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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
·
Synonyms: Evidence-Informed Healthcare or Evidence-Based Health Care or
Evidence-Based Practice.
·
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 I: Evidence obtained from at least one properly designed
randomized controlled trial.
·
Level II-1: Evidence obtained from well-designed controlled trials
without randomization.
·
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
·
The hierarchy of evidence is questionable: RCT is not always the
gold standard[[2]], [[3]]
·
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 the 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 criteria, 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
·
Methodological and ethical violations in published RCTs[[10]]
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
·
Problems of EBM have led to consideration of PBE as an alternative[[11]], [[12]]
·
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 a 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's reaction to psychotherapy[[15]]
Associate patient and
treatment characteristics with outcomes[[16]]
Nutrition evaluation[[17]]
Athletic related injuries in
schools[[18]]
Periodontal care[[19]]
Practice-Based Research Networks (BPRN)
·
PBE is a form of large data analysis
·
Collaboration between practices in collecting and analyzing healthcare data
·
Networks are very useful in primary healthcare research[[20]]
·
Examples of networks: radiation oncology registry[[21]],
multi-morbidity[[22]]
·
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 database that represents the whole of KSA because
we are a 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
[1] South
Med J. 2012 Mar; 105(3):136-43.
[2] Can
J Neurol Sci. 2013 Jul; 40(4):475-81.
[3] Can
J Neurol Sci. 2013 Jul; 40(4):465-74.
[4] Br
J Gen Pract. 2012 Jul; 62(600):e511-21.
[5] Curr
Opin Psychiatry. 2010 Mar; 23(2):145-50.
[6] Can
J Neurol Sci. 2013 Jul; 40(4):475-81.
[7] Can
J Neurol Sci. 2013 Jul; 40(4):465-74..
[8] South
Med J. 2012 Mar; 105(3):114-9.
[9] Can
J Neurol Sci. 2013 Jul; 40(4):475-81..
[10] Can
J Neurol Sci. 2013 Jul; 40(4):465-74.
[11] Int
J Clin Pract. 2011 Jun; 65(6):639-44.
[12] Arch
Phys Med Rehabil. 2012 Aug; 93(8 Suppl):S127-37
[13] PLoS
One. 2013 May 23; 8(5):e63499.
[14] Am
J Psychother. 2013; 67(1):23-46.
[15] Psychiatr
Serv. 2013 Mar 1; 64(3):252-6.
[16] Arch
Phys Med Rehabil. 2013 Apr; 94(4 Suppl):S67-74.
[17] Can
J Diet Pract Res. 2012 Spring; 73(1):e233-40..
[18] J
Athl Train. 2012 Sep-Oct; 47(5):557-66.
[19] J
Periodontol. 2013 May; 84(5):567-71.
[20] J
Am Board Fam Med. 2012 Sep-Oct; 25(5):565-71.
[21] J
Oncol Pract. 2013 May; 9(3):e90-5..
[22] BMC
Fam Pract. 2013 Aug 7; 14:112
[23] J
Am Board Fam Med. 2013 Sep-Oct; 26(5):571-8.
[24] Ann
Fam Med. 2012 Nov-Dec; 10(6):560-7.