lecture 17

name and describe the A’s of EBM

The A's of EBM

• Assess

  • A question arises during care of a pt

• Ask

  • Completely articulate all parts of the question

• Acquire

  • Conduct a thorough focused search and select the highest quality evidence

• Appraise

  • Evaluate/weigh the evidence for validity and clinical applicability

• Apply

  • Use clinical expertise to integrate applicable evidence with attention to pt values (axiology) and expectations

what are the 5 steps of the EBM process?

1. Formulate the question

   1. What kind of pt or problem? What intervention, diagnostic test, risk factor, or prognostic factor are you interested in?

2. Search for answers

   1. Has a systematic review been conducted? Are there RCTs that enrolled similar pts to yours? If using guidelines, are they evidence-based or eminence-based?

3. Appraise the evidence

   1. Is it clinically relevant? Will is work in the real world? Is it relevant to your pt? is it statistically significant (different than clinical significance)?

4. Apply the results

   1. Is it worth it? Is the intervention, treatment, diagnostic test, etc., important to you within the context of your clinical experience and important to the pt in terms of their preferences?

5. Assess the outcome

   1. Did you ask the right questions? Did you find answers? Were answers you found based on high-quality level of evidence? Did it make clinical sense? Does the pt agree?

why is it important to be self-aware when addressing patient autonomy?

What biases that you might bring to decisions making that would clash with autonomy

• important to ensure your biases are not interfering with what the pt wants

what are some ethical considerations to consider when using EBM?

• Resource allocation - using evidence to allocate resources can imply that lack of evidence means lack of value

• Applying clinical trial results - applying the results of clinical trials to individual pts can be disadvantageous

  • Have to know when to apply

• Competing interest

• Collect evidence- can be difficult to collect quality evidence (e.g. RCTs)

how does efficiency play into EBM and what helps maximize efficiency?

• Finding the right information in the most efficient manner us key to successfully practising evidence-based decision making

• Knowing what key components to use in your search increases efficiency = PICO model

describe the PICO model

• Patient/population

  • Who are the pts of interest?

  • Age group? Gender?

  • What is the health concern?

• Intervention/exposure

  • what is the treatment, therapeutic, diagnostic, preventative or other healthcare interventions?

  • What health care management strategies are you interested in comparing?

• Comparison

  • between treated and untreated

  • Is there a comparison to be evaluated against the intervention

  • Only used if more than one intervention or if no intervention is a factor

• Outcome

  • What is the desired outcome to be evaluated?

  • How will the pt or population be affected or not affected by intervention?

• T: What type of question are you asking?

• T: What is the best type of study to find the info you want?

name and describe the 4 pillars of medical ethics

• Beneficence

  • Provide benefit to all

  • The duty of healthcare providers to act in the best interest of pts, focusing on positive outcomes and minimizing harm

• Non-maleficence

  • Avoid and preventing harm

• Autonomy

  • Independent, free, self-directing, the state of self-determination

  • Respecting pts rights to make their own decisions, includes informed consent and information to make those decisions

• Justice

  • Fairness and equity to all

  • Non-discriminatory practice

Informed consent and pt rights

 understanding that pts must have adequate information to make informed choices about their treatment, including risks, benefits and alternative

Balancing risk and benefits

ethical decision making involves assessing the potential outcomes of a treatment, balancing the potential benefits to the pt with possible risks and harm

Cultural and personal beliefs

recognizing pat beliefs, values, and cultural backgrounds should inform ethical decision-making and be respected as part of a holistic approach to pt care

• e.g. Jehovah's witness does not want to receive blood transfusions, believes its wrong

Confidentiality and privacy:

 upholding pts privacy is a fundamental ethical duty, requiring that healthcare providers protect sensitive information unless disclosure is necessary for pt safety or public health

Ethical dilemmas and complex cases

many real-world cases involve conflicting ethical principles, such as respecting autonomy versus the duty to protect life

Role of ethical guidelines and professional codes

many professional organizations have codes of ethics that guide healthcare providers, helping to standardize ethical practices and provide frameworks for handling ethical dilemmas

Ethics committees and consultation

in cases of difficult ethical decisions, healthcare providers may consult with ethics committees to ensure that decisions are thoroughly evaluated from multiple perspectives

• Need people with ethical/philosophical backgrounds to work with scientists