1 Thewarug Werawatganon, MD Anesthesiology, Chulalongkorn UniversityEBM Introduction to Evidence Based Medicine Thewarug Werawatganon, MD Anesthesiology, Chulalongkorn University
2 EBM Evidence Based MedicineUse of research information in clinical decision: David Eddy Experience Based Medicine Experience, Explanation
3 Evidence-Based Medicine:DefinitionConscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. (Sackett, DL et al Evidence-based medicine: what it is and what it isn’t, BMJ 1996)
4 Evidence-Based Practice
5 Clinical problem High cholesterol Aspirin
6 EBM process 1. Translation of uncertainty to a question2. Systematic retrieval of the best evidence 3. Critical appraisal of evidence for validity 4. Application in practice 5. Evaluation of performance
7 ASSESS the patient 1. Start with the patient -- a clinical problem or question arises from the care of the patient ASK the question 2. Construct a well built clinical question derived from the case ACQUIRE the evidence 3. Select the appropriate resource(s) and conduct a search APPRAISE the evidence 4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice) APPLY: talk with the patient 5. Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice Self-evaluation 6. Evaluate your performance with this patient
8 Clinical Question Diagnosis Therapy Prognosis Etiology
9 Type of Question: type of study
10 Hierarchy of Study DesignMeta-Analysis Systematic Review Randomized Controlled Trial Cohort study Case Control study Case Report Animal study
11 Question P Patient I Intervention C Comparison O Outcome
12 Clinical trial Phase I healthy volunteers for dose-ranging Phase II efficacy and safety Phase III efficacy, effectiveness and safety Phase IV postmarketing surveillance
13 Systematic retrieval Pubmed Embase Cochrane
14 EBM Create Use
15 Use EBM for patient managementCritical Appraisal Valid Result Application
16 EBM Application Clinical decision Clinical practice guidelinePolicy – technology assessment
17 EBM Randomized Controlled Trial (RCT) Systematic ReviewClinical Practice Guideline (CPG) Health Policy
18 EBM Randomized Controlled Trial (RCT) Systematic Review: CochraneClinical Practice Guideline (CPG) Health Policy Agency for Healthcare Research and Quality's (AHRQ) National Institute for Clinical Excellence (NICE)
19 Strength of Evidence Clinical Practice Guideline (CPG) Evidence levelIa - Evidence from Meta-analysis of RCTs Ib - Evidence from at least one RCT IIa - Evidence from at least one well designed controlled trial which is not randomized IIb - Evidence from at least one well designed experimental trial III - Evidence from case, correlation, and comparative studies. IV - Evidence from a panel of experts
20 Categories of recommendationsLevel A: Good evidence suggests that the benefits substantially outweigh the risks. Should discuss the service with eligible patients. Level B: At least fair evidence suggests that the benefits outweighs the risks. Clinicians should discuss the service with eligible patients. Level C: At least fair evidence suggests that there are benefits, but the balance between benefits and risks are too close for making general recommendations. Clinicians need not offer it unless there are individual considerations. Level D: At least fair evidence suggests that the risks outweighs potential benefits. Not routinely offer the service to asymptomatic patients. Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty
21 Limitation Bias Sponsor's interests. LagPopulation segments under-researched Published and unpublished EBM from groups of people but applies to treat each patient
22 Clinical problem Aspirin 39,876 initially healthy women 45+ yrsReceive aspirin 100 mg or placebo monitored 10 years for major cardiovascular events
23 Death from cardiovascular causes 120 126 0.95 (0.74–1.22) 0.68Nonfatal (0.67–0.97) 0.02 (0.84–1.25) Fatal (0.54–2.51) 0.70 Nonfatal (0.83–1.24) 0.90 Death from cardiovascular causes (0.74–1.22) 0.68 End Point Aspirin (N=19,934) Placebo (N=19,942) P Value Stroke 221 266 0.04 Myocardial infarction 198 193 0.83
24 EBM Study course Research designsCritical appraisal: therapy, systematic review, diagnosis, prognosis Literature search Bias Diagnostic studies Randomization Measurement statistics for EBM Interim analyses / DSMB Economics analyses Qualitative research ethics / GCP Clinical trial registration Proposal writing / Manuscript writing
25 Objective Good Research Interim Analysis
26 Thewarug Werawatganon, MD Anesthesiology, Chulalongkorn UniversityFormulation of Research Question Thewarug Werawatganon, MD Anesthesiology, Chulalongkorn University
27 Question
28 careful study to find and report new knowledge
29 What is research? Previous knowledge Test hypothesis Reject / acceptNew knowledge What is research?
30 ประโยชน์ Position Honor Promotion Money Skill Knowledge GraduateImprovement
31 Research >>>….Development>>>…. Outcome Improvement
32 Example Nasotracheal intubation in ICU Oral hygeine careLess misplacement Comfortable
33 Nosocomial maxillary sinusitis during mechanical ventilation: a prospective comparison of orotracheal versus the nasotracheal route Intensive Care Med. 1990;16(6): Salord F, Gaussorgues P, Marti-Flich J, Sirodot M, Allimant C, Lyonnet D, Robert D.
34 A randomized study assessing the systematic search for maxillary sinusitis in nasotracheally mechanically ventilated patients. Influence of nosocomial maxillary sinusitis on the occurrence of ventilator-associated pneumonia. Am J Respir Crit Care Med Mar;159(3): Holzapfel L, Chastang C, Demingeon G, Bohe J, Piralla B, Coupry A.
35 Starting Point? Problem
36 Data Question Problem …Data
37 Starting Point? Problem >> Research Question
38 Research Question Work Read Think
39 Research Question
40 Research Question See Look Intelligence
41 Scope of Anesthesia General & Regional anesthesia Critical careRespiratory care Pain service Cardiopulmonary resuscitation
42 Aspect Basic science Clinical Health Service System Economic Analysis
43 Finding Advisor Friend Previous Study Pondering
44 Finding Topic of interest Explore Textbook & JournalThe most specific thought
45 Write Down The Research QuestionDefine research boundary clearly Suitable method to do
46 Evaluate The Research QuestionExist No clear answer Innovate Narrow focus Feasible Benefit Creating Not Destroying anyone Answerable by research
47 Example: Ventilator Associated PneumoniaWhat is the incidence of VAP?
48 Example: Ventilator Associated PneumoniaWhat is the incidence of VAP? What are the significant Risk factors for VAP?
49 Example: Ventilator Associated PneumoniaWhat is the incidence of VAP? What are the significant Risk factors for VAP? Is orotracheal is better than nasotracheal tube?
50 Example: Ventilator Associated PneumoniaWhat is the incidence of VAP? What are the significant Risk factors for VAP? Is orotracheal is better than nasotracheal tube? Can new mode ventilation prevent VAP?
51 Example: Ventilator Associated PneumoniaWhat is the incidence of VAP? What are the significant Risk factors for VAP? Is orotracheal is better than nasotracheal tube? Can new mode ventilation prevent VAP?
52 Example: Ventilator Associated PneumoniaWhat is the incidence of VAP? What are the significant Risk factors for VAP? Is orotracheal is better than nasotracheal tube? Can new mode ventilation prevent VAP? Does cuff material and design help prevent ventilator-associated pneumonia? Poelaert J. Chest Nov;142(5):1358-9
53 Reseach Title Concise Easy to Understand Interesting Modern
54 Title Format Written language Not exceed two lines Consisted ofPatient Intervention Comparison Outcome Orderly
55 Example Outcomes Using Lower vs Higher Hemoglobin Thresholds for Red Blood Cell Transfusion
56 Research How to success? Willing to learn and to doScientificThinking and Doing
57 คุณลักษณะที่พึงประสงค์ซื่อสัตย์ มีศีลธรรม ติดตามความรู้ ช่างคิด Scientific thinking and doing ทำจริงจัง
58 Skill Project Team Budget Data management IT Statistics
59 Comment & Question ?