Evidence based medicine: What, why and how?

Hans Van Rostenberghe

What?

Evidence based medicine

Research

GRIP
Getting Research Into Practice

Research
RM ? Billions $ US ? Trillions Euro, $AU, $S, Yen Billions or Trillions of each

Streptokinase for heart infarction

1985: 12 trials all showing benefit 1990: 78 trials all showing benefit 2000: >400 trials

Why do patients have to wait for 15 years to get the best possible treatment?

Evidence based medicine

Research

GRIP

Dr. Jumblat
Surfactant: keeps lungs open Babies who have lack of it Give it to the lungs Bovine derivative

New evidence: new product Curosurf: 1 dose instead of two doses

Curosurf
Porcine in origin Patients heard about it

Prefer to deliver at home

Evidence based medicine

Research

Patient

Characteristics of population
Genetic make up Environment, culture, habits,

Drug requiring alternate day drug monitoring

May be suitable in cities Villages?

Evidence based medicine

Research

Doctor

Patient

Example: operation before birth

Ultrasound for pregnant ladies

Abnormalities can be detected

Research:
Best option to treat spina bifida = Operation before birth

Doctor factor
Lack of skills: 90% mortality of the foetus Few mothers die as well

Second best research supported treatment

Evidence based medicine ??

??

Research

Doctor

Community based programs / teaching

Patient

Teaching skills: History taking Physical examination

Why?

Story of blood pressure control

What is the maximal normal blood pressure for a 30-year old? For a 50-year old? For a 70-year old?

140 /90 mm Hg

Story of blood pressure control

What is the maximal normal blood pressure for a 30-year old?

140 /90 mm Hg

For a 50-year old? For a 70-year old?

150 / 90 mmHg 170 / 90 mmHg

Survey on antihypertensive R/
50 to 60-year old practitioners Majority

Still used criteria to treat HT as they were taught in Medical School Drugs that were used had not changed during their 20 to 30 years of practice

Question:

Do you want to practice in 2040 according to the best evidence available in 2009 ?

or 2007 or 2006

or whenever our lecture was prepared

Students
Skills

Habit

Why?
For three persons

Why?

For the doctor

Feel good about yourself Hereafter Karma

3 rewards

Why?

For the patient

Longing for health Trust Pay Knowledgeable

Why

For the lawyer

Protect him from another sin Richness

Medicolegal aspects

Many medical journals

Layman summary

Where to get evidence?

Text

books

Very easily outdated

Where to get the evidence

Expert opinion
Easily wrong Differs from expert to expert

Turn to the journals

Quantity enormous

Quality not uniformly good

Is there a way around the journals?

Finding the right information

Asking answerable questions Searching in the right place Appraising and applying Evaluating

Circle of evidence

Background
Clinical practice

Clinical problem /question

Basic research Potential therapies

Background
Clinical practice

Clinical problem /question

Clinical practice guidelines Systematic reviews

Basic research Potential therapies

Applied research : Animal studies RCTs

Review of literature: narrative

Expert contacted Asked to write a review on a topic Expert reviews literature

Easy to pick his favorite articles Easy to ignore others

Expert writes narrative review He gives his expert opinion

Systematic review
Author describes search strategy Searches all studies Describes results of search Assesses quality of each study Combines data of good studies Does a statistical analysis (meta analysis) Presents results systematically

Systematic versus narrative reviews

Narrative reviews Lack rigor Methods not transparent Different reviewers, different conclusions Easily out of date

Systematic review Scientific rigor to minimise bias Explicit and reproducible methodology Regulary updated (Cochrane)

Cochrane library

Huge collection of
Systematic reviews Trials

Background
Clinical practice

Clinical problem /question

Clinical practice guidelines Systematic reviews

Research

Doctor

Basic research Potential therapies

patient

Applied research : Animal studies RCTs

EBP misconceptions

Fallacy EBP is useless when there is no good evidence

Facts Using best available evidence / promoting relevant research

EBP is cookbook medicine

Clinical judgement very important

EBP is just numbers and statistics

Evidence must be individualised to each patient

Evidence based medicine

From buzz word Increased in importance

Lots of implications Here to stay!