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lWithout evidence, practice becomes out of date and detrimental to patients.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.
lIntegrate valid and useful evidence with clinical expertise
lEnabling 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.
lSize of the sample.
lType of person included and excluded.
lType of control group used for comparison (ideally placebo).
lHow reliable is the methodology?
lOutcome; how convincing ? Are the statistics (e.g. P value, confidence limits) impressive?
lWhat is the rate of loss of follow-up during the study?
lAssociation and causation are not the same
lType of outcome: QALY, DASH, SF36, scoring system
lSystematic 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
lMeta-analysis is statistical analysis of the results of several RCT that address a research hypotheses
lGuidelines: NICE, SIGN, National Library for Health, Professional bodies ( Royal Colleges).
lIf no guidelines see for systematic reviews, e.g. Cochrane database.
lIf no systematic reviews, look for primary research, e.g. PubMed.
lIf 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)
lIa: systematic review or meta-analysis of RCT
lIb: at least one RCT
lIIa: at least one well-designed controlled study without randomisation
lIIb: at least one well-designed quasi-experimental study, such as a cohort study
lIII: well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, case–control studies and case series
lIV: 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)
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
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
lwas the study original?
lwhom is the study about?
lwas the design of the study sensible?
lwas systematic bias avoided or minimised?
lwas the study large enough, and continued for long enough, to make the results credible?
lconflict of interest? - pharmaceutical company