Evidence Based Medicine Dr Marwa Refaat 11-3-2012

1. E v id e n c e - B a s e d
M e d ic in e
Dr. Marwa Refaat

2. EBM
Introduction
History
Definition & Classification
Elements of EBM
Steps of EBM
Applying concepts of EBM to
management of some psychiatric
disorders

4. A dilemma
You are very ill …

5. Which doctor do you want?
William Osler, 1900 Smart young doctor

6. Rule 31 – Review the World Literature Fortnightly*
*"Kill as Few Patients as Possible" - Oscar London
5,000?
2500000
per day
Medical Articles Per Year
Medical Articles per Year
2000000
1500000
1,500
1000000 per day
95 per
500000
day
0
Biomedical MEDLINE Trials Diagnostic?

7. Evidence-based medicine
Evidence-based medicine (EBM) is the
conscientious, explicit, and judicious use of
current best evidence (about therapy,
prevention, etiology, harm, prognosis, diagnosis
and economic analysis) in making decision about
the care of individual patients (Timmermans and
Mauck, 2005) and it seeks to assess the quality
of evidence of the risks and benefits of
treatments (Elstein, 2004).

8. The practice of evidence-based medicine
is a systematic approach to clinical
problem solving, which allows the
integration of the best available research
evidence with clinical expertise

9. A Cross-Cutting Principle:
Science to Services/Evidence-Based Practices
How do we translate research into practice?
How do we connect services to science?

10. The history of EBM
Although the formal assessment of medical
interventions using controlled trials was
already becoming established in the 1940s,
it was not until 1972 that Professor Archie
Cochrane, director of the Medical Research
Council Epidemiology Research Unit in
Cardiff, expressed what later came to be
known as evidence-based medicine (EBM) in
his book Effectiveness and Efficiency: Random
Reflections on Health Services.

11. In 1992, the UK government funded the
establishment of the Cochrane Centre in Oxford
under Iain Chalmers, with the objective to
facilitate the preparation of systematic reviews of
randomized controlled trials of healthcare. The
following year it expanded into an international
collaboration of centers, of which there are now
thirteen, whose role is to co-ordinate the
activities of 11,500 researchers.
The National Health Service: AService with Ambitions.
www.archive.officialdocuments.
co.uk/document/doh/ambition/ambition.htm (last accessed 27 April
2009)

12. Skills of Evidence-based
Medicine
Critical thinking of the
Knowledge applied to patients care content of medical literature
Knowledge Critical
Translation Appraisal
KT CA
Information
Mastery
IM
Skills searching the medical literature

13. Elements of Evidence Based

14. Five essential steps of EBM
practice:
Step 1- converting information needs into an an-
swerable question
Step 2- finding the best evidence to answer the
question
Step 3- critically appraising the evidence for its
validity and usefulness
Step 4- applying the results of the appraisal into
clinical practice
Step 5- evaluating clinical performance

15. Five essential steps of EBM practice

16. Step 1 of EBM practice: formulating an
answerable clinical question
Good clinical question must be clear, directly focused on the problem, and
answerable by searching the medical literature.
1- PICO format
P Patient or problem,
I Intervention,
C Comparison,
O Outcome
2- Type of clinical question
The most common types of clinical questions is about
intervention, etiology ,risk factors, rate, diagnosis, prognosis ,
cost-effectiveness, and question about phenomena (Glasziou
P, 2003).

17. PICO format

18. CLASSIFICATION OF EBM:
1. Evidence-based Health Care, also called as the
evidence-based guidelines, is the practice of
evidence based medicine at the organizational
or institutional level. This includes the production
of guidelines, policy and regulations (Gray,
1997).
2. Evidence-based Individual Decision Making, is
the practice of evidence based medicine by the
individual health care provider (Eddy, 2005).

19. Step 2 of evidence-based medicine practice: finding
the evidence
search for relevant evidence that will
provide the answer to the question.
Some research designs are more
powerful than others in their ability to
answer research questions.

20. Levels of evidence and grade of recommendation for ranking the
validity of studies about therapy,prevention,etiology and harm,
Oxford Centre for EBM

22. The “best” evidence depends
on the type of question
Level Treatment Prognosis Diagnosis
I Systemic Systemic Systemic
Review of … Review of … Review of …
II Randomised Inception Cross
trial Cohort sectional
III

23. Level of Evidence

24. Evidence-based databases
The Cochrane Library (through the Cochrane
Collaboration, http://www.cochrane.org
The DARE: includes systematic reviews that
have been published outside of the Cochrane
collaboration, all quality-assesses and with
structured summaries
http://www.crd.york.ac.uk/crdweb

25. The Cochrane Controlled Trials Register
(CEN-TRAL):
PubMed Clinical Queries (
http://www.ncbi.nlm.nih.gov/entrez/query/static
)
SUMSearch
(http://sumsearch.uthscsa.edu/): a meta-
searching service

26. Step 3 of evidence-based medicine practice: appraising
the evidence
There are several tools for appraising a
research article. One of them was
developed by the Critical Appraisal Skills
Programme (CASP), Oxford, UK. CASP
aims to help individuals to develop the
skills to find and make sense of research
evidence, helping them to put knowledge
into the practice.

27. Step 4 of evidence-based medicine model: applying the
evidence
The evidence should be fully discussed
with the patient. The decision also should
take into account the potential side effects
of the drug (does side effect outweigh its
potential benefits in a particular patient),
the cost and availability of that particular
treatment in the hospital or practice. The
questions that we should ask before the
decision to apply the results of the study
are

28. Factors affecting decision in applying EBM:
1- pt. profile
2- Availability of treatment
3- Alternative modalities
4- Side effects profile
5- Appropiate outcomes

29. Step 5 of evidence-based medicine model: evaluating
clinical performance
we need to ask whether
we formulate answerable questions,
find best evidence quickly,
effectively appraise the evidence, and
integrate clinical expertise and patient
preferences and values with the evidence in a
way that leads to a rational, acceptable
management strategy.
We need to evaluate our approach at frequent
intervals and decide whether we need to
improve any of the four steps discussed above.

30. Evidence Based Psychiatry

31. Applying concepts of EBM to
management of Psychiatric Disorders

32. Panic Disorder

33. Panic Disorder, With or Without
Agoraphobia
Panic disorder is a chronic and recurrent
illness associated with significant
functional impairment.
The estimated lifetime prevalence of
panic attacks is 15%,with a 1-year
prevalence of 7.3%
About one-third to one-half of patients with
PD also have symptoms of agoraphobia

34. DSM-IV-TR of Panic Attack

35. Treatment of PD

36. I- Approach to Psychological
Management
CBT is the most consistently efficacious
psychological treatment for PD, according
to metaanalyses (Level 1) (Austeralian & New
Zeland GL, 2003. – Glum GA, metaanalysis 1993)
Various CBT approaches to the treatment
of panic attacks have been developed
over the years (Landon et al 2004)

37. Common components of CBT for
PD

38. Treatment Recommendations

39. II- Approach to
Pharmacologic Management

40. Strength of evidence of
pharmacological treatment of PD.cont.

43. III- Combined Psychological and
Pharmacologic Treatment
Combined treatment had some
advantages during the acute and follow-up
phases, but, when the medication was
discontinued after the follow-up phase,
there was a considerably lower relapse
rate in
the CBT and CBT-with-placebo groups
(18%), compared with the CBT-plus-
imipramine group (48%) and imipramine-
alone group (40%) (Barlow et al. 2000 )

44. Diagnosis & Assessment of
Delirium

45. Diagnosis & Assessment of
Delirium
Delirium characterized by :-
Disturbed level of consciousness
A change of cognition not better explained
by a pre-existing dementia
Disturbance develops over a short period
of time
Evidence from the history, physical,
examination, or lab. Investigation that
disturbance due to medications, medical
condition ,or substance use.

47. Assessment of Delirium

48. 3- Basic laboratory tests
Blood chemistries: electrolytes, glucose,
calcium, albumin, blood urea nitrogen (BUN),
creatinine, SGOT, SGPT, bilirubin, alkaline
phosphatase, magnesium, phosphorus
Complete blood count (CBC)
Electrocardiogram (ECG)
Chest X-ray
Arterial blood gases or oxygen saturation
Urinalysis

49. 4- Additional laboratory tests
Urine culture and sensitivity
Urine drug screen
Blood tests (e.g., VDRL, heavy metal screen, B12 and folate levels,
antinuclear antibody [ANA], urinary porphyrins, ammonia level,
human immunodeficiency virus [HIV], erythrocyte sedimentation rate
[ESR])
Blood cultures
Serum levels of medications (e.g., digoxin, theophylline,
phenobarbital, cyclosporine)
Lumbar puncture
(CT) or (MRI)
(EEG)

50. Risk factors in recurrence of major
Depressive Disorder

51. APA Guidelines for risk factors in
recurrence of major depressive
Disorder
Prior history of multiple episodes
Severity of episodes
Earlier age at onset
Presence of an additional non affective psychiatric diagnosis
Presence of a chronic general medical disorder
Family history of psychiatric illness, particularly mood disorder
Ongoing psychosocial stressors or impairment
Negative cognitive style
Persistent sleep disturbances

52. Key components of effective
Screening & care
assessment
“Collaborative
Patient education Care” IAPT
and activation program- NICE
guidelines
Treatment
Care
management
Mental health

54. Integrating Ten Rules for Quality Mental
Health Services
1. Informed Choice
2. Recovery Focus
3. Person Centered
4. Do No Harm
5. Free Access To Records
6. A System Based on Trust
7. A Focus On Cultural Values
8. Knowledge-Based
9. Partnership Between Consumer & Provider
10. Access to Services Regardless Of Ability To Pay
Infusing recovery-based principles into mental health services: A white paper by
people who are New York state consumers, survivors, patients and ex-
patients. September, 2004. New York State Office of Mental Health.

56. Summary
EBM is a great advance over informal, non-
quantitative approaches to clinical
decisions.
EBM should result in more effective, more
uniform, and more efficient medical care.
EBM is an adjunct, not a substitute for
physicians who can diagnose accurately,
access evidence efficiently, and think
analytically.
The integration of EBM with cost-benefit
analysis poses a major challenge for
health policy.

57. k
a n
h o u
T Y