(first annual) learning to practice and teach evidence-based health care an intensive workshop
TRANSCRIPT
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(First Annual)Learning to Practice and Teach
Evidence-based Health CareAn Intensive Workshop
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Introductions
• Robert Wild & Dave Thompson
• Susan Hollingsworth
• Speakers
• Facilitators
• Participants
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A true story
• A randomized trial of treating high blood pressure on the jobsite (a steel mill) vs. referral for treatment to primary care doctor
• Primary outcome: treatment compliance• No difference in compliance between the
groups• Some patients who were referred with
documented hypertension did not get treated
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Determinants of the clinical decision to treat some, but not other, high blood pressure patients:
1 The level of diastolic blood pressure.2 The patient’s age.3 _4 The amount of target-organ damage.
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Determinants of the clinical decision to treat some, but not other, hypertensive patients:
1 The level of diastolic blood pressure.2 The patient’s age.3 The physician’s year of graduation from
medical school.4 The amount of target-organ damage.
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How we “know”• observations in the world
• clinical experience
– open to bias• specious causal connections• vividness and immediacy• small samples
• laboratory and physiological research– systematic but generalization dangerous
• observational studies– non-comparable groups
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What we (did) know that ain’t so:
• HRT to decrease cardiovascular risk– observational studies consistently suggest
decreased risk– RCTs show increased risk
• High flow oxygen for RDS– My 6th grade pen-pal was in the “gifted
children” class at the Ohio state school for the blind
• Anti-arrythmics post-MI
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Contrasting Reasoning
• Patho-physiologic reasoning– Depends on logic and
knowledge of pathophysiology
– This leads to a decision to prescribe flecainide to patients after heart attack
• Evidence from systematic studies in human subjects:– Randomized trial of
flecainide after MI:• 7.7% dead on
flecainide• 3.0% dead on placebo
– Leads to a decision NOT to prescribe flecainide after MI
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Hierarchy of Evidence
Meta-analysis of RCTssystematic review of RCTs
Individual RCT
Observational studiespatient-important outcomes
Basic researchtest tube, animal, human physiology
Clinical experience
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Why don’t we practice EBM?
• Exploding information supply
• Textbooks are out of date
• No time to read
• Traditional CME doesn’t work
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Asking questions
• Practice identifying information needs:
– Routinely question decisions
– Question routine decisions
• Identify the specific issue at hand
• Do you need background or foreground information?
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Identify the type of information that is needed
• Background information: What IS myelomonocytic leukemia?? Best source of information for background questions is recent textbooks or recent general review articles.
• Foreground information: Should patients with myelomonocytic leukemia be treated with methotrexate? The best information for foreground questions comes from original research in human subjects.
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Asking Questions
• Design a focused clinical question that addresses the information need– Patient/population– Intervention– Comparison if relevant– Outcome
• The “PICO question”
• PCOS
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Why bother with EBM?
• without EBM we are helpless in the face of– misguided experts– overenthusiastic experts– drug company hype
• without EBM our ability is limited– to understand difficult tradeoffs – to help our patients make difficult decisions
• with EBM comes– understanding and power – greater effectiveness in helping our patients
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Seven Alternatives to Evidence Based Medicine
• Eminence Based Medicine (marked by radiance of white hair)
• Vehemence Based Medicine • Eloquence Based Medicine• Providence Based Medicine• Diffidence Based Medicine• Nervousness Based Medicine• Confidence Based Medicine
– (Isaacs and Fitzgerald, BMJ 1999;319:1618)
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Structure of the Workshop• Breakfast at 8:00am both days• First plenary at 9:15 am on Friday and 9:00am Saturday• Small group sessions
– 10:15-11:40 am Friday, 1:30-3:30 pm Friday– Saturday 10:15-11:30 adjourn Sat 11:30 am
• Box Lunches Friday and Saturday • Lunchtime registrants hands - on searching session
today – Sign up at registration table, limited space -
• facilitators go to room 251 Provost Conference PM • Reception this afternoon after last plenary 4:45PM• Please turn in your evaluations. CME can be obtained
for an additional $25 , slide presentations, and the library resource guide with links to many, many helpful websites will be posted on URL http://moon.ouhsc.edu/dthompso/cdm/ebhc1/ … in your packet
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Goals of the workshop
• To learn and practice skills of critical appraisal of the research literature
• To learn techniques for teaching EBM
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Your own goals
• You will have come with your own objectives for the workshop– Please share them with your group
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Ground Rules
• Facilitators are there to facilitate and demonstrate
• Please arrive on time and prepared for each session
• Have a good time!
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