Evidence based medical practise of Orthopedics

Evidence-based medicine (EBM) aims to apply the best available evidence gained from the scientific method to medical decision making. It seeks to assess the quality of evidence of the risks and benefits of treatments (including lack of treatment).

EBM recognizes that many aspects of medical care depend on individual factors such as quality- and value-of-life judgments, which are only partially subject to scientific methods. EBM, however, seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical treatment, even as debate continues about which outcomes are desirable

lIn past practice was based on loose bodies of knowledge.

lSome on the experiences of generations of practitioners

lMuch of it unscientific without evidence

lUse both individual clinical expertise and best available evidence.

lNeither alone is enough.

Without clinical expertise, practice become tyrannised

lEven excellent external evidence may be inapplicable to an individual patient

lWithout evidence, practice becomes out of date and detrimental to patients.

lEvidence-based medicine is not restricted to randomised trials and meta-analyses.

lIt involves tracking down the best external evidence with which to answer our clinical questions.

An approach to treatment rather than a specific treatment

lIndividualised clinical decisions for patients.

lPromotes collection, interpretation, and integration of valid, important and applicable patient-reported, clinician-observed, and research-derived evidence.

lThe best available evidence, moderated by patient circumstances and preferences

To improve the quality of clinical judgments and facilitate cost-effective care.

Integrate valid and useful evidence with clinical expertise

Enabling clinicians to apply evidence to the treatment of patients

Must always apply general medical knowledge and clinical judgement in assessing recommendations & it’s applicability in all circumstances

lIdentify your knowledge gap!!

lFormulate a clear clinical question..

lSearch the literature………………

lCritically appraise the articles for quality

lImplement useful findings into practice

Evaluate your performance using audit

lPrimary clinical question and Type of intervention.

Size of the sample.

Type of person included and excluded.

Type of control group used for comparison (ideally placebo).

How reliable is the methodology?

Outcome; how convincing ? Are the statistics (e.g. P value, confidence limits) impressive?

What is the rate of loss of follow-up during the study?

Association and causation are not the same

Type of outcome: QALY, DASH, SF36, scoring system

Systematic review is a literature review focused on a single question which tries to identify, select and synthesize all high quality research evidence relevant to that question

Meta-analysis is statistical analysis of the results of several RCT that address a research hypotheses

Guidelines: NICE, SIGN, National Library for Health, Professional bodies ( Royal Colleges).

lf no guidelines see for systematic reviews, e.g. Cochrane database.

lF no systematic reviews, look for primary research, e.g. PubMed.

lf no research is available, consider general internet search, e.g. Google, discuss with a local specialist (at this level beware poor quality information or individual personal bias from even the most respected specialist)

Ia: systematic review or meta-analysis of RCT

Ib: at least one RCT

IIa: at least one well-designed controlled study without randomisation

IIb: at least one well-designed quasi-experimental study, such as a cohort study

III: well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, case–control studies and case series

IV: expert committee reports, opinions and/or clinical experience of respected authorities

lA: at least one randomised controlled trial (1)

lB: well-conducted clinical studies but no RCT (2,3)

lC: evidence from expert committee reports or opinions and/ or clinical experience of respected authorities. This indicates absence of studies of good quality. (4)

Evidence grade:

lI (High): the described effect is plausible, precisely quantified and not vulnerable to bias

lII (Intermediate): the described effect is plausible but is not quantified precisely and may be vulnerable to bias

lIII (Low): concerns about plausibility or vulnerability to bias severely

Recommendation grade:

lA (Recommendation): there is robust evidence to recommend a pattern of care

lB (Provisional recommendation): on balance of evidence, a pattern of care is recommended with caution

lC (Consensus opinion): evidence being inadequate, a pattern of care is recommended by consensus

was the study original?

whom is the study about?

was the design of the study sensible?

was systematic bias avoided or minimised?

was the study large enough, and continued for long enough, to make the results credible?

conflict of interest? - pharmaceutical company