Evidence-Based Medicine

Lisa M. Lundquist, PharmD, BCPS [email protected]

Learning Objectives

 Define evidence-based medicine  Describe the rationale of the basis of making clinical decisions  List the steps involved in making patient-care decisions using evidence-based medicine  Given a clinical question, be able to search for evidence and apply to the clinical question

Evidence-Based Medicine

 Definition  The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient.

 It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

Steps in the Process

1.

2.

3.

4.

5.

6.

Identify a patient Formulate an appropriate clinical question Conduct a literature search Select the key articles Critically appraise the articles Apply the results of the search to your patient

Steps in the Process

1.

Assess 2.

Ask 3.

Acquire 4.

Appraise 5.

Apply Apply Assess Appraise Ask Acquire

Clinical Decision Making

Clinical Experience Scientific Explanation / Evidence Patient Values

Developing a Clinical Question

 Who is the patient?

 What is the intervention?

 Are any alternatives available?

 What is the expected outcome?

Types of Questions

 Diagnosis  Therapy  Prognosis  Etiology

Levels of Evidence

 Primary  Original research  Secondary  Compilation and interpretation of original research  Tertiary  Recommendations regarding clinical application of secondary evidence

Primary Evidence

Randomized controlled trial Observational study Uncontrolled trial Descriptive study Case report

Secondary Evidence

Meta-analysis Systematic review Opinion of respected authorities

Evidence Pyramid

Meta-analyses Systematic reviews RCTs Cohort studies Case-control studies Case reports/case series Animal research/laboratory studies

Tertiary Evidence

Clinical practice guidelines Level A: Strong recommendation Level B: Recommendation Level C: Option/alternative Level D: Recommendation against Level I : Insufficient evidence

Literature Search

 Search strategy  Search engines  PubMed, OVID  Cochrane Database  Systematic reviews  Clinical practice guidelines  National Clearinghouse

Evaluating the Evidence

 Were the results of the study valid?

 Trial design considerations  Generalizability  Follow-up  Power  What were the results?

 Can the results be applied to my patients?

Exercise

   Henry is an active 5 year old boy. His mother brought him in for a check-up because Henry has had a fever and a sore throat for several days. You suspect Strep and a throat culture is taken. The standard treatment for Streptococcal pharyngitis is oral penicillin three times a day; however, for Henry and his mother, you are concerned about compliance and the expense of this medication.

You recall reading that a daily dose of amoxicillin is just as good as penicillin, but costs less. You want to review the literature before you decide on amoxicillin for Henry and possibly changing your standard treatment recommendation and practice.

Developing the Clinical Question A.

What is the best treatment for relieving the symptoms of a sore throat? B.

In children with strep throat, is amoxicillin as effective as penicillin for relief of symptoms? C.

Is amoxicillin better than penicillin for young children?

Search Strategy

 Search Terms  Streptococcus  Pharyngitis  Amoxicillin  Penicillin  Limits  Randomized controlled trial  Children 0-18 years

Assignment

 Using the search strategy on the previous slide and the PubMed database, identify an article which utilizes evidence-based medicine to answer the clinical question.

 Bring the abstract of the article you identify to class tomorrow for discussion.