Introduction to Evidence-based Medicine Tony Myers MD 7/15/00.

Introduction to Evidence-based Medicine

Introduction to Evidence-based Medicine

Tony Myers MDTony Myers MD

7/15/007/15/00

GoalsGoals

Information MasteryInformation Mastery Why we need to changeWhy we need to change Patient-oriented evidence (POEM)Patient-oriented evidence (POEM) Keeping upKeeping up

Definition of EBMDefinition of EBM

““Integrating individual Integrating individual clinical clinical expertiseexpertise with the best available with the best available external external clinicalclinical evidenceevidence from from systematic research.”systematic research.”

David Sackett MDDavid Sackett MD

The GoalThe Goal

Keeping up with and critically Keeping up with and critically evaluating information so as to evaluating information so as to provide quality patient care and feel provide quality patient care and feel good about what we do.good about what we do.

Information Mastery

Are We Failing?Are We Failing?

Recognizing Failures In Communication Recognizing Failures In Communication And LearningAnd Learning

Fineberg 1987: Of 28 “Landmark” trials, Fineberg 1987: Of 28 “Landmark” trials, only 2 had an immediate (1-2 year) effect on only 2 had an immediate (1-2 year) effect on clinical practiceclinical practice

Publication to ImplementationAntman EM, Lau J, Kupelnick B, Mosteller F, and Chalmers TC.JAMA, 268:240-8, 1992

Publication to ImplementationAntman EM, Lau J, Kupelnick B, Mosteller F, and Chalmers TC.JAMA, 268:240-8, 1992

Lag time from time of “knowing” to time of implementationLag time from time of “knowing” to time of implementation

13 yrs for thrombolytic therapy.13 yrs for thrombolytic therapy. 10 yrs for corticosteroids to speed fetal 10 yrs for corticosteroids to speed fetal

lung maturity.lung maturity.

Are We Failing?Are We Failing?

Ramsey P G, et al. Ramsey P G, et al. Changes over time in the Changes over time in the knowledge base of practicing internistsknowledge base of practicing internists. JAMA . JAMA 1991; 266:1103-7.1991; 266:1103-7.

Sackett D L, et al, Sackett D L, et al, Clinical determinants of the Clinical determinants of the decision to treat primary hypertension.decision to treat primary hypertension. Clinical Clinical Research 1977; 24:648.Research 1977; 24:648.

Statistically and clinically significant negative Statistically and clinically significant negative correlation between our knowledge of up-to-date correlation between our knowledge of up-to-date care and the years that have elapsed since our care and the years that have elapsed since our graduation from medical school.graduation from medical school.

FactFact

New types of evidence are now being New types of evidence are now being generated which, when we know and generated which, when we know and understand them, create frequent, understand them, create frequent, major changes in the way we care for major changes in the way we care for our patients.our patients.

What Are We Doing?What Are We Doing?

CMECME GuidelinesGuidelines ExpertsExperts ReadingReading

Does CME Work?Does CME Work?

Davis D A, et al. Davis D A, et al. Changing physician performance. Changing physician performance. A systematic review of the effect of continuing A systematic review of the effect of continuing medical education strategiesmedical education strategies. JAMA 1995; 274: . JAMA 1995; 274: 700-1.700-1.

Sibley J C, Sibley J C, A randomized trial of continuing A randomized trial of continuing medical educationmedical education. N Engl J Med 1982; 306: 511-5. . N Engl J Med 1982; 306: 511-5.

ConclusionConclusion Traditional CME in a nice place with pleasant after lecture Traditional CME in a nice place with pleasant after lecture

diversions is, unfortunately, completely ineffective in diversions is, unfortunately, completely ineffective in changing our behavior.changing our behavior.

What About Guidelines?What About Guidelines?

Guidelines can be very usefulGuidelines can be very useful ProblemsProblems

Surprise! They don’t all agree.Surprise! They don’t all agree. Which ones do we use? (Determining Which ones do we use? (Determining

validity)validity) How do we implement? (How do we How do we implement? (How do we

remember to do what they say?)remember to do what they say?) Once validity is established they can be an excellent Once validity is established they can be an excellent

resourceresource

The Experts ?The Experts ?

Remember, they’re in the same position we Remember, they’re in the same position we are with information overload.are with information overload.

They often look at a patient and a disease in They often look at a patient and a disease in a fundamentally different way because they a fundamentally different way because they deal with a selected patient population.deal with a selected patient population.

Excellent resource once reliability has been Excellent resource once reliability has been established. established.

Do We Read ?Do We Read ?

Self-reported reading time per week. Self-reported reading time per week. (University setting)(University setting) Medical studentsMedical students 60 min.60 min. InternsInterns nonenone Senior residentsSenior residents 10 min.10 min. FellowsFellows 45 min.45 min. Attendings graduatingAttendings graduating

Post 1975Post 1975 60 min.60 min. Pre 1975Pre 1975 30 min.30 min.

Do We Read?Do We Read?

University of VirginiaUniversity of Virginia Mailing to primary care physiciansMailing to primary care physicians

50% had not read a medical journal 50% had not read a medical journal article in the last year.article in the last year.

The most commonly sited source of The most commonly sited source of information was pharmacutical information was pharmacutical representatives.representatives.

Why Don’t We Read ?Why Don’t We Read ?

We’re lazy? We’re lazy? The fact of the matter is that none of us The fact of the matter is that none of us

likes feeling out of date. We like it so little likes feeling out of date. We like it so little in fact that we are willing to work at night in fact that we are willing to work at night and on weekends in an effort to stay and on weekends in an effort to stay current. current.

Frustration.Frustration. Conflicting informationConflicting information No one taught us HOW or WHAT to read.No one taught us HOW or WHAT to read.

Running ScoreRunning Score

Traditional CME - doesn’t work.Traditional CME - doesn’t work. Guidelines - difficult to determine Guidelines - difficult to determine

validity and difficult to implement.validity and difficult to implement. Experts - deal with a different patient Experts - deal with a different patient

population.population. Reading - we don’t do it.Reading - we don’t do it.

The Magic BulletThe Magic Bullet

??

Evidence-Based MedicineEvidence-Based Medicine

“ “ Computer”Computer”

“ “ Yes Doctor”Yes Doctor”


“ “ I have a 65 y.o. woman with a blood I have a 65 y.o. woman with a blood pressure of 159/92. She has pressure of 159/92. She has osteoporosis and mild reactive airway osteoporosis and mild reactive airway disease but is otherwise healthy. What disease but is otherwise healthy. What is the best treatment for her?”is the best treatment for her?”


“ “ Since I know you are a skilled Since I know you are a skilled clinician, I’m sure you confirmed the clinician, I’m sure you confirmed the elevated BP on at least two separate elevated BP on at least two separate occasions after 5 min of rest, with the occasions after 5 min of rest, with the patient sitting, and with the patient sitting, and with the appropriate sized cuff.”appropriate sized cuff.”


“ “ Of course. Could you speed this up. Of course. Could you speed this up. Ms. Jones has been waiting for 10 Ms. Jones has been waiting for 10 min. and you know how she gets when min. and you know how she gets when her hemorrhoids flair.”her hemorrhoids flair.”


““Yes doctor, I’m sorry for questioning your Yes doctor, I’m sorry for questioning your competence. According to a high quality competence. According to a high quality guideline, the JNC6, published in 1997, guideline, the JNC6, published in 1997, your patient would benefit most from your patient would benefit most from education about HTN and self-monitoring education about HTN and self-monitoring has well as a 6 month trial of lifestyle has well as a 6 month trial of lifestyle modification including weight reduction, modification including weight reduction, exercise, moderation of alcohol intake, exercise, moderation of alcohol intake, decreased dietary sodium,…”decreased dietary sodium,…”


““Yes, yes I know all that. Anything Yes, yes I know all that. Anything else.”else.”


““As a matter of fact there is. If the above As a matter of fact there is. If the above measures are unsuccessful the guideline measures are unsuccessful the guideline suggests initiating a diuretic at a low suggests initiating a diuretic at a low dose since this class has been shown to dose since this class has been shown to decrease mortality rates from decrease mortality rates from cerebrovascular and cardiovascular ds. cerebrovascular and cardiovascular ds. It may also benefit her osteoporosis and It may also benefit her osteoporosis and should have no effect on her should have no effect on her bronchospastic ds.”bronchospastic ds.”


““Thank you computer. Now start Thank you computer. Now start searching for new hemorrhoid searching for new hemorrhoid treatments while I go see Ms. Jones”treatments while I go see Ms. Jones”

LimitsLimits

HumanHuman Excellent complex thinking skillsExcellent complex thinking skills Poor memoryPoor memory

ComputerComputer Excellent memoryExcellent memory Poor complex thinking skillsPoor complex thinking skills

What Works NowWhat Works Now

Reminder systemsReminder systems Outreach visits Outreach visits Patient education (then patients Patient education (then patients

educate their doctors)educate their doctors) Conversion of local opinion leaders.Conversion of local opinion leaders.

What Works NowWhat Works Now

Shin JH, et al. Shin JH, et al. Effect of problem-based, self-Effect of problem-based, self-directed medical education on life-long learningdirected medical education on life-long learning. . Can Med Assoc J 1993; 148: 969-76.TCan Med Assoc J 1993; 148: 969-76.T

Learning how to evaluate information for Learning how to evaluate information for relevance and validity. (Information relevance and validity. (Information Mastery).Mastery).

Bottom LineBottom Line

We need to learn not only We need to learn not only whatwhat to to read but read but how how to critically evaluate to critically evaluate

the medical literature.the medical literature.

Reasons For ReadingReasons For Reading

Keeping upKeeping up Patient-specific questions (point of Patient-specific questions (point of

care)care) Information at the Point of Care: Answering Information at the Point of Care: Answering

Clinical Questions, Ebell, M., JABFP, May Clinical Questions, Ebell, M., JABFP, May 1999.1999.

This is where texts online or other, reviews, and This is where texts online or other, reviews, and guidelines are most useful. guidelines are most useful.

The Usefulness EquationThe Usefulness Equation

UsefulnessUsefulness = = ValidityValidity x x RelevanceRelevance

of any sourceof any source WorkWork

ValidityValidity

The hard part of Information MasteryThe hard part of Information Mastery The “Truth”-Probability statement that The “Truth”-Probability statement that

what we do does more good than harm.what we do does more good than harm. Evidence-based Medicine, 1997, Sackett, D. Evidence-based Medicine, 1997, Sackett, D.

et al.et al. WorksheetsWorksheets

Determining RelevanceDetermining Relevance

Will this information have a direct Will this information have a direct bearing on the health of my patients (is bearing on the health of my patients (is it something they care about)?it something they care about)?

Is the problem common to my Is the problem common to my practice?practice?

If true, will it require me to change my If true, will it require me to change my current practice?current practice?

WorkWork

Basic law of human behavior: lowest Basic law of human behavior: lowest amount of work you can get away withamount of work you can get away with

The Usefulness EquationThe Usefulness Equation

UsefulnessUsefulness = = ValidityValidity x x RelevanceRelevance

of any sourceof any source WorkWork

Relevance: Type of EvidenceRelevance: Type of Evidence

POEPOE: Patient-oriented evidence : Patient-oriented evidence mortality, morbidity, quality of lifemortality, morbidity, quality of life

DOEDOE: Disease-oriented evidence: Disease-oriented evidence pathophysiology, pharmacology, etiologypathophysiology, pharmacology, etiology

POEMPOEM

Patient-OrientedPatient-Oriented EvidenceEvidence that Mattersthat Matters

matters to you, the clinician, because, if matters to you, the clinician, because, if valid, it will valid, it will requirerequire you to you to changechange your your practicepractice

Comparing DOES and POEMsComparing DOES and POEMsExample Disease-Oriented

EvidencePatient-Oriented

Evidence thatMatters

Comment

Antiarrhythmictherapy

Antiarrhythmic drugX decreases PVCs onECGs

Antiarrhythmic drugX increases mortality

The results of thePOEM study arecontrary to what theDOE study wouldsuggest

Antihypertensivetherapy

Antihypertensive drugtreatment lowersblood pressure

Antihypertensive drugtreatment decreasesmortality

The results of thePOEM study are inconcordance withwhat the DOE studywould suggest

Screening forprostate cancer

PSA screening detectsprostate cancer at anearly stage

Unknown whetherPSA screeningreduces mortality fromprostate cancer

Although DOE exists,the important POEMis currently unknown

Feeling Good About Not Knowing Everything:Information Mastery

Feeling Good About Not Knowing Everything:Information Mastery

Prioritize efforts to Prioritize efforts to identifyidentify, , validatevalidate, and , and applyapply common POEMs common POEMs

Responsibility: Responsibility: less to read, but more less to read, but more important to find and evaluateimportant to find and evaluate

Consider work factor with rare POEMsConsider work factor with rare POEMs Ignore and avoid rare DOEsIgnore and avoid rare DOEs

Keeping UpKeeping Up

Concentrate on “high yield” journals with Concentrate on “high yield” journals with favorable POEM:DOE ratiofavorable POEM:DOE ratio

Scan table of contents for titles of interestScan table of contents for titles of interest Consider three questions to determine Consider three questions to determine

relevancerelevance Patient-orientedPatient-oriented Common to practiceCommon to practice Require change of practiceRequire change of practice

Medical JournalsMedical Journals

““Knowledge creation” vs. Knowledge creation” vs. “translation” journals“translation” journals

Knowledge creation journalsKnowledge creation journals Good for keeping up: temptation to Good for keeping up: temptation to

bypassbypass Fountain from which all knowledge flows Fountain from which all knowledge flows

Academic translation journals vs Academic translation journals vs Throw-awaysThrow-aways

Academic Translation JournalsAcademic Translation Journals

Evidence-based MedicineEvidence-based Medicine www.acponline.org/jounals/ebm/www.acponline.org/jounals/ebm/

ebmmenu.htmebmmenu.htm

Evidence-based PracticeEvidence-based Practice jfp.msu.edu/ebp.htmjfp.msu.edu/ebp.htm

JFP POEMSJFP POEMS jfp.msu.edujfp.msu.edu

High Yield JournalsHigh Yield Journals

> 10% POEMs> 10% POEMs: JAMA, Ann Int Med, : JAMA, Ann Int Med, NEJM, JABFP, JFP, Arch Int Med, NEJM, JABFP, JFP, Arch Int Med, Am J Em MedAm J Em Med

10 or more POEMs10 or more POEMs: JAMA, Ann Int : JAMA, Ann Int Med, NEJM, Arch Int Med, BMJ, Med, NEJM, Arch Int Med, BMJ, Ob/GynOb/Gyn

ConclusionsConclusions

Read few, only if forcedRead few, only if forced Get rid of “bedside” stackGet rid of “bedside” stack Use time for other things (e.g.., letters Use time for other things (e.g.., letters

to the editor, JFP POEMs/ACP Journal to the editor, JFP POEMs/ACP Journal clubs, EBM, monthly searches)clubs, EBM, monthly searches)

Determining RelevanceDetermining Relevance

Will this information have a direct Will this information have a direct bearing on the health of my patients (is bearing on the health of my patients (is it something they care about)?it something they care about)?

Is the problem common to my Is the problem common to my practice?practice?

If true, will it require me to change my If true, will it require me to change my current practice?current practice?

Great QuotesGreat Quotes

““Don’t confuse me with the facts, my mind’s Don’t confuse me with the facts, my mind’s already made up”already made up”

““I wouldn’t believe this crap even if it were I wouldn’t believe this crap even if it were true”true”

““When I think back on all the crap I learned in When I think back on all the crap I learned in high school, it’s a wonder I can think at all”high school, it’s a wonder I can think at all”

"I know that most men (sic), including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they have proudly taught to others, and which they have woven, thread by thread, into the fabric of their lives.” Leo Tolstoy

"I know that most men (sic), including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they have proudly taught to others, and which they have woven, thread by thread, into the fabric of their lives.” Leo Tolstoy

Introduction to Evidence-based Medicine Tony Myers MD 7/15/00.

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Transcript of Introduction to Evidence-based Medicine Tony Myers MD 7/15/00.