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