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Life long learning Life long learning with with EBMEBM

• Prof Eiad Al-Faris Prof Eiad Al-Faris MD, MSc, MMEd, MD, MSc, MMEd, MRCGP MRCGP

• Consultant Family MedicineConsultant Family Medicine• Prof. King Saud UniversityProf. King Saud University• Supervisor -King Saud University Supervisor -King Saud University

chair for medical educationchair for medical education

OutlineOutline

• IntroductionIntroduction• Definition of EBMDefinition of EBM• Steps of EBMSteps of EBM• Practical searchPractical search• Conclusion Conclusion • ClosureClosure

1900 1990 2000

10,000

100,000

?250,000INFORMATION EXPLOSION

MEDICAL JOURNALS

4

Rule 31 – Review the World Literature Rule 31 – Review the World Literature Fortnightly*Fortnightly*

0

500000

1000000

1500000

2000000

2500000

Trials MEDLINE BioMedical

Med

ical

Art

icle

s p

er Y

ear

5,000?per day

1,260 per day55 per

day

Clinical ScenarioClinical Scenario

• Ibrahim is a 60 years old teacher, Ibrahim is a 60 years old teacher, he is known case of hypertension. he is known case of hypertension. He presented to the ED with severe He presented to the ED with severe chest pain for the last two hours. chest pain for the last two hours.

• In addition to hitory/ exam and ECG, In addition to hitory/ exam and ECG, you wonder should you request for you wonder should you request for the timely diagnosos: troponin or the timely diagnosos: troponin or creatine kinase- MB or both?creatine kinase- MB or both?

When confronted with a When confronted with a clinical question, whom clinical question, whom

usually you consult?usually you consult?

Colleagues- experts Colleagues- experts

• A great source of information. A great source of information. • Quick, affordable and Quick, affordable and

accessible.accessible.• But potentially very biased:But potentially very biased:

VariabilityVariability

Not updated Not updated

TextbooksTextbooks

• Rapidly out-of-date (2-4y). Rapidly out-of-date (2-4y). • They are a good source of They are a good source of

background information background information (pathophysiology), (pathophysiology),

• but a poor source of information for but a poor source of information for most foreground questions (clinical). most foreground questions (clinical).

Burn your traditional textbooksBurn your traditional textbooks

The integration of the The integration of the current best current best evidence (from research)evidence (from research) with our with our clinical expertiseclinical expertise and patient’s and patient’s values.values.

EBM isEBM isEBM isEBM is

Three (Three (EsEs)- EBM Components)- EBM Components

ClinicalClinicalPracticePractice

The “Evidence Transfer Gap”

Controlled trials

Rules of EvidenceRules of Evidence

• All evidence is All evidence is notnot created equal. created equal.

• Values Values alwaysalways influence influence decisions. decisions.

• Evidence alone Evidence alone nevernever makes makesclinical decisions.clinical decisions.

Hierarchy of EvidenceHierarchy of EvidenceMeta-analysis of RCTs

Multi-centric large RCTsMulti-centric large RCTs

Single Centre RCT

Observational studiespatient-important outcomespatient-important outcomes

Clinical experience

Basic researchtest tube, animal, human physiologytest tube, animal, human physiology 16

Ask

Acquire

Appraise

Apply

Act & Assess

Patient dilemma

Principles of evidence-based

practice

Evidence alone does not decide – combine with otherknowledge and values

Hierarchy of evidence

Process of EBP

5 5 AAs to practice EBMs to practice EBM5 5 AAs to practice EBMs to practice EBM

Ask focused Question(s)

Acquire the Evidence(s)

Appraise the Evidence(s)

Apply the best Evidence

Assess your Performance


Appraise the evidence(s)

Apply The best evidence

to patient

Assess your patient

Ask clinical questions

6 6 AAs to practice EBMs to practice EBM

Assess Yourself

Assess Your PatientAssess Your Patient

• HistoryHistory• Physical examinationPhysical examination• Objective data – labs, x-raysObjective data – labs, x-rays

• Formulate differential diagnosis• Pretest probability of disease


Appraise the evidence(s)

Apply The best evidence

to patient

Assess your patient

Ask clinical questions

6 6 AAs to practice EBMs to practice EBM

Assess Yourself

To answer a clinical question To answer a clinical question effectively, First, turn your effectively, First, turn your scenarios into scenarios into 'well-built' 'well-built' clinical clinical Q.Q.

Four domains:Four domains: PICOPICO

1) the 1) the ppatient (atient (pproblem)roblem)

2) the 2) the iintervention or ntervention or exposure exposure

3) the 3) the ccomparison omparison (intervention)(intervention)

4) the clinical 4) the clinical ooutcomesutcomes

For healthy adults For healthy adults is it is it worthwhile to worthwhile to give aspirin as give aspirin as prophylaxis to reduce prophylaxis to reduce MI and or stroke ?MI and or stroke ?

Aspirin and Primary Aspirin and Primary PreventionPrevention

1. 1. PPatient atient population.population.

2. 2. IIntervention.ntervention.

3. 3. CComparison omparison intervention.intervention.

4. 4. OOutcomes. utcomes.

Asymptomatic adults Asymptomatic adults with no risk factors with no risk factors

Aspirin Aspirin

PlaceboPlacebo

Incidence of CV eventsIncidence of CV events

““In asymptomatic adults no risk factors, would the In asymptomatic adults no risk factors, would the use of aspirin reduce the incidence of cardiovascular use of aspirin reduce the incidence of cardiovascular events?events?

Ask Clinical Questions (PICO)Ask Clinical Questions (PICO)

Patient/Population Outcome

Intervention/Exposure

Comparison

Components of Clinical Questions (PICO)

In patients withacute MI

In post-menopausal

women

In women withsuspected

coronary disease

does early treat-ment with a statin

what is the accuracy of

exercise ECHO

does hormonereplacement

therapy

compared to placebo

compared to exercise

ECG

compared to noHRT

decrease cardio-vascular mortality?

for diagnosingsignificant

CAD?

increase therisk of

breast cancer?

Presentations will cover: 1. search strategy; 2. search results; 3. the validity of this evidence; 4. the importance of this valid evidence; 5. can this valid, important evidence be applied to your patient; 6. your evaluation of this process.

3-part Clinical Question

Patient’s Name Learner:

Target Disorder:

Date and place to be filled:

Intervention (+/- comparison):

Outcome:

Types of clinical questionsTypes of clinical questions

• Therapy and harmTherapy and harm:: how to select how to select treatments to offer patients that do more treatments to offer patients that do more good than harm good than harm

• Diagnostic testsDiagnostic tests:: how to select and interpret how to select and interpret diagnostic tests, in order to confirm or diagnostic tests, in order to confirm or exclude a diagnosisexclude a diagnosis

• PrognosisPrognosis:: how to estimate the patient's how to estimate the patient's likely clinical course over timelikely clinical course over time

Acquire the Best EvidenceAcquire the Best Evidence• Prefiltered Sources:Prefiltered Sources:Secondary sourcesSecondary sources

– ACP Journal Club ACP Journal Club (www.acpjc.org) (www.acpjc.org)

– Cochrane Library (www.update-Cochrane Library (www.update-software.com/cochrane) software.com/cochrane)

– Up-to-Date Up-to-Date (www.uptodate.com) (www.uptodate.com)

– Clinical Evidence Clinical Evidence (www.evidence.org) (www.evidence.org)

– InfoRetriever InfoRetriever (www.infopoems.com) (www.infopoems.com)

– Ovid (www.ovid.com)Ovid (www.ovid.com)– MD Consult MD Consult

(www.mdconsult.com)(www.mdconsult.com)– Medscape Medscape

(www.medscape.com) (www.medscape.com) – Dynamed (Dynamed (www.dynamed.comwww.dynamed.com))

• Unfiltered SourcesUnfiltered Sources

– MEDLINE MEDLINE (www.pubmed.gov) (www.pubmed.gov) – Google Google (www.google.com(www.google.com

We need to focus and familiarize yourself with few of them

EBM journal / ACP j. clubClinical Practice Guidelines

Cochrane Library / Systematic Reviews

Computer DecisionSupport System (CDSS)eg. Dynamed“Point of care”

Single RCT in Journal

Developments (4 s) that facilitate EBM PracticeDevelopments (4 s) that facilitate EBM Practice

Pre-filtered Sources:Pre-filtered Sources:–Cochrane Library Cochrane Library http://www.thecochranelibrary.chttp://www.thecochranelibrary.comom

–Up-to-Date www.uptodate.comUp-to-Date www.uptodate.com

–Clinical Evidence Clinical Evidence

www.clinicalevidence.orgwww.clinicalevidence.org

– Ovid www.ovid.comOvid www.ovid.com

30

–ACP Journal Clubwww.acpjc.orgACP Journal Clubwww.acpjc.org

– InfoRetriever InfoRetriever

www.infopoems.com www.infopoems.com

–MD Consult www.mdconsult.comMD Consult www.mdconsult.com

–Medscape www.medscape.comMedscape www.medscape.com

–Dynamed Dynamed www.dynamed.comwww.dynamed.com

31

Best Evidence 5.lnk

PROCESSPROCESS• 120+ journals scanned120+ journals scanned

– 50,000 articles50,000 articles

• Is it Is it validvalid? (<5%)? (<5%)– Intervention: RCTIntervention: RCT– Prognosis: inception cohortPrognosis: inception cohort– EtcEtc

• Is it Is it relevant?relevant?– 6-12 GPs & specialists 6-12 GPs & specialists

asked:asked:Relevant? Newsworthy?Relevant? Newsworthy?

• < 0.5% selected< 0.5% selected

www.evidence-basedmedicine.com

EBM can reduce reading needHow much is valid AND relevant?

Number Needed to Readis 20+

Number Needed to Readis 200+

Deals with barriersDeals with barriers

Involves seniors and juniorsInvolves seniors and juniors

EBM EnvironmentEBM Environment

New EBM teaching modelsNew EBM teaching models

The Challenge – Bridging the gap!The Challenge – Bridging the gap!

Appraise the EvidenceAppraise the Evidence

• Relevance: Relevance: It focuses on medical problems common to It focuses on medical problems common to our practice. patient-oriented evidenceour practice. patient-oriented evidence

• Validity: Validity: Correctness (Correctness (likely to be true) true)

• Results: Results: Clinically important

• Can we apply the results to our Can we apply the results to our patient? patient? Applicable in and useful for my patients

RelevanceRelevance

Consider three questions to Consider three questions to determinedetermine

Relevance Relevance – Common to practiceCommon to practice– Require change of practice Require change of practice – Patient-oriented outcomePatient-oriented outcome

POEM Vs. DOEPOEM Vs. DOEPOEM Vs. DOEPOEM Vs. DOE

POEMPOEM: Patient-oriented evidence : Patient-oriented evidence that matterthat mattermortality, morbidity, quality of lifemortality, morbidity, quality of life

DOEDOE: Disease-oriented evidence: Disease-oriented evidencepathophysiology, pharmacology, pathophysiology, pharmacology,

etiologyetiology

Comparing DOE and POEMComparing DOE and POEM

DOEDOE POEMPOEM

AntihypertenAntihypertens therapys therapy

Lowers Blood Lowers Blood PressurePressure

MortalityMortality

MIMI

CVACVA

Screening for Screening for prostate CAprostate CA

PSA screening PSA screening detects detects

Prostate CA at Prostate CA at an early stagean early stage

Unknown whether Unknown whether PSA screening PSA screening

reduces Mortalityreduces Mortality

Clofibrate Clofibrate decreases decreases

cholesterol cholesterol

Clofibrate decreases CV Clofibrate decreases CV mortality/mortality/

MorbidityMorbidity

It Increases overall It Increases overall mortalitymortality

ββ ––blockers are blockers are contraindicated for contraindicated for heart failure patientsheart failure patients

ββ ––blockers are blockers are indicated for heart indicated for heart failure patientsfailure patients

Antiarrhythmic A Antiarrhythmic A decreases PVCsdecreases PVCs

Antiarrhythmic A Antiarrhythmic A decreases symptomsdecreases symptoms

Antiarrhythmic A Antiarrhythmic A increases mortalityincreases mortality

40DOE POEM

The cardiac arrhythmia suppression trial. N Engl J Med 1991.

44




MorbidityMorbidity







DOE POEM


45




MorbidityMorbidity







DOE POEM


46

5 journals with highest 5 journals with highest concentration of POEMSconcentration of POEMS

• JAMA-17%JAMA-17%• Annals of Internal Medicine-17%Annals of Internal Medicine-17%• NEJM-16%NEJM-16%• Journal of the American Board of Family Journal of the American Board of Family

Practice-16%Practice-16%• Journal of Family Practice-15%Journal of Family Practice-15%

Ebell MH et al. J Fam Pract 1999 48: 350-Ebell MH et al. J Fam Pract 1999 48: 350-

355355

ValidityValidity

In RCT:In RCT:

• RandomizationRandomization• BlindnessBlindness• Drop-outDrop-out• ITTITT

ResultsResults

Results clinical importance Results clinical importance can be assessed by its:can be assessed by its:

1.1. MagnitudeMagnitude

2.2. PrecisionPrecision

50

Results of a hypothetical Results of a hypothetical randomized trialrandomized trial

TreatmentTreatment No. who No. who improvedimproved

No. who No. who did not did not improveimprove

Total N. Total N. of Ptsof Pts

IbuprofenIbuprofen 2222 1818 4040

PlaceboPlacebo 77 3333 4040

51

Calculations made from Calculations made from these resultsthese results

• Experimental event rateExperimental event rate

• Control event rateControl event rate

• Experimental event Experimental event oddsodds

• Control event oddsControl event odds

• Odds ratioOdds ratio

• RelativeRelative riskrisk

• Relative risk Relative risk increaseincrease

• Absolute Absolute risk increase risk increase or reductionor reduction

• NNTNNT

52







53

Relative RiskRelative Risk

A relative risk is the risk in A relative risk is the risk in the treatment group the treatment group compared to the risk in compared to the risk in the control group.the control group.

A relative risk of (1) means A relative risk of (1) means there is no difference there is no difference between the groups between the groups

54







55







• Experimental event rat: Experimental event rat: • 22/4022/40 =55%=55%

• Control event rate: Control event rate: • 7/40 = 18%7/40 = 18%

• RelativeRelative risk: risk: =0.55/ 0.18= 3.1 =0.55/ 0.18= 3.1

• Relative risk increase: Relative risk increase: =0.55- 0.18/=0.55- 0.18/ 0.18 0.18 = = 2.06 2.06

• Absolute risk increase or reductionAbsolute risk increase or reduction== 0.55- 0.18 = 0.370.55- 0.18 = 0.37

• NNT = NNT = 1/ 0.37 = 2.71/ 0.37 = 2.7

58

OddsOdds

The odds of an event are the The odds of an event are the probability of it occurring probability of it occurring

compared to the probability compared to the probability of it not occurringof it not occurring

59







60

What was the ratio of What was the ratio of odds?odds?

•The odds of an event in The odds of an event in the treatment (or the treatment (or exposed) group compared exposed) group compared to the odds in the control to the odds in the control (or unexposed) group(or unexposed) group

•OR=(A/B)/(C/D)OR=(A/B)/(C/D)

61

An odds ratioAn odds ratiois the odds of an event in a is the odds of an event in a

patient in the experimental patient in the experimental group relative to that of a group relative to that of a patient in the control group. patient in the control group.

Relative risk is the risk of an Relative risk is the risk of an event in a patient in the event in a patient in the experimental group relative to experimental group relative to that of a patient in the control that of a patient in the control group.group.

62







• Experimental event odds:Experimental event odds:

22/18= 1.222/18= 1.2

• Control event oddsControl event odds::

7/ 337/ 33 = =0.210.21

• Odds ratio: Odds ratio:

1.2/ 0.21= 5.71.2/ 0.21= 5.7

ApplicabilityApplicability

3 arms for the applicability criteria 3 arms for the applicability criteria toto

be looked at be looked at (IPP) (IPP)

• IIntervention ntervention • PPatient populationatient population• PPatient preferences.atient preferences.

To answer a clinical question To answer a clinical question effectively, First, turn your effectively, First, turn your scenarios into scenarios into 'well-built' 'well-built' clinical clinical Q.Q.

Four domains:Four domains: PICOPICO

1) the 1) the ppatient (atient (pproblem)roblem)

2) the 2) the iintervention or ntervention or exposure exposure

3) the 3) the ccomparison omparison (intervention)(intervention)

4) the clinical 4) the clinical ooutcomesutcomes

Clinical ScenarioClinical Scenario

• Ibrahim is a 60 years old teacher, Ibrahim is a 60 years old teacher, he is known case of hypertension. he is known case of hypertension. He presented to the ED with He presented to the ED with severe chest pain for the last two severe chest pain for the last two hours. hours.

• You wonder should you request You wonder should you request troponin or creatine kinase- MB or troponin or creatine kinase- MB or both?both?

Treponine or creatine Treponine or creatine kinase-MBkinase-MB

1. 1. PPatient atient population.population.

2. 2. IIntervention.ntervention.

3. 3. CComparison omparison intervention.intervention.

4. 4. OOutcomes. utcomes.

Patients attending the Patients attending the ED with chest painED with chest pain

Troponine

creatine kinase-MB

Accuracy of diagnosis of IHD Accuracy of diagnosis of IHD

““In In Patients attending the ED with chest pain, , is troponine as compared to creatine kinase-MB more valid for the diagnosis of ischemic heart disease?

Information management Information management PrinciplesPrinciples

OBJECTIVE: The aim of this study was to evaluate the diagnostic OBJECTIVE: The aim of this study was to evaluate the diagnostic efficacy of multiple tests-heart-type fatty acid-binding protein efficacy of multiple tests-heart-type fatty acid-binding protein (H-FABP), cardiac troponin I (cTnI), creatine kinase-MB, and (H-FABP), cardiac troponin I (cTnI), creatine kinase-MB, and myoglobin-for the early detection of acute myocardial myoglobin-for the early detection of acute myocardial infarction among patients who present to the emergency infarction among patients who present to the emergency department with chest pain.department with chest pain.

• METHODS: A total of 1128 patients provided a total of 2924 METHODS: A total of 1128 patients provided a total of 2924 venous blood samples. Patients with chest pain were venous blood samples. Patients with chest pain were nonselected and treated according to hospital guidelines. nonselected and treated according to hospital guidelines. Additional cardiac biomarkers were assayed simultaneously at Additional cardiac biomarkers were assayed simultaneously at serial time points using the Cardiac Array (Randox Laboratories serial time points using the Cardiac Array (Randox Laboratories Ltd, Crumlin, United Kingdom).Ltd, Crumlin, United Kingdom).

• RESULTS: Heart-type fatty acid-binding protein had the RESULTS: Heart-type fatty acid-binding protein had the greatest sensitivity at 0 to 3 hours (64.3%) and 3 to 6 hours greatest sensitivity at 0 to 3 hours (64.3%) and 3 to 6 hours (85.3%) after chest pain onset. The combination of cTnI (85.3%) after chest pain onset. The combination of cTnI measurement with H-FABP increased sensitivity to 71.4% at 3 measurement with H-FABP increased sensitivity to 71.4% at 3 to 6 hours and 88.2% at 3 to 6 hours..to 6 hours and 88.2% at 3 to 6 hours..

Receiver operating characteristic curves demonstrated that H-FABP had the greatest diagnostic ability with area under the curve at 0 to 3 hours of 0.841 and 3 to 6 hours of 0.894. The specificity was also high for the combination of H-FABP with cTnI at these time points. Heart-type fatty acid-binding protein had the highest negative predictive values of all the individual markers: 0 to 3 hours (93%) and 3 to 6 hours (97%). Again, the combined measurement of cTnI with H-FABP increased the negative predictive values to 94% at 0 to 3 hours, 98% at 3 to 6 hours, and 99% at 6 to 12 hours.CONCLUSION: Testing both H-FABP and cTnI using the Cardiac Array proved to be both a reliable diagnostic tool for the early diagnosis of myocardial infarction/acute coronary syndrome and also a valuable rule-out test for patients presenting at 3 to 6 hours after chest pain onset

Applying ResearchApplying ResearchOne size doesn’t fit allOne size doesn’t fit all

Physicians searching skills Physicians searching skills are poorare poor

• 23 Physicians answered multiple-choice questions 23 Physicians answered multiple-choice questions and chose 2 to obtain further information using and chose 2 to obtain further information using their own information resources. their own information resources.

• For each questionFor each question– a mean of 13 minutes searching a mean of 13 minutes searching – an average of 1.8 resourcesan average of 1.8 resources

• Before searching Before searching – 18 (39%) of the 46 answers were correct 18 (39%) of the 46 answers were correct

• After searchingAfter searching– 19 (42%) of the 46 answers were correct. 19 (42%) of the 46 answers were correct.

• 6 answers went from incorrect to correct;6 answers went from incorrect to correct;5 went from correct to incorrect5 went from correct to incorrect

McKibbon KA, Fridsma DB. J Am Med Inform Assoc. 2006; 13(6):653-9.

Learning about “Just in Time” Learning about “Just in Time” learninglearning

• Keep a logbook of questionsKeep a logbook of questions• Answer a few important questionsAnswer a few important questions• Search and appraise yourself, thenSearch and appraise yourself, then• Discuss with colleagues / mentorDiscuss with colleagues / mentor

“Journal” Clubs

Learning about learning in teams

(Post graduate “problem-based” learning)

List our important current issues

Vote on importance

Search for evidence for next session

Example Questions

1. Does ‘bibliotherapy’ help depression?

2. Should all diabetics take aspirin?

3. Are antidepressants safe in adolescents?

4. Is atenolol OK for hypertension?

5. What is the impact of Tamiflu on flu?

6. Is diabetic self-monitoring helpful?

Questions? Questions?

The Prognosis of Ignorance is The Prognosis of Ignorance is PoorPoor

Implications for practiceInteractive workshops can improve

professional practice. Lectures alone are unlikely to change professional practice

Treatment of Ignorance

Prevention & TreatmentPrevention & Treatment

If EBM looks impossible then If EBM looks impossible then resign it!resign it!

117

JASPA*JASPA*(Journal associated score of personal angst)(Journal associated score of personal angst)

J: J: Are you ambivalent about renewing your Are you ambivalent about renewing your JOURNALJOURNAL subscriptions?subscriptions?

A: A: Do you feel Do you feel ANGERANGER towards prolific authors? towards prolific authors?

S: S: Do you ever use journals to help you Do you ever use journals to help you SLEEPSLEEP??

P: P: Are you surrounded by Are you surrounded by PILESPILES of PERIODICALSof PERIODICALS??

A: A: Do you feel Do you feel ANXIOUSANXIOUS when journals arrive? when journals arrive?

* Modified from: BMJ 1995;311:1666-1668

0 (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions)

Evidence alone is not Evidence alone is not enoughenough

Patients’ values Patients’ values

Would you treat with antibiotics: Would you treat with antibiotics:

a 75 YO patient who is, Demented, a 75 YO patient who is, Demented, bedridden, contracted, debilitated, not bedridden, contracted, debilitated, not oriented, who developed pneumonia ? oriented, who developed pneumonia ?

120

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