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Evidence-Based Medicine ( EBM ) = Médecine Factuelle.

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Présentation au sujet: "Evidence-Based Medicine ( EBM ) = Médecine Factuelle."— Transcription de la présentation:

1 Evidence-Based Medicine ( EBM ) = Médecine Factuelle

2 C-EBLM (IFCC-LM) (Cochrane, …)

3 Evidence-Based Nursing, Evidence-Based Health-Care, …

4 Evidence-Based Policy, … Evidence-Based Management,

5 Evidence-Based Sociology, Evidence-Based History, …

6 Evidence- Based Mathematics, … X

7 (EB)M = chaque décision médicale se fonde sur: 1) niveaux de preuve (les plus élevés) 2) expertise clinique (professionnelle/scientifique) 3) choix des patients

8 Prejudice-, Belief-, Faith-, Tradition-, Ideology-, Authority-, Anarchy-Based Medicine, …

9 Prejudice-based Medicine Fowler FJ Jr, McNaughton Collins M, Albertsen PC, Zietman A, Elliott DB, Barry MJ. Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer. JAMA 2000;283:

10 The quality of health care delivered to adults in the United States McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. N Engl J Med 2003 Jun 26; 348(26):

11 Study Design indicators of quality of care for 30 acute and chronic conditions, and preventive care - Telephone survey - Informed consent to examine their medical records + interview - Random sample of 6712 adults from 12 metropolitan areas

12 Examples of quality indicators Hypertension Change in treatment when blood pressure is persistently high Coronary artery disease Beta-blockers after myocardial infarction Counselling on smoking cessation Treatment of high LDL cholesterol levels Colorectal cancer Screening for high-risk patients (genetics, colonoscopy) Screening in persons at average risk (FOBT)

13 Medication 68,6 % Immunization 65,7 % Physical examination 62,9 % Laboratory testing or radiography 61,7 % Surgery 56,9 % History 43,4 % Counselling or education 18,3 % Recommended care received

14 85%: Influenzae vaccination >65y 45%: MI-beta-blockers 38%: Colorectal cancer/FOBT 24%: HbA1c X3/y

15 Conclusions patients received 54.9% ( ) of recommended care strategies to reduce these deficits are warranted

16 Strategies? EBM?

17 Niveaux de preuve? I - Randomised Trials II - Non -randomised Trials, Cohort studies III - Case-control studies, case- reports IV – Expert opinion

18 Annual biomedical literature: books articles (i n Medline: articles)

19 The medical literature can be compared to a jungle. It is fast growing, full of dead wood, sprinkled with hidden treasure, and infested with spiders and snakes

20 Systematic Reviews (Revues Méthodiques) = la pierre angulaire de l EBM

21 Systematic Review (Introduction/) Question(s) (focussed) Materials et Methods ( objectivity ) Search (systematic) (EB-librarianship) Inclusion / Exclusion / Quality assessment Results - Discussion ( limitations ) (Conclusion/) Answer(s) - balance benefits/harms (probabilités)

22 Meta-analysis - results of primary studies combined quantitatively and statistically - statistical power

23 Relative risk (95% confidence interval) Trial (Year) Barber (1967) Reynolds (1972) Wilhelmsson (1974) Ahlmark (1974) Multicentre International (1975) Yusuf (1979) Andersen (1979) Rehnqvist (1980) Baber (1980) Wilcox Atenolol (1980) Wilcox Propanolol (1980) Hjalmarson (1981) Norwegian Multicentre (1981) Hansteen (1982) Julian (1982) BHAT (1982) Taylor (1982) Manger Cats (1983) Rehnqvist (1983) Australian-Swedish (1983) Mazur (1984) EIS (1984) Salathia (1985) Roque (1987) LIT 91987) Kaul (1988) Boissel (1990) Schwartz low risk (1992) Schwartz high risk (1992) SSSD (1993) Darasz (1995) Basu (1997) Aronow (1997) Overall (95% CI) 0.80 ( ) Mortality results from 33 trials of beta-blockers in secondary prevention after myocardial infarction. Adapted from Freemantle et al BMJ 1999

24 Cumulative meta-analysis of 33 trials of beta-blockers in secondary prevention after myocardial infarction Calculated from Freemantle et al BMJ 1999

25 Publication bias All studies conductedAll studies published All studies reviewed Grey literature

26 Systematic reviews Levels of evidence

27 (EB) Guidelines Levels of evidence (I-IV) CONSENSUSJUDGMENT Strength of recommendation (A-D)

28 JUDGMENT /CONSENSUS I A I D IV D II/III/IV A

29 Cancer colorectal dépistage de masse - FOBT

30 12 guidelines USA (ACS, 2006)OUI USA (AGA, 2003)OUI UK (BSG, 2000)NON Canada (CAG, 2004)OUI Canada (CTFPHC, 2001)OUI Europe (2000)OUI USA (ICSI, 2005)OUI USA (NCCN, 2005)OUI Australie (NHMRC, 2000)OUI Nouvelle Zélande (NZGG, 2004)NON Canada (QAG, 2003)OUI Ecosse (SIGN, 2003)NON

31 8 revues systématiques dont 3 publiées en

32 Heresbach D, Manfredi S, D'halluin PN, Bretagne JF, Branger B. Review in depth and meta-analysis of controlled trials on colorectal cancer screening by faecal occult blood test. Eur J Gastroenterol Hepatol 2006 ; 18: n Méta-analyse de 4 essais contrôlés ( pts) (France, UK, USA, Danemark) n Réduction de la mortalité par CCR (RR= ), pendant la durée du dépistage uniquement (10 ans)

33 Moayyedi P, Achkar E. Does fecal occult blood testing really reduce mortality? A reanalysis of systematic review data. Am J Gastroenterol 2006 ; 101:380-4 n Méta-analyse de 3 essais contrôlés randomisés ( pts) (UK, USA, Danemark) n Réduction de la mortalité par CCR (RR= ) n Augmentation de la mortalité non liée au CCR (RR= , p=0.015 ) [Hypothèse: FOBT = vaccin anti-cancer?]

34 Hewitson P, Glasziou P, Irwig L, Towler B, Watson E. Screening for colorectal cancer using the faecal occult blood test, Hemoccult. Cochrane Database Syst Rev 2007 Jan 24;(1):CD Revue systématique + méta-analyse de 4 essais contrôlés randomisés (UK, USA, Danemark, Suède) n Réduction de la mortalité par CCR (RR= ) n Augmentation de la mortalité non liée au CCR (RR= , non significatif)

35 Hewitson P, Glasziou P, Irwig L, Towler B, Watson E. Screening for colorectal cancer using the faecal occult blood test, Hemoccult. Cochrane Database Syst Rev 2007 Jan 24;(1):CD Effets bénéfiques du dépistage de masse: - Réduction modeste de la mortalité par CCR - une possible reduction de lincidence du CCR - potentiellement, une chirurgie moins invasive Effets délétères du dépistage de masse: - faux-positifs: conséquences psycho-sociales - complications des colonoscopies, des faux négatifs - possibilité de sur diagnostic (investigations ou traitements inutiles et leurs complications)

36 9 YES: JUDGMENT: benefits outweighs harms VALID judgment, provided both benefits and harms are mentioned in guidelines

37 3 NO (UK, Scotland, New- Zealand): JUDGMENT: benefits may or may not outweigh harms, but the structure of health-system does not allow to recommend for mass-screening VALID judgment too

38 CONCLUSION 1) niveaux de preuve (balance bénéfices/risques) 2) expertise professionnelle (multi- disciplinarité) 3) choix des patients 38%


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