What did we learn to teach

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What did we learn to teach?

• Defining Evidence-Based Practice
• Steps of the EBHC Process
• Rapid Appraisal of Intervention Studies

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Steps in EBMThe Five Ah!s

• Ask an answerable question
• Acquire the best evidence
• Appraise the evidence for
• Validity
• Impact (size of the benefit)
• Applicability
• Apply the results
• Integrate with clinical expertise and patient
  values
• Assess our effectiveness and efficiency
• keep a record improve the process

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Librarians Role

• Provide instruction and resources to support
  first 2 steps of EBM Process
• At ESJH developed online Web tutorial covering
• well-built questions
• evidence pyramid
• search strategies
• appraised resources

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Evidence-based Healthcare Tutorial

• Available at www.exempla.org
• Click on the Education tab
• Choose EBM online course

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Rapid Appraisal of Intervention Studies

• Examine title, abstract, conclusion for
  relevance
• Does it answer the question?
• Do the study group characteristics match our
  patient?
• Ask three questions
• Is the study valid? (Internal Validity)
• What are the results?
• Applicability Will the results help the patient?
  (External Validity)

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Rapid Appraisal QuestionsAre the results of the
study valid?

• Criteria for internal validity
• Randomization
• Similar groups
• Follow-up
• Intention-to-treat
• Equal treatment
• Blinding

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Rapid Appraisal QuestionsAre the results of the
study valid?

• Randomization random allocation of patients to
  study groups. (Methods)
• Each patient has equal chance of being assigned
  to any group. Best way to equalize all factors,
  known and unknown.

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Rapid Appraisal QuestionsAre the results of the
study valid?

• Similarity of groups (Results)
• Patients in one group are as likely to possess a
  given characteristic as patients in another
• Look for table of Baseline Characteristics or
  measure of differences between groups (p value)

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Rapid Appraisal QuestionsAre the results of the
study valid?

• Follow-up all patients accounted for at
  conclusion of trial (Results)
• Loss to follow-up lt20
• Compare number of patients randomized to number
  computed in analysis

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Rapid Appraisal QuestionsAre the results of the
study valid?

• Intention-to-treat analysis (Results)
• Patients analyzed in groups to which they were
  randomized even of they discontinue, never
  receive the intervention or crossover

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Rapid Appraisal QuestionsAre the results of the
study valid?

• Equal treatment (Methods)
• Apart from the intervention all groups should
  receive the same care

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Rapid Appraisal QuestionsAre the results of the
study valid?

• Blinding (Methods)
• Participants (physicians, patients, researchers)
  unaware of treatment allocation
• Most important if outcome is subjective (symptoms
  or function) rather than objective (death).

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Rapid Appraisal Questions

• Is the study valid?
• Decide whether the internal validity is
  sufficient to allow firm conclusions.
• All studies have some flaws but are these flaws
  sufficient to discard the study?

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Rapid Appraisal QuestionsWhat were the results
of the study?

• How large was the treatment effect?
• Relative Effects
• Relative Risk (RR)
• Relative Risk Reduction (RRR)
• Absolute Effects
• Absolute Risk (AR)
• Absolute Risk Reduction (ARR)
• Number Needed to Treat (NNT)

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Applicability Will the results help the patient?

• How do the benefits and harms weigh up in this
  patient?
• Higher or lower risk than the study population?
• Is the patient so different that the results
  cannot apply
• Patients circumstances, concerns and goals
• Is the treatment feasible in the local setting?