EBM research experiences in Amsterdam(and the rest of the world)

EASOM 2008Amsterdam

Jan Hoving, Rob Kok, Jos Verbeek, Frederieke Schaafsma, g, , , ,Paul Smits en Frank van Dijk

Coronel Institute

BackgroundBackground

Current research on EBMCurrent research on EBM

• Many questions answered  (and …. many not answered)

New research projects on EBM  at Coronel institute

• PhD project: application of EBM in insurance medicine (randomizedPhD project: application of EBM in  insurance medicine (randomized controlled trial)

• MDA Project: comparison of information from medical databases /• MDA Project: comparison of information from medical databases / websites

Coronel Institute

Challenge effectiveness of EBMChallenge ‐ effectiveness of EBM ( Coomerasamy et al., 2004, BMJ)

• Changing behaviour is the real challenge:Changing behaviour  is the real challenge:

– Some evidence for positive effect of EBM on behaviour of professionals if given as ‘integrated’ teaching (vs standalone) in particular on:given as  integrated  teaching (vs standalone), in particular on:

• Reading habits

• Choice of information resources

• Changes in management of patient

• Guidelines 

• No evidence on improvement of patients’ health outcomes

Coronel Institute

New PhD project: EBM in insurance medicineNew PhD project: EBM in insurance medicine 

• Design: cluster randomized controlled trial (RCT)g ( )

• Subjects: insurance physicians with few skills in EBM

• Interventions:  

intervention group: 4 day course EBM + monthly tutorials (2 hrs / 6 months)– intervention group: 4 day course EBM + monthly tutorials (2 hrs / 6 months)

– Control group: business as usual 

• Outcomes: knowledge, skills, quality of evidence (vignettes), use of evidence at work, work satisfaction physicians

Coronel Institute

Challenge level of EBM ‘functioning’

Should insurance physicians be:

Challenge  – level of EBM  functioning  

Should insurance physicians be:

‐ users of EBM ?

‐ do‐ers of EBM ?‐ do‐ers of EBM ?

Should level of participation be:

‐ EBM for all physicians?

just a few ‘expert EBM’ physicians?‐ just a few  expert EBM  physicians?

Minimum level of EBM expertise?

Coronel Institute

Challenge – instruments evaluation EBM educationChallenge  instruments evaluation EBM education  

Few instruments with reasonable validity : more testing needed ( l l b l f b l ) f(validity, reliability, feasibility), on more domains of EBM (knowledge, skills, behaviour) and on different educational l l / d ( / d )levels/needs (users / do‐ers)  (Shaneyfield et al., 2006, JAMA)

‘Level 1’ Instruments: Fresno test, Berlin questionnaire, some more

Coronel Institute

Challenge – different sources of information

Which electronic information sources (databases) could we use?

Challenge   different sources of information

Which electronic information sources (databases) could we use? 

• Role of (pre‐appraised) aggregated evidence? (systematic review,  evidence based guideline, evidence based summary, synopsis )

• Role of  original  studies ? (cohort study, RCT, case‐control study)

Coronel Institute

MDA Project: comparison of information from 

• Design: questionnaire

medical databases / websitesDesign: questionnaire

• Subjects:  insurance physicians/ EBM experts

• Material: 

10 case scenario’s with medical question: different diseases complexity– 10 case scenario’s with medical question: different diseases, complexity  

– For each scenario: information from 6 different medical information di l di bilit d i (MDA) U T D t Cli i l E idsources: medical disability advisor (MDA), Up‐To‐Date, Clinical Evidence,  

Guidelines, Pubmed / Trip database / Sumsearch, Cochrane

• Outcome : questionnaire scoring relevance, feasibility, quality/validity of evidence

Coronel Institute

MDA project: example of case scenario

Patient : 53 yr old male nurse on orthopedic ward diagnosedPatient : 53 yr old male nurse on orthopedic ward diagnosed with rheumatoid arthritis 4 years ago, limited in manual work (hands), on sick leave

Physician: Progression of RA disease process over time? 

Patient’s profile favourable/unfavourable in view of RTW as a nurse?

Any (supporting) evidence in literature? 

=>  Medical question on prognosis, so we are interested in ‐ the course of RA (+ on work participation) t e cou se of ( o o pa t c pat o )‐ any prognostic factors which put this nurse at higher/lower risk for (non)RTW

Coronel Institute

Coronel Institute

Coronel Institute

Coronel Institute

Coronel Institute

Coronel InstituteExcellent resource … but not for prognostic questions!

Coronel Institute

32 hit i “ i ” filt32 hits using “review” filter

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ConclusionConclusion

Challenges are good.

We need to:

- design effectiveness studies that evaluate change of behaviour- have a clear focus on whether we want users or do-ers of EBM- further test /develop outcomes to evaluate EBM (education) - evaluate / critically assess different sources of medical

information

Coronel Institute

Thank you!

Email: J.L.Hoving@amc.uva.nl

Coronel Institute