Post on 11-Jul-2015
transcript
Why bother with Evidence-Based Practice?
Professor Paul GlasziouCentre for Evidence-Based MedicineUniversity of Oxford
I am here to learn EBM because ….
1. I am working in clinical practice2. I am working on evidence resources
(reviews, guidelines, reports , …)3. I will help others use evidence4. I plan to teach EBM5. My boss told me I had to attend
EBP Workshop – Program Day 1
Plenary: What is Evidence-based practice? Small group Tutorial: Asking well-formulated Questions
Coffee Plenary: Rapid Critical Appraisal of intervention studies Small group tutorial: Critical Appraisal of intervention studies
LUNCH
Lab Tutorial: Efficient Searching for Evidence (hands-on) Plenary: Finding the best studies (searching basics)
Tea Small Group Tutorial: Reading papers
Introductory Lecture: Objectives1. What
What is evidence-based medicine? What does it look like in practice?
2. How Formulate Clinical Questions1. Search for Evidence2. Appraisal of research3. Apply to clinical problem
What is evidence-based medicine?“Evidence-based medicine is the integration of best
research evidence with clinical expertise and patient values”
- Dave Sackett
Patient Concerns
Clinical Expertise
Best research evidence
EBM
A dilemma You are very ill …
Which doctor do you want?
William Osler, 1900 Smart young doctor
Which doctor do you want?
Wise & experienced smart young doctor
Life long learningThe hardest conviction to get into the mind of a
beginner is that the education upon which he is engaged is not … a medical course, but a life course, for which the work of a few years under teachers is but a preparation.
Sir William Osler (1849-1919), from: The Student of Medicine
The Prognosis of Ignorance is Poor
Worse with “duration in practice”
Do we know the right things? GP beliefs about prevention for a 52 yr male
0 20 40 60 80 100
*Screen for colon cancer
*Tetanus immunisation
Screen for lung cancer
Screen for prostate cancer
*Measure cholesterol
Measure glucose level
*Advise heavy drinkers
*Advise smokers to quit
*Measure blood pressure
Really Do
Should Do
EUROPREV Network Europe.Prev Med. 2005:595-601Croatia Estonia Georgia Greece Ireland Malta Poland Slovakia Slovenia Spain Sweden
Effective
Effective
Effective
Probable
Effective
Ineffective
Ineffective
Probable
Effective
JASPA*(Journal associated score of personal angst)
J: Are you ambivalent about renewing your JOURNAL subscriptions?
A: Do you feel ANGER towards prolific authors?S: Do you ever use journals to help you SLEEP?P: Are you surrounded by PILES of PERIODICALS?A: Do you feel ANXIOUS when journals arrive?
* Modified from: BMJ 1995;311:1666-1668
0 (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions)
Page 9
Rule 31 – Review the World Literature Fortnightly* *"Kill as Few Patients as Possible" - Oscar London
0
500000
1000000
1500000
2000000
2500000
Biomedical MEDLINE Trials Diagnostic?
Med
ical
Art
icle
s p
er Y
ear
5,000?per day
1,500 per day
95 per day
Med
ical
Art
icle
s Pe
r Yea
r
Is keeping up to date Mission Impossible?
Bluegreenblog 2006
Coping with the overload: three possible things you might try
A. Read an evidence-basedabstraction journal(and cancel other journals)
B. Keep a logbook of yourown clinical questions
C. Run a case-discussion journalclub with your practice
Brian Haynes, physician McMasterACP journal club
Bob Phillips, Oncology, LeedsPatients in Trials
Kevin Mackway Jones A&E ManchesterBestBets
Yaser Faden, Neonatology, Jeddeh“PICO” rounds
Some variants of Evidence-Based Practice
Part 2: The 4 steps of “pull” EBM1. Formulate an answerable question2. Track down the best evidence 3. Critically appraise the evidence4. Individualise, based clinical expertise and patient
concerns
Step 1Formulate an answerable clinical question
Structure of researchable questions – PICO-T
Population/Patients
Intervention
Comparison
Outcome
Time
What are your clinical questions? A 35 year old man says
his brother recently died of a ruptured cerebral aneurysm. He is worried about whether he might have one and what the chances are that it would rupture.
-> PICO Table
Risk Factors
Cause(s)
SymptomsSigns, Tests
Prognosis
Treatment Effect
Past current future
Types of question: stroke
Frequency
Cohort Study SurveyInception Cohort Study
Treatments
Randomised Trial
CT Scan
Cross Sectional Study
What are the … outcomes (PO?)
Outcomes ?
Patients
Page 24
Qualitative Research
The “best” evidence depends on the type of questionLevel Treatment Prognosis Diagnosis
I
II Randomised trial
Inception Cohort
Cross sectional
III
The “best” evidence depends on the type of questionLevel Treatment Prognosis Diagnosis
I Systematic Review of …
Systematic Review of …
Systematic Review of …
II Randomised trial
Inception Cohort
Cross sectional
III
2. Searching: finding good answers?
Should I ask a colleague? 12 occupational therapy questions
E.g., Is a 38-year old sewage worker subject to a higher risk of contracting Hepatitis A as a result of occupational exposure? (No)
Obtain advice from 2 professionals on 3 cases each.
37% wrong answers 17% wrong if based on literature 65% wrong if not
Schaafsma BMC Health Services Research 2005
Impact of searching on correctness of answers to clinical questions
Right to Right
Wrong to Right
Right to Wrong
Wrong to Wrong
McKibbon(GP or IM)
28% 13% 11% 48%
Impact of searching on correctness of answers to clinical questions
Right to Right
Wrong to Right
Right to Wrong
Wrong to Wrong
McKibbon(GP or IM)
28% 13% 11% 48%
Quick Clinical(GPs)
21% 32% 7% 40%
Hersh(Med students)
20% 31% 12% 36%
Hersh(Nursing)
18% 17% 14% 52%
Searching made easy
3. Rapid Critical Appraisal
It’s peer-reviewed, therefore it must be OK?
Step 4: Applying to the individual What do the results
mean on average? What do they mean
for this individual?
What are the alternatives to EBM?
Isaacs, BMJ
Where to now?
Small Group - Room on Group sheet Hobbs – right Hamlin – left Wordsworth/Board 1st floor
10:45 TEA/COFFEE
Step 3: Appraise the evidence
Did you find good quality studies?
Two steps• PICO• RAMMbo
Early Trial in K-L