introduction to-ebm-2010-03-1
TRANSCRIPT
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Why bother with Evidence-Based Practice?
Professor Paul GlasziouCentre for Evidence-Based MedicineUniversity of Oxford
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I am here to learn EBM because ….
1. I am working in clinical practice2. I am working on evidence resources
(reviews, guidelines, reports , …)3. I will help others use evidence4. I plan to teach EBM5. 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: Objectives1. What
What is evidence-based medicine? What does it look like in practice?
2. How Formulate Clinical Questions1. Search for Evidence2. Appraisal of research3. 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
Patient Concerns
Clinical Expertise
Best research evidence
EBM
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A dilemma You are very ill …
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Which doctor do you want?
William Osler, 1900 Smart young doctor
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Which doctor do you want?
Wise & experienced smart young doctor
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Life long learningThe 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
Worse with “duration in practice”
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Do we know the right things? GP beliefs about prevention for a 52 yr male
0 20 40 60 80 100
*Screen for colon cancer
*Tetanus immunisation
Screen for lung cancer
Screen for prostate cancer
*Measure cholesterol
Measure glucose level
*Advise heavy drinkers
*Advise smokers to quit
*Measure blood pressure
Really Do
Should Do
EUROPREV Network Europe.Prev Med. 2005:595-601Croatia Estonia Georgia Greece Ireland Malta Poland Slovakia Slovenia Spain Sweden
Effective
Effective
Effective
Probable
Effective
Ineffective
Ineffective
Probable
Effective
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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?
* Modified from: BMJ 1995;311:1666-1668
0 (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions)
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Rule 31 – Review the World Literature Fortnightly* *"Kill as Few Patients as Possible" - Oscar London
0
500000
1000000
1500000
2000000
2500000
Biomedical MEDLINE Trials Diagnostic?
Med
ical
Art
icle
s p
er Y
ear
5,000?per day
1,500 per day
95 per day
Med
ical
Art
icle
s Pe
r Yea
r
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Is keeping up to date Mission Impossible?
Bluegreenblog 2006
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Coping with the overload: three possible things you might try
A. Read an evidence-basedabstraction journal(and cancel other journals)
B. Keep a logbook of yourown clinical questions
C. Run a case-discussion journalclub with your practice
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Brian Haynes, physician McMasterACP journal club
Bob Phillips, Oncology, LeedsPatients in Trials
Kevin Mackway Jones A&E ManchesterBestBets
Yaser Faden, Neonatology, Jeddeh“PICO” rounds
Some variants of Evidence-Based Practice
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Part 2: The 4 steps of “pull” EBM1. Formulate an answerable question2. Track down the best evidence 3. Critically appraise the evidence4. Individualise, based clinical expertise and patient
concerns
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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.
-> PICO Table
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Risk Factors
Cause(s)
SymptomsSigns, Tests
Prognosis
Treatment Effect
Past current future
Types of question: stroke
Frequency
Cohort Study SurveyInception Cohort Study
Treatments
Randomised Trial
CT Scan
Cross Sectional Study
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What are the … outcomes (PO?)
Outcomes ?
Patients
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Qualitative Research
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The “best” evidence depends on the type of questionLevel Treatment Prognosis Diagnosis
I
II Randomised trial
Inception Cohort
Cross sectional
III
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The “best” evidence depends on the type of questionLevel Treatment Prognosis Diagnosis
I Systematic Review of …
Systematic Review of …
Systematic Review of …
II Randomised trial
Inception Cohort
Cross sectional
III
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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
Right to Right
Wrong to Right
Right to Wrong
Wrong to Wrong
McKibbon(GP or IM)
28% 13% 11% 48%
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Impact of searching on correctness of answers to clinical questions
Right to Right
Wrong to Right
Right to Wrong
Wrong to Wrong
McKibbon(GP or IM)
28% 13% 11% 48%
Quick Clinical(GPs)
21% 32% 7% 40%
Hersh(Med students)
20% 31% 12% 36%
Hersh(Nursing)
18% 17% 14% 52%
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Searching made easy
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3. Rapid Critical Appraisal
It’s 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
10:45 TEA/COFFEE
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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