Transcript Evidence-based medicine is the integration of best

Evidence-Based Practice
Paul Glasziou
University of Queensland & Oxford
What evidence-based medicine is:
“Evidence-based medicine is the
integration of best research evidence with
clinical expertise and patient values”
-
Sackett, et al 2001
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?
0 (?liar)
1-3 (normal range)
>3 (sick; at risk for polythenia gravis and
related conditions)
* Modified from: BMJ 1995;311:1666-1668
Rule 31 –
Review the World Literature Fortnightly*
*"Kill as Few Patients as Possible" - Oscar London
5,000?
per day
Medical Articles per Year
2500000
2000000
1500000
1000000
500000
55 per
day
1,400
per day
0
Trials
MEDLINE
BioMedical
Managing Information
The Airline industry
Boeing 777 manuals
24 binders
10 feet shelf space
Conversion to CD
Reduced search by 60%
The Health Industry
Memorize “the manuals”
Exams, audits, etc to check
Systematic review of bed rest
after medical procedures
10 trials of bed rest after spinal puncture
no change in headache with bed rest
Increase in back pain
Protocols in UK neurology units - 80% still
recommend bed rest after LP
Serpell M, BMJ 1998;316:1709–10
…evidence of harm available for 17 years
preceding...
Allen, Glasziou, Del Mar. Lancet, 1999
Getting Evidence in to Practice
How do you “do” EBP?
What EBP do you do/help with?
What other EBP do you know of?
Compare with you neighbour
Teaching Tip:
Special
background
for activities.
Managing Information
“Push” 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
Bimonthly “just in case” journal
Valid, Relevant & (almost) No Effort!
 80 journals scanned
 Is it valid?
 Intervention: RCT
 Prognosis: inception cohort
 Etc
 Is it relevant?
 GPs & specialists ask:
Will this change your
practice?
www.evidence-basedmedicine.com
“Just in Time” learning:
Intern’s information needs
Setting: 64 residents at 2 New Haven hospitals
Method: Interviewed after 401 consultations
Questions
Asked 280 questions (2 per 3 patients)
Pursued an answer for 80 questions (29%)
Not pursued because
Lack of time
Forgot the question
Sources of answers
Textbooks (31%), articles (21%), consultants (17%)
Green, Am J Med 2000
Intern’s information needs
Most of our questions are NEVER
answered
When answered, the information is likely
to be neither the best nor up-to-date
Your Clinical Questions
Write down one recent patient problem
What was the critical question?
Did you answer it? If so, how?
Information “pull”
Steps in EBM process
1. Formulate an answerable question
2. Track down the best evidence
3. Critically appraise the evidence
4. Integrate with clinical expertise and patient
values
An example: “the first sign of
hyperkalaemia is death”
An anxious laboratory technician phoned about
a potassium of 7.3 mmol/l (Ref Range 3.5-5.0)
found on a routine blood test of a 50 year old
woman.
I arranged an urgent repeat of the electrolytes
(to rule out a spurious elevation) and an ECG.
The latter was reassuringly normal, but left me
asking: Does a normal ECG rule out a serious
elevation of potassium?
1. The question
Does a normal ECG rule out a serious
elevation of potassium?
Population - In suspected hyperkalemia
Indicator - does a normal ECG
Comparator Outcome - rule out hyperkalemia?
1. The question
Does a normal ECG rule out a serious
elevation of potassium?
Population – hyperkal*
Indicator – ECG OR EKG
Comparator Outcome – hyperkal*
Underline keywords; think of synonyms
PubMed via
Google
Diagnosis
button
“OR” synonyms
* Means
any letters
Diagnosis
button
Sensitivity of
62% or 55%
Step 2: The “best” evidence depends on
the type of question
1. What are the phenomena/problems?
 Observation (e.g., qualitative research)
2. What is frequency of the problem? (FREQUENCY)
 Random (or consecutive) sample
3. Does this person have the problem? (DIAGNOSIS)
 Random (or consecutive) sample with Gold Standard
4. Who will get the problem? (PROGNOSIS)
 Follow-up of inception cohort
5. How can we alleviate the problem?
(INTERVENTION/THERAPY)
 Randomised controlled trial
Treating hyperkalemia
She refused to go to hospital
Resonium A, but it is around $100 (RPBS
but not PBS) which she could not afford.
My search had mentioned albuterol as a
treatment.
“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
The Barriers to EBP
1. Attitude of question & inquiry
2. Know-how in finding, appraising, and
applying evidence
3. Information Resources on tap
4. Lack of Time
EBP in Teams
Question focused journal clubs
Structure:
Appraise & apply “homework” article
New questions? Discuss & assign
Plan and monitor changes
Are there barriers to the change?
Can we measure the change?
EBP for Teams: example
Initial “EBP lunch” questions on annual check
TRIGGER: Is blood monitoring better than urine
monitoring in NIDDM? – No; give patients option
Session 1: formulate questions
Should all diabetics be on aspirin? – Most; audit
Are aerobic or resistance exercises helpful for
diabetic control? – Both improve control; audit;
purchased 12 pedometers
(Subsequent sessions)
Who needs to see the podiatrist? – High risk
What is the best test for neuropathy? - Monofilament
How can we improve compliance?
When should oral medications be started?
Using evidence for prioritising
Q: Which diabetics need podiatry?
PLAN
Current wait time is 3 Months
About half workload is diabetics
Cohort study shows 2% ulcers/yr with 5 risk factors
Current ulcer
Past ulcer
Neuropathy
Deformity
Poor pulses
Abbot. Diab ed 2002: 377-84
Summary
Is there an information deluge?
Yes – 5,000 articles per day
Does CME help?
Maybe a little
Can EBM (patient-centred learning) help?
Yes, it uses the more effective methods of CME
What are the barriers?
Evidence resources, skills, inquiring attitude