CEBM Introduction April 2013

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Evidence-Based PracticeApril 8 th 2013

Dr Carl HeneghanClinical Reader, University of Oxford

Director CEBM


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DevelopingEvidence-BasedPractice?

Carl Heneghan MA, MRCGP Centre for Evidence Based Medicine

University of Oxford


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Practice of Evidence-Based Health Care

Day One(Monday)

Day Two(Tuesday)

DayThree(Wednesday)

Registration from 08:15inReception

Coffee in the Common Rm

Session One09:00 10:30

Welcome &Plenary: Intro into EBP

(CH )

Plenary:Critical Appraisal of

RCTs(KM )

Plenary:Appraising Diagnostic

Studies(MT )

10:30 11:00 COFFEEin the Common Room

COFFEEin theCommon Room

COFFEEin the Common Room

Session Two11:00 12:30

Small Group WorkQs & Abstracts

Small GroupWork Small GroupWork

12:30 13:30 LUNCHIn theDining Room

LUNCHIn the Dining Room

LUNCHIn the Dining Room

Session Three13:30 15:00

Plenary:StudyDesigns

(JH )

Plenary:SystematicReviews

(SM )

Plenary:Ethical Issues and Critical

thinking in EBHC(JH )

15:00 1 5:30 TRANSFER T O O UCS13 BanburyRoad

TEAin theCommon Room

COFFEEin the Tawney Room

Session 415:30 17:00

Plenary:Searching

Followed by computerlab

(Nia )

Small GroupWork Developing EvidenceBased Practice

(CH )

16:30 Close

18:30 GALA DINNERQueensCollege


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Small groups

Group 1 (Room 012) Carl Heneghan & Khamis Elissi

Group 2 (Room 018) Sharon Mickan & Claire Friedemann

Group 3 (Room 310)

Kamal Mahtani, David Nunan & SadeeshSrinathan


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I am here because?I wanted 3 days of work

Formulate an answerable questions


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The aim of this session

1. To understand what is EBP

2. To recognize questions3. To develop focussed clinical questions


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www.cebm.netWhat is Evidence-Based Medicine?

Evidence-based medicineis the integration of bestresearch evidence with

clinical expertise andpatient values


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Just in Time learning The EBM Alternative Approach

Shift focus to current patient problems(just in time education)

Relevant to YOUR practice Memorable Up to date

Learn to obtain best current answers

Dave Sackett


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Would any of you have agreed toparticipate in a placebo controlled trial of

prophylactic antibiotics for colorectalsurgery after 1975?
http://images.google.co.uk/imgres?imgurl=http://www.cochrane.org/logo/files/cclogo-big-trans.gif&imgrefurl=http://www.cochrane.org/logo/&h=1060&w=905&sz=16&hl=en&start=1&sig2=yixqkpVLkyBiGiCmTfOD_w&usg=__RyvDp4oBZmKyHmfSkNV8ThIUOD8=&tbnid=mxRpyEGWpd8XlM:&tbnh=150&tbnw=128&ei=VKDoSParKIOQQOnQ4JgM&prev=/images?q=cochrane+logo&gbv=2&hl=en&sa=G


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Reduction of perioperative deaths by antibioticprophylaxis for colorectal surgery


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Would you ever have put babiesto sleep on their tummies?


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Why do we need RANDOMIZED CONTROLLED TRIALS ?

In the early 1980s newly introducedantiarrhythmics were found to be highlysuccessful at suppressing arrhythmias.

Not until a RCT was performed was itrealized that, although these drugssuppressed arrhythmias, they actuallyincreased mortality.

The CAST trial revealed Excessmortality of 56/1000.

By the time the results of this trial were

published, at least 100,000 such patientshad been takin these dru s.


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What does CEBM do?


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The 5 steps of EBM

1. Formulate an answerable question

2. Track down the best evidence

3. Critically appraise the evidence for validity,clinical relevance and applicability

4. Individualize, based clinical expertise and

patient concerns5. Evaluate your own performance

G i E id i P i


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Getting Evidence in to PracticeHow do you do EBP?

What Evidence based practice doyou do/help with?

What other EBP do you know of?
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Median minutes/week spent reading aboutmy patients:

Self-reports at 17 Grand Rounds:

Medical Students: 90 minutes

House Officers (PGY1): 0 (up to 70%=none) SHOs (PGY2-4): 20 (up to 15%=none) Registrars: 45 (up to 40%=none) Sr. Registrars 30 (up to 15%=none) Consultants:

Grad. Post 1975: 45 (up to 30%=none) Grad. Pre 1975: 30 (up to 40%=none)


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Size of Medical Knowledge

NLM MetaThesaurus 875,255 concepts 2.14 million concept names

Diagnosis Pro 11,000 diseases 30,000 abnormalities (symptoms, signs, lab,

X-ray,) 3,200 drugs (cf FDAs 18,283 products)

1 disease per dayfor 30 years

To cover the vast field of medicine in four years is an impossible task.- William Olser


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How many randomized trials are published eachyear


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B t ( tl ) l i d


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But we are (currently) poorly equippedto tell good from bad research

BMJ study of 607 reviewers 14 deliberate errors inserted

Detection rates On average


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Managing InformationPush and Pull methods

Push - alerts us to new information Just in Case learning

Use ONLY for important, new, valid research

Pull access information when needed Just in Time learning

Use whenever questions arise EBM Steps: Question; search; appraise; apply


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Your Clinical Questions

Write down one recent patientproblem

What was the critical question?

Did you answer it? If so, how?
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: Asking well-formulated questions

In your books


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www.cebm.netAngela is a new patient who recently moved to the area to be closer toher son and his family

She is 69 years old and has a history of congestive heart failure broughton by a recent myocardial infarctions.

She has been hospitalized twice within the last 6 months for worseningof heart failure and has a venous leg ulcer.

At the present time she reports she is extremely diligent about takingher medications (lisinopril and aspirin) and wants desperately to stayout of the hospital. She is mobile and lives alone with several cats butreports sometimes she forgets certain things.

She also tells you she is a bit hard of hearing, has a slight cough, is an ex-

smoker of 20 cigs a day for 40 years. Her BP today is 170/90, her ankles areslightly swollen and her ulcer is painful and her pulse is 80 and slightlyirregular .

What are your questions?


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Background Questions

About the disorder, test, treatment, etc.

2 components:

a. Root* + Verb : What causes b. Condition: SARS?

* Who, What, Where, When, Why, How


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Foreground Questions

About patient care decisions and actions

4 (or 3) components:

a. P atient, problem, or population

b. Intervention, exposure, or maneuver c. C omparison (if relevant)

d. Clinical O utcomes (including time horizon)


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Background & Foreground


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About patient care decisions and actions

4 (or 3) components:

a. In P atients with Bell s Palsy b. Do ( I) corticosteroids c. Compared to placebo d. Improve facial function ( O ) at 3 months

Foreground

Questions


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For every 100 people with Bell

s palsy at 3 months

83 in the corticosteroid group will have recoveredfacial function

64 in the placebo group will have recovered facialfunction

Risk difference = 19%

Relative Risk Reduction = 23% Number Needed to Treat = 6

Does this intervention help?o


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www.cebm.netExample 1Jean is a 55 year old woman who quite oftencrosses the Atlantic to visit her elderly mother. Shetends to get swollen legs on these flights and isworried about her risk of developing deep veinthrombosis (DVT), because she has read quite abit about this in the newspapers lately. She asksyou if she would wear elastic stockings on her next trip to reduce her risk of this.

PIC

O


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www.cebm.ne tExample 2Jeff, a smoker of more than 30 years, has come tosee you about something unrelated . You ask him if he is interested in stopping smoking. He tells you hehas tried to quit smoking unsuccessfully in the past.

A friend if his , however, successfully quit withacupuncture. Should he try it? Other interventionsyou know about are nicotine replacement therapyand antidepressants

PICO
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www.cebm.ne tExample 3 At a routine immunisation visit, Lisa, the mother of asix-month-old tells you that her baby suffered a nastylocal reaction after her previous immunisation. Lisa isvery concerned that the same thing may happenagain this time. Recently, a colleague told you thatneedle length can affect local reactions toimmunisation in young children but you cantremember the precise details

PICO
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www.cebm.ne tExample 4Susan is expecting her first baby in two months. Shehas been reading about the potential benefits andharms of giving newborn babies vitamin K injections.She is alarmed by reports that vitamin K injections innewborn babies may cause childhood leukaemia.She asks you if this is true and, if so, what the riskfor her baby will be.

P

ICO Aetiology and risk

factors
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Example 5

Julie is pregnant for the second time. She had her first baby when she was 33 and had amniocentesisto find out if the baby had Down Syndrome. The testwas negative but it was not a good experience,because she did not get the result until she was 18

weeks pregnant. She is now 35 and 1 monthpregnant, and asks if she can have a test that wouldgive her an earlier result. The local hospital offersserum biochemistry plus nuchal translucencyultrasound screening as a first trimester test for Down syndrome. You winder if this combination of tests is as reliable as a conventional amniocentesis


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Example 6

Mr Thomas, who is 58 years old, has correctlydiagnosed his inguinal lump as a hernia. He visitsyou for confirmation of his diagnosis and informationabout the consequences. You mention the possibilityof strangulation, and the man asks How likely is

that? You reply pretty unlikely (which is as much asyou know at the time) but say that you will try to findout more precisely.

Y Cli i l Q i


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Your Clinical Questions

Write down one recent patientproblem

What is the PICO of the problem?

Q i


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Questions

Recognize: your questions Select: which questions to pursue Guide: how to ask and answer Assess: how well & what to improve


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www.cebm.netThe Real Three Rs of Learning

Resilient

Reflective

Resourceful


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www.cebm.netFAQ: How Long ? Proficient? Quickly Mastery? Lifetime

Human expertise takes>10,000 hours, >10years

Deliberate practice


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Any questions?

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CEBM Introduction April 2013

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