Evidence-Based Practice

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Evidence-Based Practice

• Paul Glasziou
• University of Queensland Oxford

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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

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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) 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

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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

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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
  1998316170910
• evidence of harm available for 17 years
  preceding...

Allen, Glasziou, Del Mar. Lancet, 1999
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Getting Evidence in to PracticeHow 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.
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Managing InformationPush 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

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Bimonthly just in case journalValid, Relevant
(almost) No Effort!

• 80 journals scanned
• Is it valid?
• Intervention RCT
• Prognosis inception cohort
• Etc
• Is it relevant?
• GPs specialists askWill this change your
  practice?

www.evidence-basedmedicine.com
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Just in Time learningInterns 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
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Interns information needs

• Most of our questions are NEVER answered
• When answered, the information is likely to be
  neither the best nor up-to-date

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Your Clinical Questions

• Write down one recent patient problem
• What was the critical question?
• Did you answer it? If so, how?

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Information pullSteps 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

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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?

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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?

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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

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PubMed via Google
Diagnosis button
OR synonyms
Means any letters
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Diagnosis button
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Sensitivity of 62 or 55
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Step 2 The best evidence depends on the type
of question

• What are the phenomena/problems?
• 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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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.

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Just in Time learningThe 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

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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

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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?

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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?

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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
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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

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