Beruflich Dokumente
Kultur Dokumente
Promoting EBM Group Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
Integration of
Combinations of appropriate and timely utilization of available evidence to improve clinical expertise and patient values leading to the best practices
Process of EBM
clinical question searching evidence
critical appraisal
using evidence evaluation
Type of questions
Background questions Foreground questions
The Patients: pregnant women with preterm labor Intervention: calcium channel blocker Comparison: other tocolytics Clinical outcome: prolongation of pregnancy
Is calcium channel blocker more effective in prolongation of pregnancy than other tocolytics?
Categories of evidence
I: RCT Ia: Evidence from meta-analysis of RCTS Ib: Evidence from at least one RCT II: Controlled trials IIa: Evidence from at least one controlled study without randomization IIb: Evidence from at least one controlled study with quasi-randomization III. Evidence from descriptive studies IV. Evidence from expert committee reports and/or clinical experience of respected authorities
2. Searching evidence
Search term: keywords Search Database
Evidence-based database: systematic review & meta-analysis Medical database: original randomized controlled trial (RCT)
Study design/search Clinical questions: therapy, harm, systematic review, diagnosis, prognosis
Search database
Evidence-based databases EBM online (http://ebm.bmjjournals.com) Cochrane Library CRD (http://nhscrd.york.ac.uk) Clinical evidence (http://www.clinicalevidence.com) Medical database PubMed Scientific information (http://wwwscirus.com) Proquest, OVID, ScienceDirect
(narrative) review
Describing
review
review
Prognosis
Harm
Valid: Less bias Important: Significant results Application: Considering a specific patient
Worksheet for
Therapy
Valid: Therapy
Items Yes/No Note
1.
Was the assignment of patients to treatments randomised? Was the randomisation list concealed? Were all patients analysed in the groups to which they were randomised (intention-to-treat)? Were patients and clinicians kept "blind" to treatment? Were the groups treated equally, apart from the experimental treatment (co-intervention)? Were all patients who entered the trial accounted for at its conclusion (follow up complete)?
2. 3. 4. 5. 6.
Important: Therapy
Number Absolute risk Relative risk Needed to reduction/ reduction/ Treat (NNT) increase (ARR/ARI) increase (RRR/RRI) /Harm (NNH)
1/ARR
Incidence
CER
EER
(CER-EER)/CER
CER-EER
1/ARI
Example
event rate
ARR= ICER-EERI
Application: Therapy
Items Yes/No Note
1.
Is your patient so different from those in the study that its results cannot apply?
Are they met by this regimen and its consequences- benefit and harm? Do your patient and you have a clear assessment of their values and preferences?
4.
Worksheet for
Systematic Review
1. Is it an systematic review of randomized trials of the treatment you are interested in? 2. Does it include a method section described the finding and including all the relevant trials?
3. Does it include a method section described the assessing their individual validity? 4. Were the consistency of individual study considered in the method?
(CEREER)/CER
CER-EER
1/ARR
1.
Is your patient so different from those in the study that its results cannot apply? Is the treatment feasible in your setting? Are they met by this regimen and its consequences- benefit and harm? Do your patient and you have a clear assessment of their values and preferences?
2.
3.
4.
Worksheet for
Diagnosis
Valid: Diagnosis
Item
Yes/No Note
1.
Was there an independent, blind comparison with a reference ("gold") standard of diagnosis?
2. Was the diagnostic test evaluated in an appropriate spectrum of patients (like those in whom it would be used in practice)?
3. Was the reference standard applied regardless of the diagnostic test result?
Important: Diagnosis
Standard result Positive Negative
b d b+d
Total
a+b c+d a+b+c+d
Test result
a c a+c
Sensitivity = a / (a+c) Specificity = d / (b+d) LR+ = sensitivity /(1-specificity) LR- = (1-sensitivity) / specificity Positive predictive value = a /(a+b) Prevalence = (a+c) / (a+b+c+d) Pre-test odds = prevalence / (1-prevalece) Post-test odds = pre-test odds * LR Post-test probability = posttest odds /(1+ posttest odds)
Application: Diagnosis
Item
1.
Yes/No Note
Is the diagnostic test available, affordable, accurate, and precise in your setting?
2. Are the results applicable to my patients? 3. Will the results change my management? 4. Will patients be better off as a result of this test?
Worksheet for
Prognosis
Valid: Prognosis
Item
1.
Yes/No Note
Was a defined, representative sample of patients assembled at a common (usually early) point in the course of their disease? Was patient follow-up sufficiently long and complete? Were outcome criteria applied in a blind fashion?
2.
3.
4.
If subgroups with different prognoses are identified, was there adjustment for important prognostic factors?
Important: Prognosis
Item
1.
Yes/No Note
Application: Prognosis
Item
1. Were the study patients similar to your own? 2. Can I use the results in managing patients in my practice?
Yes/No Note
Worksheet for
Harm
Valid: Harm
Item Yes/No Note
1.
2. Ware treatment exposures and clinical outcomes measured the same ways in both groups? 3. Was the follow-up of study patients complete and long enough? 4. Do the results satisfy for causation?
Important: Harm
Item
1.
Yes/No Note
Important: Harm
Adverse outcome
Positive (Case) Exposure to treatment Yes (Cohort) No (Cohort) Total
a c a+c
Negative (Control)
b d b+d
Total
a+b c+d a+b+c+d
RR
= [a/(a+b)]/[c/(c+d)]
Application: Harm
Item
1.
Yes/No Note
Is your patient so different from those in the study that its results cannot apply?