Let's pass clinical MRCPCH    Yousry Abd Elsamad 

Evidence based medicine

Objective: find answer for the questions will be asked by 'role player
1. What's EBM?
2. Why the patient values and preferences should be put in consideration?
3. How it is developed? – 5 As
4. What is EBM Pyramid? And what it is used for?
5. Are we using EBM in our hospital?

What is EBM?
Definition: 'conscientious ‫ﻣﺜﺎﺑﺮ‬ ‫أو‬ ‫ ﻣﺠﺘﻬﺪ‬explicit   ‫ﺟ‬ ‫واﺿﺢ‬  ‫&ﺑ‬
judicious ‫ ﺣﻜ ﻢ‬Use of current best evidence to take 'best decisions
about 'individua pt care
Achieved by the integration of 3 components "draw":
1. Clinical expertise:
2. Best evidence
3. Patient values & preferences
Example: doctor use his experience to define 'pt problem but he may have Rx options
that is no more valid … if he searches for 'best evidence-based intervention, 'outcomes will
be better. But sometimes this new Rx options are not accepted by 'pt, so pt values &
preferences should be put in consideration.

What are the steps of developing EBM (5As)?
 Step 1: Ask a Q: to identify a key problem - PICO (see before)
 Step 2: Acquire: 'best evidence to answer 'question - how can we weigh the
strength of evidence? By using 'EBM pyramid
 Step 3: Appraise 'evidence for its validity, importance & applicability.
 Step 4: Apply 'best evidence
 Step 5: Assess (evaluating steps of 'procedure & outcomes, & seeking ways to
improve them).
What is the EBM Pyramid and why is it important‫ ‐ ؟‬Draw
EBM Pyramid → a diagram that help us to weigh
'strength of 'evidence. It is divided into levels. 'More we
ascend, 'stronger is evidence & 'more confident we
became about accuracy of evidence & 'less chance of
statistical errors.

What is level of evidence & grading of
recommendation?
 Level of evidence is a ranking system that enable us to
measure the strength of the evidence we have
 Ex; evidence obtained from expert opinion is the least strong and lies at 'bottom of pyramid,
while evidence from SR or MA is the strongest and lies at top of 'pyramid and leveled at I.
 Grading of recommendations is done by the developers of CPGs by weighing the benefits of
intervention in one hand against 'risks, burden, and costs on the other hand.

Information & expert opinion:  → important but heavily influenced by beliefs & opinions.

Case reports (retrospective): 'first stage of testing an observation

It's a detailed report of symptoms, sigs, diagnosis, investigations, and Rx, it usually describes
novel or unusual occurrence.
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Let's pass clinical MRCPCH    Yousry Abd Elsamad 
Case series (retrospective)
 It tracks patients who received a similar intervention (inv/Rx) for outcomes

Case control studies → Retro observational study similar to case reports but it compares a
group of people with disease or an intervention to a group without.
 Measures 'relative odds (= odds ratio) of prior exposure (risk factor) for ex; pts ‘e
COPD had higher odds ‫أﻋ‬ ‫ اﺣﺘﻤﺎﻻت‬of a H/O of smoking than those without COPD.
 Disadvantages: small numbers of participants + not randomized MCQ

Cohort studies
• Cohort studies has 2 differences from Case control studies
o Follow a large group of people who share 'same characteristics (=Cohort)
o it is prospective → follow 'effect of future exposure on 'outcomes/dis of interest
E.g. Effect of smoking, life style, diet on lung cancer .
• Uses: it looks for the relative risk as well as Prognosis/survival analysis
• Disadvantages:
 Requires large sample, long time to complete → expensive 
 Can't be randomize, nor controlled for outside variables

The Randomized Control Trial (RCT) → a major point in 'Pyramid

 True experimental study in 'w population of interest are divided into 2 groups
randomly, one group receives 'new intervention under investigation & 'other receives
no Rx (a placebo)
 A large Double Blinded RCT is 'most reliable study design (provides 'strongest evidence
on relationship between intervention/outcome. However, these studies are expensive
and can be ethically problematic .

Critically appraised topics → are not actually a study design. They are short summaries of 'best
available evidence (= abbreviated systematic review created to answer a specific question). 

The systematic reviews "Cochrane library": top of 'pyramid

It is s a single document that summarizes the findings from a wide collection of relevant study
in a systematic way → provides us a more accurate estimate of intervention effectiveness – in
comparison to a single study
The Cochrane Collaboration takes systematic reviews to the next level. They are the experts
of the systematic review and have an added a level of rigor as an independent voice, as well as
developing special techniques to identify bias in studies.

Meta‐analysis → integrates ‘quantitative statistical findings from separate but similar studies
and provides a numerical estimate "a statistical summary" that represents intervention
effectiveness across multiple studies .

Tools & resources of Evidence based Practice: "are we using this EBM in practice?
1. Personal CPD & CME
2. Journal clubs
3. Ward rounds, Ground rounds
4. Students teaching
5. Clinical researches
6. Clinical Audit
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Let's pass clinical MRCPCH    Yousry Abd Elsamad 
Searching 'literature:
Consider ‘4S’ approach to access evidence-based information .
Systems: Computerized decision support systems e.g. UpToDate
Synopses ‫ﻣﻮﺟﺰ‬ ‫ﻣﻠﺨﺺ‬  ‫ﻣﺨﺘ‬ 
 Short evidence-based journal abstracts e.g BMJ
Systematic reviews (as before)
Studies "the original published articles in journals"

Clinical researches & clinical audit 
 
Clinical research is a structured activity intended to provide a new knowledge about  
 Disease → incidence and prevalence  
 Investigation: → sensitivity & specificity of diagnostic tools.  
 Rx: the safety and effectiveness (efficacy) of medications, devices, treatment regimens 
intended for human use.  
 
Clinical Audit: a quality improvement process  ⎯⎯⎯⎯  improve pt care and outcomes through 
certain steps 
1. Identify 'problem "improper hand hygiene"  
2. Set standards 
3. Observe practice & collect data 
4. Improve →identify areas of improvement 
5. Implement changes  
6. Re‐ audit  
 

Research  Audit 
A finding tool searching for a new best  Measure whether 'best approved practice is 
practice  actually being delivered  
"creates new knowledge – adds to the  Comparing a service with an existing standard – 
knowledge base  helps to improve quality of care 
Requirements: approval from research  Requirements: registration 'e local clinical 
ethics committee  audit dep. 
Experimental or observational Observational " measures against standard 
Tests 'null thesis   criteria  
 
Place of clinical audit in practice: 
 Clinical governance 
 Clinical effectiveness 
 Risk management 
 Education and training 
 Research and development.   
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