Evidence in Practice The EvidenceBased Cycle

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Evidence in PracticeThe Evidence-Based Cycle

• Poole House Thursday 15th June 2006
• John Blenkinsopp (with thanks to Tony McKenna)
• Clinical Effectiveness Advisor
• University Hospital of North Tees
• Evidence in Practice Group
• Amanda McGough, John Blenkinsopp, Tony Roberts,
  Ann Lister
• www.teesebp.net

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Evidence-Based PracticeThe cycle of evidence
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The Alternative EBP Cycle
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EBP Cycle

• This is not just an academic exercise try
  putting the skills you have learned in this
  course into a real life evidence-based cycle
• Imagine a real problem that you have or may face
  with a patient or a work related issue how
  would you search for information, appraise it and
  deal with that information in the real world?

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Sacketts Figure of Eight

• In a truly knowledge-based health system the flow
  of knowledge would form a virtuous circle or a
  figure of eight. (Sackett)

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The Figure of Eight

• Healthcare providers and patients generate
  questions during consultations.
• You do a search for published materials
• If there aren't ready answers in evidence-based
  guidelines or handbooks, questions should be
  assessed by systematic review of the literature

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The Figure of Eight

• Good evidence to support clinical decisions are
  (hopefully) found which can then be fed into
  practice.
• If a systematic review finds insufficient
  evidence to support a clinical decision, this
  represents a gap in our knowledge base, which
  should be fed back into the research agenda
• Ultimately, new research should be incorporated
  into further systematic reviews and the results
  of these used to guide practice

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The Figure of Eight

• You review your practice and move on
• Healthcare providers and patients generate more
  questions during more consultations.
• .and on and on

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One students Evidence-Based Cycle

• A GP based in Tees Valley
• Looking for an example from practice
• Has a patient who has heart failure
• Issues specific to her
• Lives alone
• Doesnt want to lose her independence
• On a diuretic
• Cant take a beta blocker because of co-existent
  problem

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One students Evidence-Based Cycle

• E.A. is an 80y old woman who lives independently
  but alone, who has heart failure but is also
  hypotensive and is still mildly symptomatic. She
  is on less than half the ACE-I dose used in the
  major trials and is also on a diuretic and cannot
  take a Beta-blocker because of co-existing
  respiratory disease.
• When I increase her ACE-I dose her BP falls
  further and she is at risk of falling and can
  become bed bound and/or at risk of losing her
  independence. Would she benefit from remaining on
  her low dose ACE-I in terms of risk of death and
  hospital admission or will she only gain these
  benefits if the dose is up-titrated to the
  trial ACE-I dose level?

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PICO
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The most relevant papers

• Selection of key papers- no meta-analysis of this
  sub-group of heart failure patients.
• Three Key papers found
• 1. Milton Packer et al Comparative effects of low
  and high doses of the ACE-I Lisinopril on
  mobidity and mortality in chronic heart failure-
  Circulation. 19991002312.

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The Method

• Double blind, RCT between 1992-97 , 3164
  randomised from 3793 patients with class II-IV
  heart failure were allocated to Lisinopril low
  dose (2.5-5mg/d- n1596) or high doses
  (32.5-35mg/d, n1568)

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Other Key Papers

• Key paper 2 . Kittleson-Michelle et al.
  Development of Circulatory-Renal Limitation (CRL)
  to ACE-I identifies patients with severe heart
  failure and early mortality Journal of American
  College of cardiology 2003 Jun 4, VOL41(11)
  P2029-35
• 259 heart failure patients were followed up an
  average of 8.5 months and 23 couldnt tolerate
  ACE-I because of symptomatic hypotension and or
  renal impairment
• Key paper 3 meta-analysis Flather MD Longterm
  ACE-I in patients with Heart failure or LVD-
  Systematic overview of data from individual
  patients. Lancet 2000 3551575-81
• Benefits from high dose ACE-I treatment of
  Heart failure
• Mortality- Absolute Risk for untreated HF
  27, Relative Risk Reduction 15

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The Bottom line from the three papers

• Treating HF with full dose/ trial dose ACE-I
  reduces mortality and morbidity more than low
  dose treatment.
• Patients with Symptomatic Hypotension (or CRL)
  have a higher risk of dying in the next 8.5months
  and are generally older but their quality of
  remaining life may be higher more research
  needed
• Between 23 and 27 of patients couldnt tolerate
  full dose ACE-I if they had symptomatic
  hypotension and or renal impairment

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Implications for our patient

• Patient seems to have an approximate doubling of
  mortality absolute risk if she is on a low dose
• The patients choice is against increasing her
  ACE-I dose because of her social situation and
  concerns of losing independence/ falling. Because
  she feels relatively fit she is willing to remain
  on her low dose ACE-I unless her Systolic BP
  falls further as her disease progresses.

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Implications for my learning

• The printed articles did not always identify the
  exact problem that my patient had, but my ability
  to find and appraise the right ones had meant
  that my research was Evidence-Based
• I found it interesting to pursue the themes of my
  searches but frustrating as even when I
  identified a recent article I found it hard to
  track down the full text

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Summary

• Look at an issue in your practice
• Plan a PICO
• Do the search
• Appraise the evidence for validity and outcomes
• Look for a bottom line
• Implications for your patient (you are a health
  professional not Fanny Craddock!)
• Implications for your learning
• Ask your Tutor for help and to read it through
  with you