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Section 17: Evidence Based Medicine (EBM)

EBM is the integration of the current best research evidence with clinical expertise and patient’s values, preferences and circumstances.[57] By best research evidence we mean most updated and relevant clinical research. By clinical expertise we mean the clinical skills and past experience to identify each patient's unique health state and diagnosis and the specific risks and benefits of potential interventions. By patient values we mean the specific preferences, concerns, personal values.

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68 views

Section 17: Evidence Based Medicine (EBM)

EBM is the integration of the current best research evidence with clinical expertise and patient’s values, preferences and circumstances.[57] By best research evidence we mean most updated and relevant clinical research. By clinical expertise we mean the clinical skills and past experience to identify each patient's unique health state and diagnosis and the specific risks and benefits of potential interventions. By patient values we mean the specific preferences, concerns, personal values.

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أحمد خيري التميمي
Copyright
© © All Rights Reserved
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Section 17: Evidence based medicine (EBM)

Section 17: Evidence based medicine (EBM)


1. What is EBM

EBM is the integration of the current best research evidence with clinical
expertise and patient’s values, preferences and circumstances.[57] By best
research evidence we mean most updated and relevant clinical research. By
clinical expertise we mean the clinical skills and past experience to identify each
patient's unique health state and diagnosis and the specific risks and benefits of
potential interventions. By patient values we mean the specific preferences,
concerns, personal values, and expectations of each patient. [58]

Figure: Three E’s - EBM components

2. Why we need EBM

In the past, physicians relied on their own experience or that of other health care
workers to take decisions regarding patients’ treatment. Currently this approach
is inadequate and poor as health care workers rapidly find themselves unable to
cope with the influx of a huge variety of new information, from the irrelevant to
the very important. Therefore, the need for the evidence-based decision came
from:[59]

a. Our daily need for valid information about diagnosis, prognosis, therapy
and prevention.
b. The inadequacy of traditional sources for this information because they
might be out-of-date (textbooks), potentially wrong (colleagues), or too
overwhelming in their volume (medical journals).

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Section 17: Evidence based medicine (EBM)

c. The disparity between our diagnostic skills/clinical judgment, which


increases with experience, and our up-to-date knowledge which declines
with time.
d. Our inability to afford more than a few minutes per patient for finding and
assimilating this evidence or to set aside more than few hours per week for
general reading and study.

3. EBM principles

EBM involves two fundamental principles:[59]

a. Evidence alone is never the sole basis for decisions: Benefits and risks, costs
and alternative strategies, as well as the patients’ values are all factors that
must be taken into consideration alongside with evidence when taking the
decision.
b. EBM has a hierarchy of strength of evidence for treatment decisions: The
hierarchy of evidence is a spectrum of potential sources beginning with
those most likely to provide the evidence to those with the least likely.
Thus, the physician must begin with the highest available evidence from the
hierarchy.

Figure: Hierarchy of Evidence

4. EBM steps

Practicing EBM is primarily based on five well defined steps (5 A’s), which can
be broadly categorized as the five A’s:[58,60,61]
a. Asking Focused Questions: The question should be directly relevant to the
problem at hand and should be phrased to facilitate searching for a precise

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Section 17: Evidence based medicine (EBM)

answer. To achieve these aims, the question must be divided into four
components, which are called ‘PICO’.
x P: The Patient and/or Problem being addressed. Ex: Young children
with otitis media
x I: The Intervention or exposure being considered. Ex: Treatment with
Amoxicillin
x C: The Comparison intervention when relevant. Ex: Compared with
placebo
x O: The clinical Outcomes of interest. Ex: Results in faster
improvement?

The overall question becomes: Does Amoxicillin lead to faster improvement


in otitis media among young children compared to placebo?

b. Acquiring the Evidence: In this step we make a systematic retrieval of the


best evidence available. Choosing the best resource to search is an important
decision.

Following is a list of some valuable resources for practicing EBM:[62]


x Summaries of the primary evidence: ACP Journal Club, Clinical
Evidence
x Databases: PubMed, Cochrane Library
x Electronic textbooks and libraries: AccessMedicine, ACPMedicine,
x Meta-Search Engines: SUMSearch, TRIP Answers

c. Appraisal of evidence: It is the process of assessing and evaluating the


evidence for its internal validity, its clinical relevance, and applicability.
Appraisal of evidence depends on the following 4 pillars -RVRA:
x Relevance: It focuses on the relevance of the literature to the question
asked
x Validity: Are the results of the study valid?
x Results: What are the overall results? How precise are they?
x Applicability: Are the results Applicable in and useful for my patients

d. Application of the best evidence in practice: Based on the findings of the


above, a clinical decision is to be made.

e. Assessing and evaluating the performance: Evaluating our effectiveness and


efficiency in executing Steps 1 - 4 and seeking ways to improve them both
for next time.

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Section 17: Evidence based medicine (EBM)

Ask Appraise Apply the


Acquire the Assess your
answerable the best
evidence(s) performance
question evidence(s) evidence

Figure: EBM steps, the 5 A’s

5. Limitations of EBM

Although EBM is regarded as the best standard of conventional clinical practice


there are a number of limitations for its use:[58,60]
a. Lack of good evidence for many clinical questions
b. Results may not be relevant for all treatment situations
c. Lag in time between when the research studies is conducted, when its results
are published when these are properly applied

6. Linking research to EBM

Finally, to be able to practice medicine based on the best evidence, the health
care practitioner has to be equipped with both clinical and research knowledge.
More specifically, research knowledge includes understanding of research process,
ethical consideration, study design, statistical analyses, and results
interpretation.

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