evidence-based practice paul glasziou university of queensland & oxford
TRANSCRIPT
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?
* Modified from: BMJ 1995;311:1666-1668
0 (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions)
Rule 31 – Review the World Literature Fortnightly*
*"Kill as Few Patients as Possible" - Oscar London
0
500000
1000000
1500000
2000000
2500000
Trials MEDLINE BioMedical
Med
ical
Art
icle
s p
er Y
ear
5,000?per day
1,400 per day55 per
day
Managing Information
The Airline industryBoeing 777 manuals
24 binders10 feet shelf space
Conversion to CDReduced search by 60%
The Health IndustryMemorize “the manuals”Exams, audits, etc to check
Systematic review of bed rest after medical procedures
Allen, Glasziou, Del Mar. Lancet, 1999
10 trials of bed rest after spinal puncture no change in headache with bed restIncrease 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...
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.
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 ariseEBM Steps: Question; search; appraise; apply
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 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 hospitalsMethod: Interviewed after 401 consultationsQuestions
Asked 280 questions (2 per 3 patients)Pursued an answer for 80 questions (29%)Not pursued because
Lack of timeForgot the question
Sources of answersTextbooks (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 hyperkalemiaIndicator - does a normal ECGComparator - Outcome - rule out hyperkalemia?
1. The question
Does a normal ECG rule out a serious elevation of potassium? Population – hyperkal*Indicator – ECG OR EKGComparator - Outcome – hyperkal*
Underline keywords; think of synonyms
Diagnosisbutton
* Means any letters
“OR” synonyms
PubMed via Google
Diagnosisbutton
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 hospitalResonium 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” 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
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 clubsStructure:Appraise & apply “homework” articleNew questions? Discuss & assign
Plan and monitor changesAre there barriers to the change?Can we measure the change?
EBP for Teams: exampleInitial “EBP lunch” questions on annual check
TRIGGER: Is blood monitoring better than urine monitoring in NIDDM? – No; give patients option
Session 1: formulate questionsShould all diabetics be on aspirin? – Most; auditAre aerobic or resistance exercises helpful for diabetic control?
– Both improve control; audit; purchased 12 pedometers(Subsequent sessions)
Who needs to see the podiatrist? – High riskWhat 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 MonthsAbout half workload is diabetics
Cohort study shows 2% ulcers/yr with 5 risk factorsCurrent ulcerPast ulcer NeuropathyDeformityPoor 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