Introduction to Evidence-Based Medicine Bill Cayley Jr MD MDiv UW Health Augusta Family Medicine Objectives 1. Describe the use of evidence in making medical decisions 2. Demonstrate searching for an evidencebased answer to a medical question What is “evidence-based medicine?” Two fundamental questions… • What is the purpose of medicine? • How do I decide what to do? You have to know where you’re going before deciding how to get there… What is the purpose of medicine? • Patient care • Public health • Research Improving the quality of patients’ lives… What is evidence-based medicine? Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Sackett, et al. BMJ 1996;312:71-72 What is “EBM” NOT? • What we have always done • “Cookbook medicine” • Only a cost-cutting trick • Only randomized trials Evidence based medicine IS… Tracking down the best external evidence with which to answer our clinical questions… EBM – a short history… • JAMA 1992 “EBM: a new approach…” • JAMA 1993 – 2000 “Users' Guides to the Medical Literature” • 1990s – 3 trends – Systematic reviews – Search engines – Knowledge distillation and “push” services Classification of evidence How do I decide what to do? How do I make decisions? • Dogma: “Natural is best” • Tradition: “We’ve always done it that way” • Convention: “Everyone does it this way” • Evidence-Based: “Evidence supports this way” How do I decide what to do? The answer from EBM… “…use of current best evidence…” Evidence: systematic observation Meta-Analysis Randomized Controlled Trial Uncontrolled Trial Case Series Anecdote Meta-Analysis Randomized Controlled Trial Uncontrolled Trial Case Series Anecdote More systematic observation ► better evidence Integrating evidence & practice What type of outcome measures? • Surrogate markers of disease: – Hb A1c, cholesterol, blood pressure • Stage or extent of disease: – Diabetic ulcers, angiographic CAD, stroke • Patient-oriented outcomes: – Mobility, suffering, longevity – Morbidity and mortality Patient or disease oriented? • Disease-Oriented Outcomes. – Intermediate, histopathologic, physiologic, or surrogate results – Examples: blood sugar, blood pressure, flow rate, coronary plaque thickness – May or may not reflect improvement in patient outcomes. • Patient-Oriented Outcomes. – Outcomes that matter to patients and help them live longer or better lives – Examples: including reduced morbidity, reduced mortality, symptom improvement, improved quality of life, or lower cost Which outcomes???? • Topical antibiotics for bacterial conjunctivitis may improve early and late resolution rates, but nearly all cases ultimately have complete remission. • Br J Gen Pract. 55: 962-4. • Digoxin for symptomatic heart failure provides no significant difference in mortality but is associated with lower rates of hospitalization and of clinical deterioration. • J Card Fail. 10:155-64. • Long-acting beta-2 agonists for asthma are effective in reducing symptoms but may increase mortality or exacerbations. • Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD006363. SORT When guidelines conflict… Questions of evidence • Were the clinical questions different? • Were different studies considered? • Were the results analyzed differently? • Was the quality of evidence assessed differently? Questions of outcomes • Did the effect estimates for important outcomes differ? • Did judgments about evidence quality differ? • Were health consequences weighed differently? • Were economic consequences considered differently? Systems applications Clinical Questions • Background - “What is it?” – General information on a condition or disease • Foreground – “What do I do for this patient?” – Patient – Intervention/Investigation – Comparison Intervention/Investigation – Outcome (Patient-Oriented) Clinical Questions - “PICO” Example: • In a 5 year old child with conjunctivitis (patient) will topical antibiotics (intervention) compared to no treatment (comparison) lead to quicker symptom relief (outcome)? • In a 5 year old child with conjunctivitis (patient) will topical antibiotics (intervention) compared to no treatment (comparison) lead to improved cure rates (outcome)? Finding Evidence-based Answers • Trip Database (http://www.tripdatabase.com/) • Database of Abstracts of Reviews of Effectiveness (http://www.crd.york.ac.uk/crdweb/) • DynaMed (http://www.dynamicmedical.com/) – *Subscription required. • Essential Evidence Plus (http://www.essentialevidenceplus.com/) – *Subscription required. • Cochrane Library (http://www.cochrane.org/) – *Subscription for full access, abstracts free. • FPIN (http://www.fpin.org/) – *Subscription required. • Clinical Evidence (www.clinicalevidence.com/) – *Subscription required. For further reading… • Woolever DR. The art and science of clinical decision making. Fam Pract Manag. 2008 May;15(5):31-6. PMID: 18546805 (http://www.aafp.org/fpm/20080500/31thea.html) • Krumholz H, Lee T. Redefining Quality -- Implications of Recent Clinical Trials. N Engl J Med 2008 358: 2537-2539 (http://content.nejm.org/cgi/content/full/358/24/2537) • Ebell MH. How to find answers to clinical questions. Am Fam Physician. 2009 Feb 15;79(4):293-6. PubMed PMID: 19235495. (http://www.aafp.org/afp/2009/0215/p293.html) In short… EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Patient-oriented evidence preferable to Stage of disease preferable to Evidence Systematic observation = high-quality evidence Surrogate markers