EBM QUESTIONS ANYONE

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EBMQUESTIONS ANYONE ?

• Todd D. Tillmanns, MD, FACOG
• Assistant Professor
• Division of Gynecologic Oncology
• West Clinic
• University of Tennessee Health Science Center

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What is Evidence Based Medicine (EBM)

• Evidence-based medicine is the care of patients
  using the best available evidence from the
  results of research to guide clinical decision
  making 1-3

• Sackett, DL, Straus, SE, Richardson, WS, et al.
  Evidence-based medicine. How to practice and
  teach EBM, 2nd edition, Churchill Livingstone,
  Edinburgh 2000.
• 2. Sackett, DL, Rosenberg, WM, Gray, JA, et al.
  Evidence-based medicine. What it is and what it
  isn't. BMJ 1996 31271.
• 3. Geyman, JP, Deyo, RA, Ramsey, SD.
  Evidence-Based Clinical Practice,
  Butterworth-Heinemann, Woburn, MA 1999.

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What EBM is not!

• Eminence
• Vehemence
• Eloquence
• Confidence of the source
• Practicing defensive medicine
• The way we do it, you could..

Isaacs, D, Fitzgerald, D. Seven alternatives to
evidence based medicine. BMJ 1999 3191618.
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Dont put the cart before the horse

• The question must be defined before the answer to
  the question can be elucidated through a careful
  search

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Good Evidence Based Questions

• Is the finding abnormal?
• What is the diagnosis?
• How often does it occur?
• What are the risk factors for the disease?
• What is the pathogenesis?
• What is the natural history?
• How effective (harmful) is the treatment?
• How effective or (harmful) are preventative
  interventions?

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Putting EBM into practice

• What is the incidence and prevalence?
• What are the signs and symptoms?
• What are the best diagnostic tests with the best
  clinical findings that confirm the suspected
  diagnosis?
• What is the best treatment of the disease
  process?
• Once treated what is the best way to maintain
  health for discharge from your care?
• How would you prevent the disease process?

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Where do you find the answers?

• You must invest your time to become proficient
  searching these sites and others
• full text journals (OVID, Medline, Pubmed)
• Cochran Data Base
• Organizations
• American College of Physicians
• American Society of Internal Medicine
• APGO, ACOG
• Infectious Disease Society of America
• governmental organizations
• National Institutes of Health
• Centers for Disease Control and Prevention
• National Guideline Clearinghouse
  www.guideline.gov

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Summary of Good Sources for Quick EBM Review

• UpToDate editors and authors revise the program
  continually. New information is highlighted in
  each new edition of the CD-ROM and internet
  versions, and the date when the topic was last
  updated is noted at the beginning of each topic
  review. Other textbooks are finding ways to
  update regularly, but readers should be aware of
  how often each part of the information base is
  updated and when the last update of each section
  they are depending on was done.
• ACP Journal Club is published every two months by
  the American College of Physicians/American
  Society of Internal Medicine. It reviews the
  world's English-language medical journals in
  internal medicine, selects scientifically strong
  articles by explicit criteria, and summarizes
  those meeting these criteria as structured
  abstracts with commentary by an expert, one
  article per page. (ACP Journal Club, ACP-ASIM,
  190 North Independence Mall West, Philadelphia,
  PA 19106-1572, USA 800-523-1546)
• The Medical Letter, a four-page, biweekly,
  evidence-based review of drugs, including
  effectiveness, mechanism of action, side effects
  and interactions, and cost for new drugs in
  relation to older alternatives. (The Medical
  Letter, Inc., 1000 Main Street, New Rochelle, NY
  10801 800-211-2769).
• Evidence-Based Medicine is similar to ACP Journal
  Club but with a wider scope, including articles
  of interest to family medicine, pediatrics,
  obstetrics and gynecology, surgery, and
  psychiatry. (Evidence-Based Medicine, ACP-ASIM,
  190 N. Independence Mall West, Philadelphia, PA
  19106-1572 800-523-1546)
• The Family Practice Newsletter is a four-page,
  "biweekly update and commentary on new and
  practical clinical information for the primary
  care practitioner," written by a family physician
  with public health and law degrees. (Primary Care
  Press, 5423 Monocracy Drive, Bethlehem, PA 18017
  888-399-7442 fax [phone] cpkerr_at_nni.com).
• Evidence-Based Practice, "patient-oriented
  evidence that matters," from the publishers of
  The Journal of Family Practice. (Dowden Health
  Media, 110 Summitt Ave., Montvale, NJ 07645-9894
  800-707-7040 ebp_at_dowdenhealth.com)
• Journal Watch is a monthly publication of the
  Massachusetts Medical Society that summarizes
  recent articles with commentary. (Massachusetts
  Medical Society. 860 Winter St. Waltham, MA
  02451.1411. 781-893-4610).

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Credibility of Resources

• Internal validity Are the results of clinical
  research correct for the patients in the study?
  (threatened by two processes bias and chance)
• Generalizability Do the results of the study
  apply to my patients
• Classification of levels of evidence and
  recommendations

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Guidelines for practicing EBM

• Worksheet for EBM presentations by residents
• Clinical question
• Reference research articles by level of evidence
• Identify the incidence and prevalence of disease
  or disorder
• Give background
• Signs and symptoms ( M/C symptom most reliable)
• Laboratory, studies, findings that confirm
  diagnosis (and exclude others)
• Treatment (Best, most economical and options for
  second line)
• Discharge measures and follow up evaluation
• Preventative measures
• EBM Guidelines
• Guidelines for proposing good EBM questions
  (Sackett)

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THANK YOU!QUESTIONS?
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