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