BOOK
Evidence-Based Medicine E-Book
Sharon E. Straus | Paul Glasziou | W. Scott Richardson | R. Brian Haynes
(2018)
Additional Information
Book Details
Abstract
Now in its fifth edition, this classic introduction to the practice and teaching of evidence-based medicine is written for busy clinicians at any stage of their career who want to learn how to practise and teach evidence-based medicine (EBM). It is short and practical, emphasizing direct clinical application of EBM and tactics to practise and teach EBM in real-time.
The online toolkit includes Critical appraisal worksheets, Educational prescription, Pocket Cards, EBM calculators, Educational Prescriptions, Clinical Questions log, Self evaluations.
- Thoroughly updated with examples from latest evidence/studies.
- Revised electronic ancillaries, now available online
- Expanded coverage of audit and measuring quality improvement.
- Teaching moments now indexed for easy reference.
- New contributing authors Reena Pattani and Areti Angeliki Veroniki
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | cover | ||
| Inside Front Cover | ifc1 | ||
| Half title page | i | ||
| Dedication | ii | ||
| Evidence-Based Medicine | iii | ||
| Copyright Page | iv | ||
| Table Of Contents | v | ||
| Contents of EBM Toolbox | vi | ||
| Index of Teaching Moments | vii | ||
| Preface | ix | ||
| Acknowledgements | xii | ||
| Introduction | 1 | ||
| What is evidence-based medicine? | 1 | ||
| Why the interest in EBM? | 1 | ||
| Why the need for a new edition of this book? | 4 | ||
| How do we practise EBM? | 4 | ||
| Can clinicians practise EBM? | 6 | ||
| What’s the “E” in EBM? | 7 | ||
| What are the limitations of EBM? | 9 | ||
| How is this resource organized? | 10 | ||
| References | 11 | ||
| 1 Asking answerable clinical questions | 19 | ||
| Background and foreground questions | 21 | ||
| Our reactions to knowing and to not knowing | 23 | ||
| Where and how clinical questions arise | 24 | ||
| Practising evidence-based medicine in real time | 26 | ||
| Why bother formulating questions clearly? | 27 | ||
| Teaching questions for EBM in real time | 29 | ||
| References | 33 | ||
| 2 Acquiring the evidence | 35 | ||
| Orientation to evidence-based information resources: where to find the best evidence | 36 | ||
| Treat traditional textbooks as if they were long past their “best before” date | 36 | ||
| Take a “P5” approach to evidence-based information access | 40 | ||
| Systems | 40 | ||
| The ideal | 40 | ||
| The present state of evolution | 42 | ||
| Synthesized summaries for clinical reference (online, evidence-driven, clinical textbooks) | 42 | ||
| Systematically derived recommendations (evidence-based guidelines) | 43 | ||
| Systematic reviews (syntheses) | 44 | ||
| Studies | 45 | ||
| Synopsis | 45 | ||
| Evidence-based meta-search services | 46 | ||
| General search engines | 46 | ||
| Organize access to evidence-based information services | 47 | ||
| Is it time to change how you seek best evidence? | 49 | ||
| How to deal with the evidence that finds US (“push” evidence): keeping up to date efficiently | 50 | ||
| Cancel our full-text journal subscriptions | 50 | ||
| Invest in evidence-based journals and online evidence services | 50 | ||
| Walking the walk: searching for evidence to solve patient problems | 51 | ||
| Carrying out the searching steps | 54 | ||
| Problems | 54 | ||
| Asking answerable questions | 54 | ||
| Selecting an evidence resource | 55 | ||
| Where to find the best evidence on interventions | 56 | ||
| Executing the search strategy | 57 | ||
| BMJ Best Practice (http://bestpractice.bmj.com) | 57 | ||
| DynaMed Plus | 57 | ||
| EBM Guidelines | 58 | ||
| UpToDate (www.uptodate.com) | 59 | ||
| Systematically derived recommendations (evidence-based guidelines) | 60 | ||
| Studies | 60 | ||
| What about traditional textbooks of medicine? | 61 | ||
| Examining the evidence | 62 | ||
| Applying the evidence | 62 | ||
| Other ways to find evidence | 63 | ||
| References | 63 | ||
| 3 Appraising the evidence | 67 | ||
| Further reading | 69 | ||
| 4 Therapy | 71 | ||
| Reports of individual studies | 72 | ||
| Are the results of this individual study valid? | 74 | ||
| 1. Was the assignment of patients to treatment randomized? | 74 | ||
| 2. Was the randomization concealed? | 78 | ||
| 3. Were the groups similar at the start of the trial? | 79 | ||
| 4. Was follow-up of patients sufficiently long and complete? | 79 | ||
| 5. Were all patients analyzed in the groups to which they were randomized? | 82 | ||
| 6. Were patients, clinicians, and study personnel kept blind to treatment? | 83 | ||
| 7. Were groups treated equally, apart from the experimental therapy? | 84 | ||
| Putting it all together | 85 | ||
| Are the valid results of this individual study important? | 85 | ||
| 1. What is the magnitude of the treatment effect? | 86 | ||
| 2. How precise is this estimate of the treatment effect? | 96 | ||
| Practising evidence-based medicine in real time: calculating the measures of treatment effect—a shortcut | 98 | ||
| Practising EBM in real time: using preappraised evidence | 99 | ||
| Are the valid, important results of this individual study applicable to our patient? | 101 | ||
| 1. Is our patient so different from those in the study that its results cannot apply? | 102 | ||
| 2. Is the treatment feasible in our setting? | 103 | ||
| 3. What are the potential benefits and harms from the therapy to our patient? | 104 | ||
| The long way, via PEER | 104 | ||
| 4. How can we present this information to the patient in a way that can support shared decision making? What are our patient’s values and expectations for both the outcome we are trying to prevent and the treatment we are offering? | 107 | ||
| Practising EBM in real time: preappraised literature for patients | 109 | ||
| Further reading about individual randomized trials | 112 | ||
| Reports of systematic reviews | 112 | ||
| Are the results of this systematic review valid? | 114 | ||
| 1. Is this a systematic review of randomized trials? | 114 | ||
| 2. Does it describe a comprehensive and detailed search for relevant trials? | 114 | ||
| 3. Were the individual studies assessed for validity? | 115 | ||
| 4. Were individual patient data (or aggregate data) used for the analysis? | 117 | ||
| Are the valid results of this systematic review important? | 117 | ||
| 1. Are the results consistent across studies? | 117 | ||
| 2. What is the magnitude of the treatment effect? | 119 | ||
| Are the valid, important results of this systematic review applicable to our patient? | 121 | ||
| Further reading about systematic reviews | 124 | ||
| A few words on qualitative literature | 124 | ||
| Are the results of this qualitative study valid? | 125 | ||
| 1. Was the selection of participants explicit and appropriate? | 125 | ||
| 2. Were the methods used for data collection and analysis explicit and appropriate? | 126 | ||
| Are the valid results of this qualitative study important? | 126 | ||
| 1. Are the results impressive? | 126 | ||
| Are the valid, important results of this qualitative study applicable to our situation? | 127 | ||
| 1. Do we think these same phenomena apply to our patient/participant? | 127 | ||
| Further reading about individual randomized trials and qualitative studies | 128 | ||
| Reports of clinical decision analyses | 128 | ||
| Are the results of this CDA valid? | 131 | ||
| Are the valid results of this CDA important? (Box 4.12) | 132 | ||
| Are the valid, important results of this CDA applicable to our patient? (Box 4.13) | 133 | ||
| Further reading about clinical decision analysis | 133 | ||
| Reports of economic analyses | 134 | ||
| Are the results of this economic analysis valid? | 135 | ||
| Are the valid results of this economic analysis important? | 137 | ||
| Are the valid, important results of this economic analysis applicable to our patient/practice? | 137 | ||
| Further reading about economic analysis | 138 | ||
| Reports of clinical practice guidelines | 138 | ||
| Are the results of this practice guideline valid? (Box 4.18) | 140 | ||
| Is this valid guideline applicable to my patient/practice/hospital/community? | 142 | ||
| n-of-1 trials | 145 | ||
| Further reading about n-of-1 trials | 147 | ||
| References | 148 | ||
| 5 Diagnosis and screening | 153 | ||
| What is normal or abnormal? | 157 | ||
| Is this evidence about the accuracy of a diagnostic test valid? | 158 | ||
| 1. Representative: Was the diagnostic test evaluated in an appropriate spectrum of patients (e.g., those in whom we would use it in practice)? | 159 | ||
| 2. Ascertainment: Was the reference standard ascertained regardless of the diagnostic test’s result? | 160 | ||
| 3. Measurement: Was there an independent, blind comparison with a reference (“gold”) standard? | 160 | ||
| Does this (valid) evidence demonstrate an important ability of this test to accurately distinguish patients who do and don’t have a specific disorder? | 161 | ||
| Sensitivity, specificity, and likelihood ratios | 163 | ||
| Can the test rule in or rule out? | 165 | ||
| How can I apply this valid, important diagnostic test to a specific patient? | 166 | ||
| 1. Is the diagnostic test available, affordable, accurate, and precise in our setting? | 167 | ||
| 2. Can we generate a clinically sensible estimate of our patient’s pretest probability? | 168 | ||
| 3. Will the resulting posttest probabilities affect our management and help our patient? | 170 | ||
| More extreme results are more persuasive | 173 | ||
| Multiple tests | 176 | ||
| 4. Was the cluster of tests validated in a second, independent group of patients? | 176 | ||
| Practising evidence-based medicine in real time | 177 | ||
| Screening and case finding—proceed with caution! | 177 | ||
| 1. Is there RCT evidence that early diagnosis really leads to improved survival, quality of life, or both? | 178 | ||
| 2. Are the early diagnosed patients willing partners in the treatment strategy? | 181 | ||
| 4. Do the frequency and severity of the target disorder warrant the degree of effort and expenditure? | 181 | ||
| References | 182 | ||
| Further reading | 183 | ||
| 6 Prognosis | 185 | ||
| Types of reports on prognosis | 186 | ||
| Are the results of this prognosis study valid? | 187 | ||
| 1. Was a defined, representative sample of patients assembled at a common point in the course of their disease? | 187 | ||
| 2. Was the follow-up of the study patients sufficiently long and complete? | 189 | ||
| 3. Were objective outcome criteria applied in a blind fashion? | 191 | ||
| 4. If subgroups with different prognoses are identified, was there adjustment for important prognostic factors and validation in an independent group of “test set” patients? | 192 | ||
| Is this valid evidence about prognosis important? (Box 6.2) | 195 | ||
| 1. How likely are the outcomes over time? | 195 | ||
| 2. How precise are the prognostic estimates? | 196 | ||
| Can we apply this valid, important evidence about prognosis to our patient? (Box 6.3) | 197 | ||
| 1. Is our patient so different from those in the study that its results cannot apply? | 197 | ||
| 2. Will this evidence make a clinically important impact on our conclusions about what to offer or tell our patient? | 198 | ||
| Practising evidence-based medicine in real time | 198 | ||
| References | 199 | ||
| Further reading | 199 | ||
| 7 Harm | 201 | ||
| Types of reports on harm/etiology | 202 | ||
| Are the results of this harm/etiology study valid? | 203 | ||
| 1. Were there clearly defined groups of patients, similar in all important ways other than exposure to the treatment or other cause? | 203 | ||
| 2. Were treatments/exposures and clinical outcomes measured in the same ways in both groups? (Was the assessment of outcomes either objective or blinded to exposure?) | 208 | ||
| 3. Was the follow-up of the study patients sufficiently long (for the outcome to occur) and complete? | 209 | ||
| 4. Do the results of the harm study satisfy some of the diagnostic tests for causation? | 210 | ||
| Is it clear that the exposure preceded the onset of the outcome? | 210 | ||
| Is there a dose–response gradient? | 210 | ||
| Is there any positive evidence from a “dechallenge–rechallenge” study? | 210 | ||
| Is the association consistent from study to study? | 211 | ||
| Does the association make biological sense? | 211 | ||
| Are the valid results of this harm study important? | 211 | ||
| 1. What is the magnitude of the association between the exposure and outcome? | 211 | ||
| Practising and teaching EBM in real time | 215 | ||
| 2. What is the precision of the estimate of the association between the exposure and outcome? | 216 | ||
| Can this valid and important evidence about harm be applied to our patient? | 217 | ||
| 1. Is our patient so different from those included in the study that its results cannot apply? | 217 | ||
| 2. What are our patient’s risks of benefit and harm from the agent? | 218 | ||
| 3. What are our patient’s preferences, concerns, and expectations from this treatment? | 218 | ||
| 4. What alternative treatments are available? | 219 | ||
| Practising and teaching EBM in real time | 219 | ||
| References | 221 | ||
| Further reading | 222 | ||
| 8 Evaluation | 223 | ||
| How am I doing? | 223 | ||
| Evaluating our performance in asking answerable questions | 223 | ||
| Evaluating our performance in searching | 224 | ||
| Evaluating our performance in critical appraisal | 225 | ||
| Evaluating our performance in integrating evidence and patients’ values | 226 | ||
| Is our practice improving? | 227 | ||
| How much of our practice is evidence based? | 230 | ||
| Evaluating our performance as teachers | 231 | ||
| Who are the “patients”? | 232 | ||
| What is the intervention (and the control manoeuvre)? | 233 | ||
| What are the relevant outcomes? | 233 | ||
| References | 235 | ||
| Further reading | 236 | ||
| 9 Teaching evidence-based medicine | 237 | ||
| Three modes of teaching EBM | 237 | ||
| Teaching EBM—top 10 successes | 240 | ||
| 1. When it centres on real clinical decisions and actions | 240 | ||
| 2. When it focuses on learners’ actual learning needs | 240 | ||
| 3. When it balances passive (“diastolic”) with active (“systolic”) learning | 241 | ||
| 4. When it connects “new” knowledge to “old” (what learners already know) | 241 | ||
| 5. When it involves everyone on the team | 241 | ||
| 6. When it attends to all four domains of learning—affective, cognitive, conative, and psychomotor | 242 | ||
| 7. When it matches, and takes advantage of, the clinical setting, available time, and other circumstances | 243 | ||
| 8. When it balances preparedness with opportunism | 243 | ||
| 9. When it makes explicit how to make judgements, whether about the evidence itself or about how to integrate evidence with other knowledge, clinical expertise, and patient preferences and circumstances | 244 | ||
| 10. When it builds learners’ lifelong learning abilities | 244 | ||
| Teaching EBM—top 10 failures | 245 | ||
| 1. When learning how to do research is emphasized over how to use it | 245 | ||
| 3. When teaching EBM is limited only to finding flaws in published research | 245 | ||
| 5. When teaching with or about evidence is disconnected from the team’s learning needs about either their patients’ illnesses or their own clinical skills | 246 | ||
| 6. When the amount of teaching exceeds the available time or the learners’ attention | 246 | ||
| 8. When the teacher strives for full educational closure by the end of each session, rather than leaving plenty to think about and learn between sessions | 247 | ||
| 9. When it humiliates learners for not already knowing the “right” fact or answer | 247 | ||
| Teaching and learning EBM on an inpatient service | 248 | ||
| Teaching and learning EBM in the outpatient clinic | 253 | ||
| Writing structured summaries of evidence-based learning episodes | 256 | ||
| Incorporating EBM into existing educational sessions | 258 | ||
| Morning report | 258 | ||
| Journal club | 262 | ||
| Integrating EBM into a curriculum | 267 | ||
| Integrating EBM into 4-year medical school curriculum— a worked example, | 271 | ||
| Year 1 | 271 | ||
| Year 2 | 272 | ||
| Year 3 | 273 | ||
| Year 4 | 274 | ||
| Learning more about how to teach EBM | 274 | ||
| Tips for teaching EBM in clinical teams and other small groups | 275 | ||
| Help team/group members understand why to learn in small groups | 275 | ||
| Help team/group members set sensible ground rules for small group learning | 276 | ||
| Help team/group members plan the learning activities wisely | 278 | ||
| Help team/group members keep a healthy learning climate | 280 | ||
| Help team/group members keep the discussion going | 281 | ||
| Help team/group members keep the discussion on track | 281 | ||
| Help team/group members manage time well | 282 | ||
| Help team/group members address some common issues in learning EBM jargon | 283 | ||
| Quantitative study results | 283 | ||
| Statistics | 284 | ||
| Help team/group members identify and deal with counterproductive behaviours | 285 | ||
| Nihilism | 285 | ||
| Discussion tangents | 286 | ||
| A dominating overparticipator | 287 | ||
| A quiet nonparticipator | 288 | ||
| Help team/group members prepare for using EBM skills “back home” | 288 | ||
| References | 289 | ||
| Appendix 1 Glossary | 299 | ||
| Terms you are likely to encounter in your clinical reading | 299 | ||
| Terms specific to treatment effects | 303 | ||
| When the experimental treatment reduces the probability of a bad outcome (worsening diabetic retinopathy) | 303 | ||
| When the experimental treatment increases the probability of a good outcome (satisfactory hemoglobin A1c levels) | 304 | ||
| When the experimental treatment increases the probability of a bad outcome (episodes of hypoglycemia) | 304 | ||
| How to calculate likelihood ratios (LRs) | 305 | ||
| Sample calculation | 306 | ||
| Calculation of odds ratio/relative risk | 308 | ||
| Appendix 2 Confidence intervals | e1 | ||
| Statistical inference | e1 | ||
| Calculating confidence intervals | e3 | ||
| Multiple estimates of treatment effect | e8 | ||
| Confidence intervals in meta-analysis | e9 | ||
| Fixed-effect meta-analysis model | e10 | ||
| Random-effects meta-analysis model | e11 | ||
| Inference for the summary treatment effect | e13 | ||
| Clinical significance section | e14 | ||
| Comment | e14 | ||
| References | e15 | ||
| Index | 309 | ||
| A | 309 | ||
| B | 310 | ||
| C | 310 | ||
| D | 312 | ||
| E | 313 | ||
| F | 314 | ||
| G | 314 | ||
| H | 315 | ||
| I | 315 | ||
| J | 316 | ||
| K | 316 | ||
| L | 316 | ||
| M | 316 | ||
| N | 317 | ||
| O | 317 | ||
| P | 318 | ||
| Q | 319 | ||
| R | 319 | ||
| S | 321 | ||
| T | 322 | ||
| U | 323 | ||
| V | 323 | ||
| W | 324 | ||
| Y | 324 | ||
| Inside Back Cover | ibc1 |