Transcript Thank you…

 If
you give someone a fish,
he will eat today …

If you teach him how to fish,
he will eat every day…
Evidence –Based Medicine
Journal Club
Prof. EIAD AL-FARIS
Chairman, Department of Family and Community Medicine
College of Medicine,King Saud University
Contents
1.
2.
3.
4.
5.
6.
7.
8.
Aims and Objectives
Introduction
Definition of EBM.
Steps For EBM Practice.
Well Built Clinical Questions.
Identifying The Evidence
Search Strategy.
Conclusion
Aims and Objectives
What is EBM ?

Integration of best research evidence with
clinical experience & patient values.
Which database you are prescribed
to?








Pubmed
Cochrane Library
Clinical Evidence
Best Evidence
Bandolier
Therapeutic Initiative
Trip database
Google
WHAT IS EBM ?
The conscientious, explicit and judicious
use of current best evidence in making
decisions about the care of individual
patients.
DAVID SACKETT
Five steps process ?



Asking the right question.
Searching for information.
Evaluating the evidence for
validity and usefulness.

Implement useful findings in
clinical practice

Evaluate the whole process

Step I.
Converting the need for
information into a answerable
question.
To answer a clinical question effectively,
First, turn your scenarios into 'well-built'
clinical Q.
Four domains: PICO
1) the patient (problem)
2) the intervention or exposure
3) the comparison (intervention)
4) the clinical outcomes
For healthy adults is it
worthwhile to give aspirin
as
prophylaxis to reduce
MI and or stroke ?
Aspirin and Primary Prevention
1. Patient population.
Asymptomatic adults with no
risk factors
2. Intervention.
Aspirin
3. Comparison
intervention.
Placebo
4. Outcomes.
Incidence of CV events
“In asymptomatic adults no risk factors, would the
use of aspirin reduce the incidence of cardiovascular
events?
Information management
Principles
Clinical Scenario


Ibrahim is a 30 years old teacher, he is known
case of allergic rhinitis. He presented to your
clinic for follow up, he is having a flare up of
rhinitis symptoms, and he wants to get refills
of the antihistamine pills that he used to get
from his physician.
You wonder should you prescribe intranasal
steroids or refill the antihistamines?!
Step 1
Formulating an answerable
question
Formulating clinical questions




Patient/ Population : Patients with Allergic
Rhinitis
Intervention
: Intranasal steroids
Comparison
: Antihistamines
Outcome
: Control of symptoms
Formulating clinical questions

In patients with Allergic Rhinitis, is Intranasal
steroids more effective than antihistamines in
the management of Allergic Rhinitis
symptoms?
Step II.
Searching best evidence to answer the
question.
Identifying The Evidence
Medline
Embase
• Primary Sources
• Secondary Sources
Systematic Reviews
Clinical Guidelines
Where to Find the Best Evidence
?

Invest in evidence databases
• Using Prefiltered sources
• Using Unfiltered sources
Search strategy





Disease and intervention well understood &
fully
evaluated
Textbook
Common problem
Clinical evidence
ACP Journal Club
New intervention
Medline PubMed
clinical queries.
Broad questions
System review
articles e.g
Cochrane library
Internet google
Scenario and Questions (Cont’d)

Q1. For healthy adults is it worthwhile
to give aspirin as prophylaxis to reduce
MI and or stroke.
PRIMARY SOURCES

Primary Sources of evidence
MEDLINE
EMBASE
Other Search Engines




EMBASE
CANCERLIT
CINAHL
HealthSTAR
Secondary sources of
Evidence
SECONDARY SOURCES
A Unique Source…

Its contents are driven by questions
rather than by the availability of
research evidence.

It is updated every 6 months.
Clinical Evidence

Produced by the BMJ Publishing Group
Updated every six months

www.clinicalevidence.org

Aspirin and Primary Prevention
1. Patient population.
2. Intervention.
Asymptomatic adults with no
risk factors
Aspirin
3. Comparison
Placebo
4. Outcomes.
Incidence of CV events
“In asymptomatic adults no risk factors, would the
use of aspirin reduce the incidence of cardiovascular
events?
Aspirin and Primary Prevention
Benefit




CER=4.8%
EER=4.2%
ARR=4.8-4.2=0.6%
NNT=167
Harms
IC bleeds: NS
EC bleeds:
 ARI=0.8-0.5=0.3%
 NNH=333
The Cochrane Library
The Cochrane Library
http://www.thecochranelibrary.com
Clinical Scenario


Khalid is a 40 years old smoker, would like to quit
smoking, he tried to do that, by himself, several times
over the last two years, but he could not tolerate the
withdrawal symptoms. Recently he read an article in
the newspaper reporting that anti-depression
medications can be used to help smoker to quit, he
would like your advise about this issue!
You wonder what is the role of antidepressants in
smoking cessation?!
Formulating clinical questions




Patient/ Population : Smoking Cessation
Intervention
: Antidepressants
therapy
Comparison
: Placebo
Outcome
: Rate of smoking
Cessation
The Cochrane Database of Systematic
Reviews
Live Demonstration
Archie Cochrane
“It is surely a great criticism of our profession that we have not
organised a critical summary, by specialty or subspecialty, adapted
periodically, of all relevant randomised controlled trials.”
The Cochrane Database of
Systematic Reviews (CDSR)

Include more than 50 review groups.

Contains over 3541 completed reviews and
review protocols.

The CDSR abstracts are free

The CDSR impact factor is 4.654 ranking
number 14

The collection is updated quarterly.

Reviews are updated every 2 years.
Review Groups










Acute respiratory infections
Airways
Anaesthesia
Back
Breast cancer
Colorectal cancer
Consumers and communication
Cystic fibrosis and genetic
disorders
Dementia & cognitive
improvement
Depression, anxiety & neurosis










Developmental, psychosocial
and learning problems
Drugs and alcohol
Ear, nose and throat disorders
Effective practice and
organisation of care
Epilepsy
Eyes and vision
Fertility regulation
Gynaecological cancer
Heart
Hepato-biliary
Database Of Abstracts Of
Reviews Of Effectiveness
(DARE)

DARE is a collection of abstracts of
well-conducted and quality-assessed
research reviews about the effectiveness
of health care interventions.

http://nhscrd.york.ac.uk/darehp.htm
ACP Journal Club
Selects articles from the
literature that are original
commented on by clinical
experts.
 More than 2000 reviews
currently available.
 http://www.acpjc.org/

ACP Journal Club

Selects articles from the literature that are
original commented on by clinical experts.
More than 2000 reviews currently available.

http://www.acpjc.org/

Scenario and Questions (cont’d)

Q2. One of my healthy patients
asked whether to take folic
acid or not ?
Bandolier



Search for systematic reviews and abstract
them
Include NNT tables
http://www.jr2.ox.ac.uk/Bandolier/
SECONDARY SOURCES

Bandolier is an Oxford based
appraisal site with lots of good
material.
http://www.jr2.ox.ac.uk/bandolier/bformHJ.ht
ml
Scenario and Questions (cont’d)
Q3. One of your residents asked you
should we stop prescribing traditional
NSAID, and shift to the selective C0X2
inhibitors?

SECONDARY SOURCES

Evidence Based Therapeutics Initiative
from
UBC,
Canada
http://www.ti.ubc.ca/index.html
Scenario and Questions (Cont’d)
Q4.
A.
For
type
I
diabetic
patient
with
microalbuminurea, which is the best ACEI or
ARB that will protect the kidney?
B.
In diabetic and HTN patients, which is more
effective in preventing stroke, captopril or
enalapril?
TRIP Database



The TRIP Database searches 70 sites of highquality medical information.
The site is updated monthly.
http://www.tripdatabase.com/
Step (3): Critical Appraisal of the
Evidence



Is the evidence from this article valid? METHOD
If valid, are the RESULTS important?
If valid and important, can you apply the
evidence in the caring for the patients in the local
contexts?
Conclusion
Five steps process ?



Asking the right question.
Searching for information.
Evaluating the evidence for
validity and usefulness.

Implement useful findings in
clinical practice

Evaluate the whole process
Conclusion Cont.
The main thing is to
keep asking questions.
Thank You
[email protected]
King Saud Khazindar Free Journals
http://www.alkhazindar.com.sa/onlinejourna
ls/first.asp
Literature
Review
Training Medical Students in Evidence-based
Medicine: A Community Campus Approach.
Family Med 1999, 31 (10): 703-8.
Michigan State University (MSU)
 A nine-session 20 hours curriculum
 Third year medical students
 It compared this group with the AAMC
graduates and the 1994 class who were not
taught this course

AAMC Comparison of
Literature Analysis Skills
90%
80%
70%
60%
50%
AAMC
MSU
40%
30%
20%
10%
0%
1994
1995
1996
1997
AAMC Comparison of Research
Technique Skills
70%
60%
50%
40%
AAMC
MSU
30%
20%
10%
0%
1994
1995
1996
1997
CONCLUSION
If
you give someone a fish,
he will eat today …

If you teach him how to fish,
he will eat every day…
 Be open to
questions;
never avoid
or ignore a
question.
 Show
interest in
the patient’s
story; never
act bored.
Do not give
the patient
false
reassurance.
INFORMATION EXPLOSION
?250,000
100,000
10,000
1900
1990
2000
MEDICAL JOURNALS
DOE
POEM
Disease
Oriented Evidence
(DOE)
Patient Oriented Evidence that
Matters (POEM)
the
outcomes that matter
most to our patients.

POEMs
Decreased symptoms,
mortality, morbidity, cost
 Increased QOL.


Doe

pathophysiological
point of view
USEFULNESS OF
INFORMATION
=
RELEVANCE X VALIDITY
WORK
Shaughnessy et. al. JFP 1994.
Relevance

Applicability to practice.


DOE VS POEMs
Frequency of the
Problem
DOE makes sense
 Can we apply it to our
patients before POEM?
EBM encourages a healthy
skepticism
 Example from the history
 Antiarrhytharic ??
 β -blockers

DOE
Clofibrate
decreases
cholesterol
POEM
Clofibrate decreases CV
mortality/
Morbidity
β –blockers are
contraindicated for
heart failure patients
Antiarrhythmic A
decreases PVCs
Clofibrate Increases
overall mortality
β –blockers decrease
mortality in heart
failure patients
Antiarrhythmic A
decreases symptoms
Antiarrhythmic A
increases mortality
The cardiac arrhythmia suppression trial. N Engl J
Med 1991.
Five steps process ?



Asking the right question.
Searching for information.
Evaluating the evidence for
validity and usefulness.

Implement useful findings in
clinical practice

Evaluate the whole process
Step 1
Formulating an
answerable
question
To answer a clinical question effectively, First,
turn your scenarios into 'well-built' clinical
Q.
Four domains: PICO
1) the patient (problem)
2) the intervention or exposure
3) the comparison (intervention)
4) the clinical outcomes
Clinical Scenario

Ibrahim is a 30 years old teacher, he is known case
of allergic rhinitis. He presented to your clinic for
follow up, he is having a flare up of rhinitis
symptoms, and he wants to get refills of the
antihistamine pills that he used to get from his
physician.

You wonder should you prescribe
intranasal steroids or refill the
antihistamines?!

Patient
: Patients with
Allergic Rhinitis

Intervention
: Intranasal
steroids

Comparison
: Antihistamines

Outcome
: Symptoms Control
Step 2
SEARCHING FOR THE
Best EVIDENCE
Identifying The Evidence
Medline
Embase
• Primary Sources
• Secondary Sources
Systematic Reviews
Clinical Guidelines
Medline search
Secondary
sources of
Evidence
Where to Find the Best Evidence ?

Invest in evidence
databases
• Using Prefiltered sources
They do steps 3 and 4
 Focus on relevant

information

Evaluate its validity.
Aspirin and Primary Prevention
Benefit




CER=4.8%
EER=4.2%
ARR=4.8-4.2=0.6%
NNT=167
Harms
IC bleeds: NS
EC bleeds:
 ARI=0.8-0.5=0.3%
 NNH=333
3rd session:
Boolean Operators
A AND B
Boolean Operators
A OR B
SPECIALIST (MEDICINE
SPECIFIC) SEARCH ENGINE
e.g. i-TRIP Database
ii- OMNI (Organization Medical Network Information)
Agency for Health Care Research
& Quality (AHRQ)





Include a comprehensive guidelines for 19 separate
conditions.
http://www.ahrq.gov/clinic/cpgarchv.htm.
Include recommendations on a wide range of
clinical preventive services.
Evidence-based Practice Centers (EPC) Reports:
http://www.ahrq.gov/clinic/epcindex.htm
Other sources of systematic
reviews

CFP Critical Appraisal Index

The Therapeutics Initiative
Canadian Practice Guidelines
Infobase

The most up-to-date Canadian based
guidelines site.

Most of the guidelines are evidence-based.
http://mdm.ca/cpgsnew/cpgs/index.asp

National Guideline Clearinghouse

Include structured abstracts of guidelines with
links to full-text guidelines.

Not all guidelines are evidence-based.

http://www.guidelines.gov
Guideline Advisory Committee

Gives quick access to recommended guidelines
for common medical conditions.

Include summaries and ratings of the
guidelines with full text links to guidelines.

http://www.gacguidelines.ca/
Other sources of Evidence-based
Guidelines

The Scottish Intercollegiate Guidelines
Network (SIGN)

http://pc47.cee.hw.ac.uk/sign/clinical.htm.

The New Zealand Guidelines Group


http://www.nzgg.org.nz/index.cfm.
The NHS and department of Health
Technology assessment programme.

http://www.hta.nhsweb.nhs.uk/htapubs.htm
The Canadian Task Force on
Preventive Health Care

A practical guide for a wide variety of
preventive health interventions using EBM
recommendations.

Include age and sex specific recommendation
tables.

http://www.ctfphc.org/
Canadian Practice Guidelines
Infobase

The most up-to-date Canadian based
guidelines site.

Most of the guidelines are evidence-based.
http://mdm.ca/cpgsnew/cpgs/index.asp

National Guideline Clearinghouse

Include structured abstracts of guidelines with
links to full-text guidelines.

Not all guidelines are evidence-based.

http://www.guidelines.gov
 Be open to
questions;
never avoid
or ignore a
question.
 Show
interest in
the patient’s
story; never
act bored.
Do not give
the patient
false
reassurance.
Introduction

Two million articles /year

500 meters high!
JASPA*
(Journal associated score of personal angst)
J: Are you ambivalent about renewing your JOURNAL
subscriptions?
A: Do you feel ANGER towards prolific authors?
S: Do you ever use journals to help you SLEEP?
P: Are you surrounded by PILES of PERIODICALS?
A: Do you feel ANXIOUS when journals arrive?
0 (?liar)
1-3 (normal range)
>3 (sick; at risk for polythenia gravis and
related conditions)
* Modified from: BMJ 1995;311:1666-1668
Systematic review of bed rest
after medical procedures

10 trials of bed rest after spinal puncture



no change in headache with bed rest
Increase in back pain
Protocols in UK neurology units - 80% still
recommend bed rest after LP
Serpell M, BMJ 1998;316:1709–10

…evidence of harm available for 17 years
preceding...
Allen, Glasziou, Del Mar. Lancet, 1999
DOE
Clofibrate
decreases
cholesterol
POEM
Clofibrate decreases CV
mortality/
Morbidity
β –blockers are
contraindicated for
heart failure patients
Antiarrhythmic A
decreases PVCs
It Increases overall
mortality
β –blockers are
indicated for heart
failure patients
Antiarrhythmic A
decreases symptoms
Antiarrhythmic A
increases mortality
The cardiac arrhythmia suppression trial. N Engl J
Med 1991.
DOE
Clofibrate
decreases
cholesterol
POEM
Clofibrate decreases CV
mortality/
Morbidity
β –blockers are
contraindicated for
heart failure patients
Antiarrhythmic A
decreases PVCs
It Increases overall
mortality
β –blockers are
indicated for heart
failure patients
Antiarrhythmic A
decreases symptoms
Antiarrhythmic A
increases mortality
The cardiac arrhythmia suppression trial. N Engl J
Med 1991.
DOE
Clofibrate
decreases
cholesterol
POEM
Clofibrate decreases CV
mortality/
Morbidity
β –blockers are
contraindicated for
heart failure patients
Antiarrhythmic A
decreases PVCs
It Increases overall
mortality
β –blockers are
indicated for heart
failure patients
Antiarrhythmic A
decreases symptoms
Antiarrhythmic A
increases mortality
The cardiac arrhythmia suppression trial. N Engl J
Med 1991.
Primary Sources of Evidence
PubMed




PubMed is a Web-based retrieval system
developed by the National Center for
Biotechnology Information (NCBI) at the
NLM.
The database is updated weekly
Approximately 12 million citations
Citations from over 3,900 journals
PubMed

85% of citations are in English

75% of citations have abstracts

Data is leased to commercial providers (e.g.,
OVID)
Guidelines



Center for Disease Control
http://www.cdc.gov/
This is an easy to navigate site with a good
section on Traveler's Health. Travel map
Internet Page
http://www.cdc.gov/travel/travelmap.html
National
Cancer
Institute
http://cancernet.nci.nih.gov/pdq.htm
Systematic Reviews





Well-formulated question
Comprehensive data search
Unbiased selection and abstraction process
Critical appraisal of data
Synthesis of data
Evidence-Based
Guidelines
The Canadian Task Force on
Preventive Health Care

A practical guide for a wide variety of
preventive health interventions using EBM
recommendations.

Include age and sex specific recommendation
tables.

http://www.ctfphc.org/
Guideline Advisory Committee

Gives quick access to recommended guidelines
for common medical conditions.

Include summaries and ratings of the
guidelines with full text links to guidelines.

http://www.gacguidelines.ca/