, old hat (a dangerous innovation)

堃 2008.11.06

EBM 2008/05/30

ex. NNT NNH meta-analysis intention to treat Cochrane collaboration

~Dr. Sydney Burwell (1956 Dean, Harvard Medical School)

History of EBM The term EBM may be new and is being actively taught in medical schools, but the concept has been around for a long time. EBM

History of EBM Ancient era, Renaissance era (17th century) Bloodletting, Scurvy Transitional era (1900 1970s) randomized controlled trials (RCTs) Modern era (1970s~) Archie Cochrane ( Effectiveness and efficiency: random reflections on health services. 1972), David Sackett (World J. Surg. 29, 547 553 (2005) DOI: 10.1007/s00268-005-7910-1 )

Ben Cao Tu Jing (1061). (Atlas of Materia Medica). Song Dynasty (960-1279). Translation: It was said that in order to evaluate the effect of genuine Shangdang ginseng, two persons were asked to run together. One was given the ginseng while the other ran without. After running for approximately three to five li [equivalent to 1500 to 2500 meters], the one without the ginseng developed severe shortness of breath, while the one who took the ginseng breathed evenly and smoothly. From page 92 in the Ben Cao Tu Jing (Atlas of Materia Medica), collected and edited by Zhijun Shang and published by Anhui: Anhui Science and Technology Press (In Chinese) in 1994.

History of EBM 1972 Archie Cochrane, 'Effectiveness and efficiency', EBM. 1975 The term meta-analysis is coined by Gene V. Glass from the Laboratory of Educational Research at the University of Colorado to describe a method whereby you synthesize the results from various effect studies. 1990 The term "evidence based" was first used in 1990 by David Eddy 1992 Cochrane Centre British National Health Service Archie Cochrane

Professor Archibald Leman Cochrane, CBE FRCP FFCM, (1909-1988) Cochrane center

History of EBM (from Wikipedia) Although testing medical interventions for efficacy has existed since the time of Avicenna's The Canon of Medicine in the 11th century, it was only in the 20th century did this effort evolve to impact almost all fields of health care and policy. Cochrane's work was honoured through the naming of centres of evidencebased medical research Cochrane Centres and an international organization, the Cochrane Collaboration. The explicit methodologies used to determine "best evidence" were largely established by the McMaster University research group led by David Sackett and Gordon Guyatt.

David Sackett (1934~) (EBM) 1967 McMaster 1994 Center of EBM Clinical Epidemiology:A Basic Science for Clinical Medicine

EBM Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Sackett et al., 1996 Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996). "Evidence based medicine: what it is and what it isn't". BMJ 312 (7023): 71-2. PMID 8555924

Evidence-based medicine a systemic approach to analyze published research as the basis of clinical decision making. (investigators from McMasters University began using the term during the 1990s.)

" " 1992 McMaster Gordon Guyatt EBM (Clinical Practice Guidelines, CPGs)

(Level of evidence Grade of Recommendation [A] Level of Evidence 1a 1b 1c Therapy Systemic review of RCTs Single RCT All-or-none [B] 2a 2b 3a 3b Systemic review of cohort studies Cohort study or poor RCT Systemic review of case-control studies Case-control study [C] 4 Case series [D] 5 Expert opinion, physiology, bench research

RCT(Randomized Controlled Trial) RCT RCT Diagnosis, Prognosis, Clinical Exam RCT Type of Question Etiology/Harm Diagnosis Prognosis Therapy Prevention Clinical Exam Cost Suggested best type of Study RCT > cohort > case control > case series prospective, blind comparison to a gold standard cohort study > case control > case series RCT>cohort > case control > case series RCT>cohort study > case control > case series prospective, blind comparison to gold standard economic analysis

---

識理論論理論 S P 不 P 便論論說 S P 念 E 論 E 不 P S P P S P http://tpa.hss.nthu.edu.tw/0old/committee/tpaseminar/2007/4c_2.pdf

RCT best evidence

EBM and Internet EBM Internet

The Cochrane Collaboration The Cochrane Collaboration was founded in 1993 and named for the British epidemiologist--archie Cochrane. The Cochrane Collaboration is an international nonprofit, independent organization dedicated to making up-to-date, accurate information about the effects of health care readily available worldwide. a worldwide endeavor dedicated to tracking down, evaluating, and synthesizing RCTs in all areas of medicine. It produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions.

5 Doer X User X Replicater X X

Just in time learning Pull Just in case learning Push

EBM search strategy of MCH

(CFD) (CFD) 11

upcoming events 2008.12.06 W6 2009.02

--EBM

Thank you for your attention!