •Concise short statements that summarized the
evidence for a particular clinical question
 •Available of multiple sources over the internet
 •Some are downloadable to handheld devices
Example of Synopses
 •ACP Journal Club
 •BMJ Updates
 •Bandolier
 •Essential Evidence Plus

BMJ UPDATES
From BMJ Publishing Group and McMaster
University's Health Information Research Unit.
 Quality articles from over 110 clinical journals
are selected by research staff, then rated for
clinical relevance and interest by an
international group of physicians.
 Includes a searchable database of the best
evidence from the medical literature and an
email alerting system

ACP JOURNAL CLUB
published by the American College of PhysiciansAmerican Society of Internal Medicine.
 The editors of this journal screen the top 100+
clinical journals and identify studies that are
methodologically sound and clinically relevant.
 An enhanced abstract, with conclusions clearly
stated, and a commentary are provided for each
selected article

Systems
Summaries
SYNTHESIS
synopses
Synthesis
Studies
If more detail is needed or no synopsis is at hand,
then databases of systematic reviews (syntheses)
are available,
 Examples

Cochrane Library
 Ovid’s EBMR service.

COCHRANE DATABASE OF SYSTEMATIC
REVIEWS (COCHRANE REVIEWS)
'Gold Standard' for high-quality systematic reviews
 Full-text included in Cochrane Library
 Cochrane Reviews includes complete reviews and
protocols (reviews that are still in progress).
 Cochrane Reviews abstracts are in PubMed

COCHRANE DATABASE OF SYSTEMATIC
REVIEWS (COCHRANE REVIEWS) DATABASES
Cochrane Database of Systematic Reviews (Cochrane Reviews)
Database of Abstracts of Reviews of Effects (Other Reviews)
Central Register of Controlled Trials (Clinical Trials)
Cochrane Methodology Register (Methods Studies)
Health Technology Assessment Database (Technology Assessments)
NHS Economic Evaluation Database (Economic Evaluations)
EBM
DATABASE OF ABSTRACTS OF REVIEWS
OF EFFECTS (OTHER REVIEWS - DARE)






prepared by the National Health Service Centre for
Reviews and Dissemination, University of York,
England.
Complements the Cochrane Reviews by offering a
selection of quality assessed reviews in those subjects
where there is currently no Cochrane review.
Brief critical appraisals of previously published
reviews of the effects of health care.
Structured abstracts, not full-text
DARE not indexed in PubMed, but original research
articles may be
Also available at no charge on the web from
University of York | www.crd.york.ac.uk/crdweb/
PUBMED MEDLINE - SYSTEMATIC
REVIEWS
part of PubMed's Clinical Queries
 Identifies systematic reviews and other similar
types of studies found in biomedical journals
included in PubMed database.
 No evaluation of comparative quality of different
reviews on a topic.
 Abstracts supplied by authors/journals.
 No separate evaluation of quality of research.
 Identify systematic reviews in the biomedical
area - gathers together much larger collection
than other evidence-based practice resources.

Systems
Summaries
STUDIES
synopses
Synthesis
Studies
original studies
 It takes time to summarize new evidence, and
systems, synopses and syntheses necessarily
follow the publication of original studies, usually
by at least 6-12 months.

EXAMPLE OF STUDIES



There are also at least two levels of evidence-based databases to search
directly:
specialized and general.
If the topic falls within the areas of internal medicine, primary care, nursing or
mental health, then









ACP Journal Club (www.acpjc.org, formerly Best Evidence)
Evidence Based Medicine (http://ebm.bmjjournals.com/),
Evidence Based Nursing (http://ebn.bmjjournals.com/)
Evidence Based Mental Health (http://ebmh.bmjjournals.com/)
If the search is for a treatment,
the Cochrane Library includes the Cochrane Central Register of Controlled
Trials
also available as part of EBMR on Ovid, where it is integrated with ACP
Journal Club and DARE.
For original articles and reviews MEDLINE itself is freely available and the
Clinical Queries screen
If you still have no luck and the topic is, say, a new treatment (that one of your
patients has asked about but you don’t yet know about …), then you can try
Google (http://www.google. com
EXPERT OPINION
Evidence in these resources may vary from
expert opinion to high-level evidence but
 updates are generally less frequent and level of-evidence grading systems are lacking.
 –UpToDate
 –eMedicine
 –Harrison's Online

UP TO DATE
Provide comprehensive reviews on primary care,
internal medicine, and pediatric topics.
 Content is enhanced by
–many graphics links
–Lexi-Comp's drug reference
–PubMed abstracts.
 Evidence gaps are filled by expert opinion.
EBM
EXAMPLE OF EBM SEARCH
ENGINES