Based-evidence medicine

Susanna Hilda Hutajulu, MD, PhD

Student Coaching – Department of Internal Medicine

What is EBM?
• A simple definition from 1996 is:

• the conscientious explicit and judicious use of current

best evidence in making decisions about the care of
individual patients

• tracking down the best external evidence to answer the

clinical question.

Sackett, et al. BMJ 1996;312:71-72

What is EBM?
• “Current best evidence”.
• may be not a perfect evidence
• but not old or out-of-date evidence.

• How is this to be done?

• Conscientious – being careful and thorough
• Explicit – open, clear and transparent
• Judicious – using good judgement and common sense
 Why is EBM important?

Up-to-date knowledge and clinical performance can

deteriorate with time

Traditional continuing medical education programs have

not been shown to improve clinical performance

Reduce the use of ineffective, costly or potentially

hazardous interventions.

Ramsey PG, Carline JD, Inui TS et al: Changes over time in the knowledge base of practicing internists. JAMA 1991;266:1103-
7.
Davis DA, Thompson MA, Oxman AD, Haynes RB: Changing physician performance. A systematic review of the effect of
Develop clinical questions

• To get the right answer, ask the right question.

• Questions may be simple: does drinking tea reduce

your blood pressure?

• Or complex: what is the best treatment to improve the

vision of elderly diabetic patients with macular
degeneration?
 Developing the clinical question
Step 1: Formulate the clinical issue into a searchable,
answerable question.

Step 2: Distinguish what type of question you may have.

Background

Foreground

Experience with Condition

 Background questions
Background questions ask for general information about a
condition or thing.
A question root (who, what, when, etc) combined with a
verb.

-What microbial organisms can cause community-

acquired pneumonia?
-What factors can causes diabetes?

Background questions are typically answered by

textbooks.
 Foreground questions
Foreground questions ask for specific knowledge
about a specific patient with a specific condition 
What do I do for this patient?

Is morphin effective in relieving the symptoms of

pain in cancer patients?

Foreground questions are typically answered by

databases that access the research literature
 Developing the question
Foreground questions usually have four components.

P = Patient population

I = Intervention

C = Comparison intervention

O = 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 improved cure rates
(outcome)?
 PICO: Components of an answerable, searchable question
Patient population/disease The patient population or disease of interest
- age
- gender
- ethnicity
- with certain disorder (e.g., hepatitis)
Intervention The intervention or range of interventions of interest
- Exposure to disease
- Prognostic factor A
- Risk behavior (e.g., smoking)
Comparison What you want to compare the intervention against
- No disease
- Placebo or no intervention/therapy
- Prognostic factor B
- Absence of risk factor (e.g., non-smoking)
Outcome Outcome of interest
- Risk of disease
- Accuracy of diagnosis
- Rate of occurrence of adverse outcome (e.g.,
death)
Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare : A guide to best practice. Philadelphia,
PA: Lippincott Williams & Wilkins.
 Medical literature searching
Primary – original
research
Experimental (an intervention
is made or variables are
manipulated)
Randomized Control Trials
Controlled trials
Observational (no
intervention or variables are
manipulated)
Cohort studies
Case-control studies
Case reports
Secondary – reviews of
original research
Meta-analysis
Systematic reviews
Practice guidelines
Reviews
Decision analysis
Consensus reports
Editorial, commentary
Case Control Studies
• Studies in which patients who already have a specific
condition are compared with people who do not

• Rely on medical records and patient recall for data

collection
Cohort studies
• From a large population

• Follows patients who have a specific condition or receive

a particular treatment over time

• Compares with another group that has not been affected

by the condition or treatment studies
Randomized controlled trials
• Study effect of therapy on real patients

• Include methodologies that reduce the potential for bias

• Patients assigned in randomized fashion

• Blinded or non-blinded studies

• Intervention group vs control group

Systematic review
• Extensive literature search is conducted in systematic

fashion
• Only uses studies with sound methodology

• Studies are collected, reviewed, assessed and the results

summarized according to predetermined criteria of the

review question
Meta-analysis
• Examines a group of valid studies on a topic

• Combines results using accepted statistical methodology

to reach a consensus on the overall results.

Level of evidence pyramid

Meta-analysis
Systematic Review
Randomized Controlled Trial
Cohort Studies
Case Control Studies
Case Series/Case Reports
Animal Research
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.
 Five steps in judging the evidence
and determining the circumstances and patient values
Thank you

http://www.bsmpg.com/Blog/bid/103786/Evidence-based-medicine-a-movement-in-crisis
 The practice of EBM

http://community.cochrane.org/about-us/evidence-based-health-care
Integrating evidence & practice
What is “EBM” not?
• What we have always done
• “Cookbook medicine”
• Only a cost-cutting trick
• Only randomized trials
 Where we can find the best
decision?
Common source include:

Personal experience
Reasoning and intuition
Colleagues
Published evidence

By educating healthcare professionals the strength of

published evidence sources of information, we reduce the
use of ineffective, costly or potentially hazardous
interventions.
Developing clinical questions

“To get the right answer,

you must first ask the right question.”

The principles of EBM

to find and evaluate the information available
assess its reliability
decide if you can apply the results to your patients
Types of Questions
Diagnosis: How to select a diagnostic test or how to
interpret the results of a particular test.
Prognosis: What is the patient's likely course of disease,
or how to screen for or reduce risk.
Therapy: Which treatment is the most effective, or what
is an effective treatment for a particular condition.
Harm or Etiology: Are there harmful effects of a particular
treatment, or how these harmful effects can be avoided.
Prevention: How can the patient's risk factors be
adjusted to help reduce the risk of disease?
Cost: Looks at cost effectiveness, cost/benefit analysis.
 Question Templates for Asking PICO Questions

Therapy
In __________________, what is the effect of ____________________ on
______________________ compared with __________________?

Etiology
Are ______________ who have _________________ at ________________
risk for/of ____________________ compared with _____________________
with/without ______________________?

Diagnosis or Diagnostic Test

Are (Is) _________________________ more accurate in diagnosing
________________ compared with ________________?

Prevention
For _________________ does the use of _______________ reduce the
future risk of ________________ compared with _________________?

Prognosis
Does _______________ influence _________________ in patients who have

__________________?
Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare : A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins.
 Finding evidence-based answers
Systems
Computerized
decision support

Summaries
Dynamed, UptoDate
Clinical Evidence, EBM guidelines

Synopses
TRIP
ACP Journal Club

Syntheses
Cochrane Systematic Reviews,
DARE

Studies
PubMed, CINAHL, Scopus

Haynes RB. Of studies, summaries, synopses, and systems: the “5S" evolution of services for finding current best evidence. ACP Journal
Club. 2001;134: A11–13.