NOTES

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NOTES

• BEFORE LECTURE
• Get Rooms for final slide directions
• Whiteboard
• Number of changes
• PICO
• LECTURE
• Orient to pack
• Announcements
• Introduce yourself to neighbour

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Why bother with Evidence-Based Practice?
Professor Paul Glasziou Centre for Evidence-Based
Medicine University of Oxford
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I am here to learn EBM because .

• I am working in clinical practice
• I am working on evidence resources (reviews,
  guidelines, reports , )
• I will help others use evidence
• I plan to teach EBM
• My boss told me I had to attend

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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

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Introductory Lecture Objectives

• 1. What
• What is evidence-based medicine?
• What does it look like in practice?
• 2. How
• Formulate Clinical Questions
• Search for Evidence
• Appraisal of research
• Apply to clinical problem

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What is evidence-based medicine?

• Evidence-based medicine is the integration of
  best research evidence with clinical expertise
  and patient values - Dave Sackett

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A dilemma

• You are very ill

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Which doctor do you want?
Smart young doctor
William Osler, 1900
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Which doctor do you want?
Wise experienced smart young doctor
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Life long learning

• The 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

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The Prognosis of Ignorance is Poor
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Do we know the right things? GP beliefs about
prevention for a 52 yr male
EUROPREV Network Europe.Prev Med.
2005595-601 Croatia Estonia Georgia Greece
Ireland Malta Poland Slovakia Slovenia Spain
Sweden
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Changes in the past 12 months

• Practice changes you have made
• Who/where did you learn them from?
• What was the evidence?

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JASPA(Journal associated score of personal
angst)
Page 9

• 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) gt3 (sick at risk
for polythenia gravis and related conditions)
Modified from BMJ 19953111666-1668
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Rule 31 Review the World Literature
Fortnightly "Kill as Few Patients as Possible"
- Oscar London
Medical Articles Per Year
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Is keeping up to date Mission Impossible?
Bluegreenblog 2006
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1990 Sacketts Just in Time learningAn EBM
Approach to Education

• Evidence cart on ward rounds - 1995
• Looked up 2-3 questions per patient
• Took 15-90 seconds to find
• Change about 1/3 decisions
• Rounds took longer!

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Coping with the overload three possible things
you might try
A. Read an evidence-based abstraction
journal(and cancel other journals)
B. Keep a logbook of your own clinical
questions C. Run a case-discussion journalclub
with your practice
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Some variants of Evidence-Based Practice
Brian Haynes, physician McMaster ACP journal club
Bob Phillips, Oncology, Leeds Patients in Trials
Kevin Mackway Jones AE Manchester BestBets
Yaser Faden, Neonatology, Jeddeh PICO rounds
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Filtered knowledge How much is valid AND relevant?

• PROCESS
• 140 journals scanned
• 60,000 articles
• Is it valid? (lt5)
• Intervention RCT
• Prognosis inception cohort
• Etc
• Is it relevant?
• 6-12 GPs specialists askedRelevant?
  Newsworthy?
• lt 0.5 selected

www.evidence-basedmedicine.com
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B. Recognise important knowledge gaps

• Keep a logbook of questions
• Answer a few important questions
• Discuss evidence with colleagues (journal club)

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C. Run and EBM journal club
H

• Example Questions
• Are antidepressants safe in adolescents?
• Is atenolol OK for hypertension?
• Should all diabetics take aspirin?
• Do probiotics prevent AB diarrhoea?
• Does bibliotherapy help depression?
• What is the impact of Tamiflu on flu?
• Are combined inhalers better in asthma?
• Pelvic floor exercises for ED?
• Bold from EBM journal

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Some tools that help
2. Whiteboard for questions
1. Flipchart (preformat)
3. Good evidence resources
4. Good coffee!
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3. Cased-BasedJournal Clubs
H

• Case focused
• Vote on topics
• Simple appraisal
• Note further actions
• More information
• Equipment
• Training
• etc

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Part 2 The 4 steps of pull EBM

• Formulate an answerable question
• Track down the best evidence
• Critically appraise the evidence
• Individualise, based clinical expertise and
  patient concerns

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Your own health care problems

• Write down one recent patient problem
• What were the critical questions?

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Step 1Formulate an answerable clinical question

• Structure of researchable questions PICO-T
• Population/Patients
• Intervention
• Comparison
• Outcome
• Time

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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.

-gt PICO Table
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Types of question stroke
Cohort Study
Inception Cohort Study
Survey
Frequency
Prognosis
Risk Factors
Treatments Randomised Trial
Treatment Effect
Symptoms Signs, Tests
Cause(s)
Past current
future
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Question Structure PICO
Patients
Page 24
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What are the outcomes (PO?)
Patients
Outcomes ?
Qualitative Research
Page 24
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What is the frequency? PO (prevalence) or PO-T
(incidence)
Patients
Outcomes -
Frequency prevalence or incidence Prognosis
average outcome
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How common is an earlobe crease?
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Risk Factors Do patients with rheumatoid
arthritis have higher mortality?
Patients
Predictors, Risk Factors, tests
Page 24
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Treatment Do patients with rheumatoid arthritis
benefit from methotrexate?
Patients
Page 24
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The best evidence depends on the type of
clinical question

• What are the phenomena/thoughts?
• Observation (e.g., qualitative research)
• What is frequency of the problem? (FREQUENCY)
• Random (or consecutive) sample
• Does this person have the problem? (DIAGNOSIS)
• Random (or consecutive) sample with Gold Standard
• Who will get the problem? (PROGNOSIS)
• Follow-up of inception cohort
• How can we alleviate the problem?
  (INTERVENTION/THERAPY)
• Randomised controlled trial

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The best evidence depends on the type of
question
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The best evidence depends on the type of
question
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2. Searching finding good answers?
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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
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Impact of searching on correctness of answers to
clinical questions
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Impact of searching on correctness of answers to
clinical questions
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Searching made easy ?
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Finding the best evidence for the question type
use Methods Filters
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3. Rapid Critical Appraisal

• Its peer-reviewed, therefore it must be OK?

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Step 4 Applying to the individual

• What do the results mean on average?
• What do they mean for this individual?

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What are the alternatives to EBM?
Isaacs, BMJ
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Where to now?

• Small Group - Room on Group sheet
• Hobbs right
• Hamlin left
• Wordsworth/Board 1st floor
• 1045 TEA/COFFEE

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Levels of Evidence forAnecdote-based medicine

• Level I Beardy old gent from royal college
• Level II Doctor with air of credibility and
  honest face
• Level III Academic with mad stare
• Level IV NHS manager with trust in financial
  crisis

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Step 3 Appraise the evidence

• Did you find good quality studies?

• Two steps
• PICO
• RAMMbo

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Early Trial in K-L