Evidence based medicine nandinii080100332

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EVIDENCE BASED MEDICINE (EBM) Nandinii Ramasenderan 080100332

Transcript of Evidence based medicine nandinii080100332

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EVIDENCE BASED MEDICINE (EBM)

Nandinii Ramasenderan080100332

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OVERVIEW Definition History Factors driving EBM Steps in EBM Case discussion

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WHAT IS EBM?A systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values

-Dave Sackett-

Patient Concerns

Clinical Expertise

Best research evidence

EBM

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INTEGRATED WITH CLINICAL EXPERTISE

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RISE OF EVIDENCE BASED MEDICINE

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LIFE LONG LEARNINGThe hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not … a medical course, but a life course, for which the work of a few years under teachers is but a preparation.

Sir William Osler (1849-1919), from: The Student of Medicine

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STEPS IN PRACTISING EBM

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STEP 1 : FORMULATE QUESTION Background Question-Ask for general knowledge about a condition or thing-Have 2 essential components:a)A question root (who, what, where, when how, why) and a verbb)A disorder, test, tx, or other aspect of health care.Eg: -how does heart failure cause ascites? -what causes SARS?

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STEP 1 : FORMULATE QUESTION Foreground Question-Ask for specific knowledge to inform clinical decision / actions-4 essential components:a)Patient and /or problemb)Intervention (or exposure)c)Comparison, if relevantd)Outcome (clinical), including time if relevantEg: “ In adults with heart failure who are in sinus rhythm, would adding warfarin to standard therapy reduce morbidity or mortality from thromboembolism enough over 3-5 years to be worth warfarin’s harmful effects and inconveniences.”

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BACKGROUND

FOREGROUND

TYPE OF QUESTION

CLINICAL EXPERIENCE

STEP 1 : Formulate QuestionThe nature of the question asked is critically experience dependent.

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STEP 2: USE BEST EVIDENCE TO ANSWER QUESTION

Computerized decision support system (CDSS)

Evidence-based journal abstracts

Cochrane reviews

Original published articles in journals

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STEP 2: USE BEST EVIDENCE TO ANSWER QUESTION

System-Evidence based clinical information, researches

-Electronic basedBMJ Clinical Evidence (http://www.clinicalevidence.com)UpToDate (http://www.uptodate.com)PIER: The Physician’s Information and Education Resource (http://pier.acponline.org/index.html).

Synopses-A brief summary/ review of individual studies

-Provide only information to support a clinical actionACP [American College of Physicians] Journal Club(http://www.acpjc.orgEBM (http://ebm.bmj.com).

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STEP 2: USE BEST EVIDENCE TO ANSWER QUESTION

Syntheses-summaries of articles/ reviews The Cochrane Library Web site (http://www3.interscience.wiley.com/ cgibin/mrwhome/106568753/HOME)DARE(www.york.ac.uk/inst/crd/welcome.htm)

Studies-original research journalMedline/ PubMed Clinical Queries (www.pubmed.com)EMBASE (OVID) (www.ovid.com)

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HIERARCHY OF EVIDENCE PYRAMID

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LEVEL OF EVIDENCE Level type of investigation

IaIa Evidence obtained from meta analysis of Evidence obtained from meta analysis of randomized controlled trialsrandomized controlled trials

IbIb Evidence obtained from at least one Evidence obtained from at least one randomized controlled trialrandomized controlled trial

IIaIIa Evidence obtained from at least one well Evidence obtained from at least one well designed controlled study without designed controlled study without randomizationrandomization

IIbIIb Evidence obtained from at least one other Evidence obtained from at least one other type of well designed quasi experimental type of well designed quasi experimental studystudy

IIIIII Evidence obtained from well designed non Evidence obtained from well designed non experimental studies, such as comparative experimental studies, such as comparative studies, correlational studies, and case studies studies, correlational studies, and case studies

IVIV Evidence obtained from expert committee Evidence obtained from expert committee reports or opinionsreports or opinions

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STEP 3: CRITICALLY APPRAISE EVIDENCE

To understand the methods and results of research and to assess the quality of the researchTHREE MAIN ASPECTS TO BE APPRAISED: V I A

1. VALIDITY : VALID (CLOSENESS TO THE TRUTH) IN THE METHODOLOGY SECTION

2. IMPORTANCE :IMPORTANT (USEFULNESS) IN THE RESULTS SECTION

3. APPLICABILITY :APPLICABLE (CAN BE APPLIED IN CLINICAL PRACTICE) IN THE DISCUSSION SECTION

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STEP 4: INTEGRATE FINDINGS INTO PRACTISE Making a concise decision based on research finding & information found.Discuss with patient regarding our findings & risk-benefit assessment

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CASE DISCUSSION

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68 years old Malay FemaleHx of Congestive Heart Failure & HypertensionSurgical Hx: CABG 10 years agoOn medication: Digoxin, Lasix, Isosorbide nitrateMild increase of dysnea on exertion past 4 daysHaving acute Shortness of breath 1hour prior to admission

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On examination: BP: 188/104 mmHg Pulse rate:122 bpmRespiratory rate: 30 Temp: 37.5 CelsiusSpO2: 90% (On Non-rebreather mask)Lung auscultation: Crackles to ½ bilateralJugular vein distended, S3 gallopPretibial edema bilaterally

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PLAN & INVESTIGATIONIV, O2, & vital sign MonitoringChest Xray, ECG, Cardiac markers, Digoxin levelECG: Sinus tachycardia, old inferior myocardial infarction, no st-elevation changesCXR: acute pulmonary edema (pulmonary venous congestion, small bilateral effusion)TreatmentGTNLasixMorphine

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QUESTION—GENERAL STATEMENT What about using ACE inhibitors for acute pulmonary edema?

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BACKGROUNDDescribe pathophysiology of CHF and acute pulmonary edemaDiscuss causes of decompensation of CHFDiscuss Differential Diagnosis of acute pulmonary edemaRelate pathophysiology of CHF to treatment, especially role of ACE-I in CHFDescribe treatment goalsDescribe standard treatment of CHF

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EBM QUESTION Patients: Acute Pulmonary Edema Intervention: ACE Inhibitor Comparison: Placebo Outcome: Mortality Intubation Hemodynamic parameters ICU/CCU admission

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THANK YOU