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Presentation at the Grand Round of the
Department of Internal Medicine, King Fahad Medical City on April 2, 2014 by
Professor Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard)
KEY WORDS
·
EBM = evidence
based medicine
·
RCT =
randomized clinical trial
·
Meta-analysis
·
Practice-based
evidence
·
PBRN =
Practice-based research network
·
Data mining
·
Knowledge
discovery in data
DEFINITION OF EBM
·
Use of the latest evidence in
clinical decision making
·
In 1996 David Sackett wrote that "evidence-based medicine is
the conscientious, explicit and judicious use of current best evidence in
making decisions about the care of individual patients
·
Bridge between research and practice
FIVE STEPS OF EBM
·
Formulate the
problem as an answerable question
·
Systematic
retrieval of research articles
·
Critical
appraisal of the evidence for internal and external validity
·
Application of results in
practice after analysis and getting summary/combined measures by meta-analysis
·
Evaluation of performance
APPLICATION OF EBM TO PATIENT CARE[1]
·
Assess the
patient
·
Ask a clearly
focused clinical question
·
Acquire the
best evidence available from the medical literature
·
Appraise the
evidence
·
Apply the
evidence to patient care)
LEVELS OF EBM EVIDENCE ACCORDING TO THE US U.S. Preventive Services Task Force
·
Level II-2: Evidence
obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
·
Level II-3: Evidence
obtained from multiple time series designs with or without the intervention.
Dramatic results in uncontrolled trials might also be regarded as this type of
evidence.
·
Level III: Opinions of
respected authorities, based on clinical experience, descriptive studies, or
reports of expert committees
PROBLEMS WITH EBM 1
·
EBM is a new
word but the concept is not new; medicine has always been evidence-based
·
Complicated: GPs
do not have the time, skills, or resources to used EBM[4]
·
Complicated
statistics of meta analysis that the researcher cannot internalize[5] [6] [7] but
decision cannot be based on a single study we must combine evidence from
various studies
·
Appraising the
quality of the evidence is a difficult skill[8]
·
Basic science
data is ignored[9]
PROBLEMS OF EBM BASED ON RCTs
·
RCTs evidence not
representative: artificial population with severe inclusion/exclusion cruteria,
unrepresented populations, publication bias,
·
RCTs may be biased in what
diseases and treatments are studied because of sponsor interests
·
Lag time between the
research and its publication
·
RCT evidence applies to
groups; the individual patient may be different
FROM EVIDENCE BASED MEDICINE (EBM) to PRACTICE BASED EVIDENCE (PBE)
·
Both EBM and PBE
are evidence based; the difference is the type of evidence involved
·
PBE involves
collecting and analyzing real-time clinical data to reach various conclusions
on diagnosis, screening, treatment, prognosis etc
·
Mining clinical
data[13]
·
PBE is
laboratory for studying actual practices in a natural environment
·
PBE is more
realistic and more immediately usable
EXAMPLES OF| PBE
·
Psychotherapy
data over 45 years[14]
·
Use of
inpatient data to assess children reaction to psychotherapy[15]
·
Associate
patient and treatment characteristics with outcomes[16]
·
Nutrition
evaluation[17]
·
Athletic
related injuries in schools[18]
·
Peridontal care[19]
PRACTICE BASED RESEARCH NETWORKS (BPRN)
·
PBE is a form
of large data analysis
·
Collaboration
between practices in collecting and analyzing health care data
·
Networks are
very useful in primary health care research[20]
·
Communication is the key
to network success[23]
·
Models of electronic
support for the networks[24]
PBE AT KFMC
·
Saudi Arabia presents
unique opportunities for research because of its genetic pool: paradoxically
both open and closed
·
Some conditions like DM
have unique presentations and natural history
·
We have a large data base
that represents the whole of KSA because we are an MOH referral hospital
·
We can make original
contributions to medicine by publishing evidence from our practice
·
Problems: data quality and
statistical software (Innovation Center)
NOTES