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    Use of EBM in Developing CPG

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    Hilma Nadhifa
    Use of EBM in Developing Clinical Practice Guidelines Evidence-based medicine (EBM) involves using the best available evidence from scientific research to guide medical decisions. EBM follows several steps: formulating answerable clinical questions, searching for and critically appraising relevant evidence, and applying the evidence to individual patients. Clinical practice guidelines are recommendations for optimal care based on systematic reviews of the evidence. Developing high-quality guidelines requires explicitly documenting the methodology, evidence reviewed, findings, and recommendations. EBM aims to improve outcomes by promoting interventions that are most likely to benefit patients based on the available scientific data.

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    Use of EBM in Developing CPG

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    Hilma Nadhifa
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    Use of EBM in Developing Clinical Practice Guidelines Evidence-based medicine (EBM) involves using the best available evidence from scientific research to guide medical decisions. EBM follows several steps: formulating answerable clinical questions, searching for and critically appraising relevant evidence, and applying the evidence to individual patients. Clinical practice guidelines are recommendations for optimal care based on systematic reviews of the evidence. Developing high-quality guidelines requires explicitly documenting the methodology, evidence reviewed, findings, and recommendations. EBM aims to improve outcomes by promoting interventions that are most likely to benefit patients based on the available scientific data.

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    Use of EBM in Developing CPG (1)

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    Use of EBM in Developing Clinical Practice Guidelines Evidence-based medicine (EBM) involves using the best available evidence from scientific research to guide medical decisions. EBM follows several steps: formulating answerable clinical questions, searching for and critically appraising relevant evidence, and applying the evidence to individual patients. Clinical practice guidelines are recommendations for optimal care based on systematic reviews of the evidence. Developing high-quality guidelines requires explicitly documenting the methodology, evidence reviewed, findings, and recommendations. EBM aims to improve outcomes by promoting interventions that are most likely to benefit patients based on the available scientific data.

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    Download as ppt, pdf, or txt
    130 views50 pages

    Use of EBM in Developing CPG

    Uploaded by

    Hilma Nadhifa
    Use of EBM in Developing Clinical Practice Guidelines Evidence-based medicine (EBM) involves using the best available evidence from scientific research to guide medical decisions. EBM follows several steps: formulating answerable clinical questions, searching for and critically appraising relevant evidence, and applying the evidence to individual patients. Clinical practice guidelines are recommendations for optimal care based on systematic reviews of the evidence. Developing high-quality guidelines requires explicitly documenting the methodology, evidence reviewed, findings, and recommendations. EBM aims to improve outcomes by promoting interventions that are most likely to benefit patients based on the available scientific data.

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    Use of EBM in Developing Clinical Practice Guidelines

    Kuntjoro Harimurti
    Department of Internal Medicine Center for Clinical Epidemiology and Evidence-Based Medicine Faculty of Medicine UI / Cipto Mangunkusumo Hospital Jakarta

    What is EBM?
    Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. - David Sackett -

    Evidence-based Medicine
    Evidence-based Medicine

    Gathering medical information

    Evaluating quality of medical information

    Making medical decisions using best evidence

    The EBM Paradigm


    Patient with problem

    Apply the evidence

    Formulate in answerable question

    Critically appraise the evidence

    Search the evidence

    Elements of EBM - identify relevant best evidence


    Define clinical question to be answered (for a specific clinical situation)
    Find best scientific evidence relevant to the specific clinical question (using systematic methods) Rely on best evidence to guide clinical decisionmaking

    Elements of EBM - identify relevant best evidence


    Original evidence clinical epidemiology (e.g. clinical trials) descriptive epidemiology outcomes research / economic studies Literature synthesis / analysis systematic literature reviews / meta-analyses

    clinical practice guidelines


    cost-effectiveness studies

    Elements of EBM - focus on clinical outcomes


    Clinical outcomes (things that matter to patients and families) survival impairment / disability / disfigurement symptom severity quality of life (QOL) cost / convenience

    Elements of EBM - use standard measures of effect


    Evaluate therapies using standard measures: How does it affect rate, degree or timing of:
    Physical impairment, disfigurement or death Return to normal functioning Symptom resolution Potential harms (from therapy) Total costs (for patient, employer and society)

    Allows comparisons of benefits and harms of different clinical methods

    Elements of EBM - assess likely benefits / harms


    Evaluate clinical methods on benefits / harms
    Beneficial Likely to be beneficial Trade off between benefits and harms Unknown effectiveness Unlikely to be beneficial Likely to be ineffective or harmful

    Promotes informed decision-making by clinicians and patients

    Elements of EBM - base decisions on best evidence


    Find best scientific evidence that is applicable to the specific clinical situation
    individual patients clinical situation program or policy decision

    Use evidence to guide decision-making


    does the likelihood of benefit outweigh likelihood of harm enough to justify the cost? same question applies to individual and society

    EBM is important because provides a science-based method for


    Improving physician practice
    increase effectiveness / decrease harms (better clinical outcomes / cost-effectiveness)

    Increasing consumer knowledge


    understand potential benefits / harms

    Building quality into healthcare systems


    using practice guidelines, quality indicators

    Guiding government / employer policies


    guide programs / policies on healthcare

    What are clinical practice guidelines?


    Clinical practice guidelines are recommendations for clinicians and consumers about optimal and

    appropriate care for specific clinical situations

    Formal or informal guidelines are the basis for all clinical practice
    Basis for most clinical decisions Foundation of clinical teaching

    Mental short-cuts and memory aids for common or complex problems


    Primary method to evaluate care patterns and monitor standards of care

    When are guidelines needed ?


    Institute of Medicine (IOM) criteria clinical practice guidelines are useful when: the problem is common or expensive there is great variation in practice patterns there is enough scientific evidence to determine appropriate and optimal care

    (IOM , 1992)

    Types of guideline development approaches


    Single author - expert opinion
    Single author - systematic literature review Consensus panel using expert opinion only Consensus panel using evidenced-based approach

    Steps in developing guideline recommendations


    define clinical questions of interest develop summary of evidence on:
    clinical efficacy (potential benefits) potential harms / projected costs

    weigh likelihood of benefit versus likelihood of harms, and consider costs develop finding / recommendation statements document all aspects of the process

    Evidence-based guidelines - need to explicitly document


    methodology and assumptions evidence reviewed summary of findings decision-making rules for recommendations rationale for each conclusion and recommendation statement

    Types of guideline statements


    Based on AHCPR guidelines, the types of guideline statements are: Recommendation for use Option for use Recommendation against use

    Strength of evidence ratings for guideline recommendations


    A = Strong research based evidence
    multiple relevant, high quality studies

    B = Moderate research based evidence


    one relevant, high quality study

    C = Limited research based evidence


    one adequate study, somewhat relevant

    D = Panel opinion
    based on information not meeting criteria for A-C

    Steps in EBM practice


    Formulate clinical problems in answerable questions 2. Search the best evidence: use internet or other onVIA line database for current evidence 3. Critically appraise the evidence for Validity (was the study valid?) Importance (were the results clinically important?) Applicability (could we apply to our patient?) 4. Apply the evidence to patient 5. Evaluate our performance
    1.

    Main area
    Diagnosis (Determination of disease or problem) Treatment (Intervention necessary to help the patient)
    Prognosis (Prediction of the outcome of the disease)

    Others:
    Meta-analysis Clinical guidelines Economic analysis Clinical decision making Cost-effectiveness analysis Qualitative research

    (I) Formulating clinical questions

    Four elements of good clinical question: PICO


    The Patient or Problem The Intervention Comparative intervention (if relevant) The Outcome

    Four elements of a well constructed clinical question: PICO


    P I C O

    The Outcome Description The main of patient intervention alternative expected or problem considered to compare from this with the intervention? intervention
    B e b r i e f a n d s p e c i f i c

    Relevance: Type of Evidence


    POE: Patient-oriented evidence
    mortality, morbidity, quality of life DOE: Disease-oriented evidence pathophysiology, pharmacology, etiology

    Comparing DOES and POEMs


    Example DOE
    Drug A PVC On ECG

    POEM
    Drug A > mortality Drug X mortality

    Comment
    DOE & POEM contradicts

    Antiarrhythmic Therapy
    Antihypertens. Therapy Prostate screening

    Drug X BP

    POEM agrees With DOE

    PSA screening detects prostate Ca. early

    ? whether PSA screening mortality

    DOE exists, but POEM unknown

    II Searching the evidence

    Online Medical Information Resource


    Resource Google Scholar MedlinePubmed emedicine Medscape Medical Matrix Clinical practice guidelines MD consult UpToDate Best Evidence
    18:24

    Internet address http://scholar.google.com.br/ www.ncbi.nlm.nih.gov/PUBMED www.emedicine.com www.medscape.com www.medmatrix.org/index.asp www.guidelines.gov www.cma.caa/cpgs www.mdconsult.com

    Annual Cost Free Free Free Free Free Free Free $200

    www.Uptodate.com $495 www.acponline.org/catalog/electronic/best_evidence.htm $85


    EBM Searching

    Step Searching in PubMed


    1. 2. 3. Formulate a focused PICO question. Define keywords. Identify the type of article that is most likely to answer your question: therapy, diagnosis, harm, etc. 4. Identify the design that is most likely to answer your question: RCT, cohort, cross sectional, case control, etc. 5. Always try to find systematic reviews. 6. Use MeSH or Thesaurus or text words for searching 7. Combine concepts with Boolean operators (AND/OR/NOT). 8. Limiting to age, sex, language, year of publication, etc. 9. Evaluate search results. 10. Use "Related Articles" link option.

    Types of study
    Question
    Intervention Etiology and risk factor

    Best study design


    Randomised controlled trial (RCT) RCT Cohort study Case-control study Cohort study Cross-sectional study Cross-sectional study with random or consecutive sample Cohort/survival study

    Frequency and rate Diagnosis Prognosis and prediction

    Boolean operators
    AND

    OR

    NOT

    Strategy of using Boolean operators: first increase sensitivity, then specificity


    1. 2. 3. 4. 5. 6. 7. 8. 9. 10. One keyword concerning the patient Another keyword concerning the patient #1 OR #2 One keyword concerning the intervention Another keyword concerning the intervention #4 OR #5 One keyword concerning the outcome Another keyword concerning the outcome #7 OR #8 #3 AND #6 AND #9

    Answerable question - PICO


    Patient or Problem
    Description of the patient or the target disorder of interest questions

    Intervention

    Comparison Intervention

    Outcome

    Could include: Relevant most often Clinical outcome of Exposure when looking at interest to you and Diagnostic test therapy your patient Prognostic factor Therapy Patient perception etc.

    Centre for Evidence-Based Medicine; http://www.cebm.utoronto.ca

    Answerable question - PICO


    P Population/patients
    In elderly patients with hypertension,

    Intervention/indicator
    does the ACE-inhibitors use

    C Comparator
    compared to other hypertension treatment

    O Outcome
    will reduce cardiovascular-related mortality/morbidity?

    Effective searchinguse PI(C)O!


    AND AND

    Patients Elderly OR OR OR Older people Geriatric

    Intervention ACE-inhibitors ACE-i Angiotensinconverting enzymes

    Outcome Death Stroke Myocardial infarction

    Senior

    Clinical problem Define important, searchable question Select most likely resource Select second most likely resource

    General search strategy

    Design search strategy


    Summarized the evidence Apply the evidence Poor yield

    Design search strategy


    Summarized the evidence

    III Appraising the evidence: VIA

    VIA
    Validity: In Methods section: design, sample, sample size, eligibility criteria (inclusion, exclusion), sampling method, randomization method, intervention, measurements, methods of analysis, etc Importance: In Results section characteristics of subjects, drop out, analysis, p value, confidence intervals, etc Applicability: In Discussion section + our patients characteristics, local setting

    Example: Critical appraisal Diagnostic Test


    Was there an independent, blinded comparison with a gold standard? Was the test evaluated in an appropriate spectrum of patients? Was the reference standard applied regardless of the test result? Was the test validated in a second, independent group of patients? Calculate sensitivity, specificity, positive and negative predictive value, likelihood ratio

    Example: Critical appraisal for therapy


    Were the subjects randomized? Were all subjects received similar treatment? Were all relevant outcomes considered? Were all subjects randomized included in the analysis? Calculate CER, EER, RRR, ARR, and NNT Were study subjects similar to our patients in terms of prognostic factors?

    Translating evidence into a clinical practice guideline


    Using and gathering opinion
    Will be used to interpret evidence and to derive recommendation in the absence of evidence To assess issue such as generalisability of evidence

    Resource implications and feasibility


    Different view of implication among clinician and healthcare providers Feasibility issues: time, skills, staffs, equipment

    Grading recommendation
    Provide user a confidence that following guideline will produce the desired health outcome Strength of recommendation classification: range from simple to complex

    Weight of Scientific Scrutiny

    Hierarchy of evidence
    Meta-analysis of RCT
    Level 1

    Rec A

    Large RCT
    Small RCT
    Level 2

    Non-Randomized trials
    Observational studies Case series / reports Anecdotes, expert, consensus
    Level 4 Level 3

    Suggestions in developing guidelines


    Making the goals of each guideline explicitfor example, effectiveness, cost effectiveness, equity Providing information on the reasons for disagreements within a guideline development groupsuch as, differences in interpretation of the research literature, differences in personal experience, different perceptions of or responses to costs Publishing information on the closeness of agreement about a recommendation as well as the strength of support for a recommendation.

    Updating clinical guideline


    Situations might require clinical guidelines to be updated:
    Changes in evidence on the existing benefits and harms of interventions Changes in outcomes considered important Changes in available interventions Changes in values placed on outcomes Changes in resources available for health care

    Thank you

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