Evidence-Based Medicine Introduction



welcome to the evidence-based practice course sponsored by the UIC library of the Health Sciences the story of evidence-based medicine started in the 1970s with a group of clinical epidemiologists at McMaster University led by David Sackett and Brian Haines who published a series of articles advising clinicians on how to read clinical journals this series on critical appraisal appeared in the Canadian Medical Association Journal in 1980 the term EBM first appeared in print in 1991 in the ACP journal club the term was coined by Gordon Guyot who was the internal medicine residency director at McMaster where he and Sackett introduced the concept of EBM as both a philosophy of medical practice and medical education the McMaster group eventually linked up with other physicians to form the first EBM working group this group produced a new series of articles to promote a more practical approach to applying the medical literature to clinical practice this 25 part series called the users guide to the medical literature was first published in JAMA and later as a book one of the enduring definitions of EBM comes from the book evidence-based medicine how to practice and teach EBM now a classic text which has gone through several editions Sackett and all defined EBM as the integration of best research evidence with clinical expertise and patient values this definition clearly emphasizes that what we learn from the research reported in the medical literature is only one third of the picture just as important is the clinical experience of the health professional and the Preferences of the individual patient it wasn't long until other health practitioners began to realize that the principles of EBM were equally applicable to nurses dentists and others terms such as evidence-based health care and evidence-based practice are more appropriate to cover the whole spectrum but EBM seems to have stuck as the generic term used to describe the process IBM became a mesh term in 1997 and it wasn't until 2009 that other EBP terms were introduced the EDM process is described in five steps which involves one converting information needs into focused clinical questions to efficiently tracking down the best evidence with which to answer the question three critically appraising the evidence for validity and clinical usefulness for applying the results in clinical practice and five evaluating performance of the evidence and clinical application during this course we will be examining the elements of these five steps and focusing on the skills needed for the first three steps of the process another definition from the EBM working group concentrated on EBM as an education process as well as a patient care process this definition describes EBM as a lifelong self-directed learning process in which the clinician uses information to solve clinical problems in practice IBM was born out of the demands of a changing health information environment from 1957 to 1963 the NIH budget increased by an average of 40 percent annually resulting in an explosion of medical knowledge and article publication at the same time technical logical capabilities were expanding which made possible vast search searchable databases and the National Library of Medicine created MEDLINE to provide better access to the medical literature and to help health practitioners deal with the overload of new clinical information in the 1950s a medical student might graduate knowing perhaps 80% of what there was to know now graduates might know 40% half of which will probably be out of date in just 10 years Alper at all found that to keep up with the estimated 7,000 articles published monthly in primary care it would take a physician 29 hours per work day or the equivalent of 3.6 FTE a physician effort studies have shown that it takes an average of 17 years to implement clinical research studies fully into general practice reducing the time and effort that it takes research to translate into practice is one of the goals or outcomes of EBP while a 1988 study showed that patients with acute MI who were treated with streptokinase and an aspirin had significantly less mortality we find a 1999 study which found that patients presenting to an ER with MI only 55% two aspirin so even when high quality relevant evidence exists it can remain invisible a newer definition in the evolution of EBM refers specifically to the role of Technology in the mid-1990s PubMed became freely available on the Internet this free access to the database gave more health professionals and ever exposure to a vast array of medical literature now that many medical libraries offer online full-text access to journal articles health professionals have immediate access to much of the world's medical literature this has truly produced information overload along with the expectation that every health professional should be up to date on any medical problem that comes along yet we know that some clinicians don't regularly consult the literature what is the biggest barrier time these two elements information explosion and lack of time has led to some EBM by products or tools that attempt to provide synthesized and evaluated summaries of clinically relevant studies at the highest levels of evidence these tools include systematic reviews meta analyses clinically focused search strategies and specialized databases we will we will be learning more about these tools later in the course in addition to McMaster University in Canada other important early leaders were and continue to be active and EBP efforts these include the agency for Healthcare Research and quality in the United States and the Center for evidence-based medicine in the United Kingdom today the ahrq has 14 designated EVP centres the charge of these centers is to synthesize scientific evidence to improve quality and effectiveness in health care the websites of these organizations especially the CBM offer a wealth of resources and tools many of which we will introduce in this course in closing let's address the misconception that EBP is just about statistics and algorithms in reality EBP begins and ends with the individual clinician treating the individual patient the clinician extracts the information from the study evaluates the findings of the study in the context of his or her clinical judgment and finally considers the needs of the individual patient in deciding how to apply the evidence this concludes this presentation

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