Translating Evidence into Practice

Danny Liew

Melbourne EpiCentreMedical Unit 1

Application of Evidence in Practice

• education and training

• access to, and interpretation of,

evidence

• identifying and overcoming barriers

• culture change

• outcomes research: ‘practice-based

evidence’

Overview

• (the problem with) evidence-based

practice

• outcomes research

– comparative effectiveness research

– health technology assessment

Evidence-Based Practice

Efficacy vs Effectiveness

• efficacy: intervention ‘works’ in a

research (clinical trial) setting

• effectiveness: intervention ‘works’ in

the real-life setting

often a large gap

• circumscribed populations

• focus: benefit >> harm

• artificial environment

• short-term

• ?competing morbidity and

mortality

• ?costs

Clinical Trial vs Real-Life Settings

Can it work?(Efficacy)

Does it work?(Effectiveness)

Is it worth it?(Cost-Effectiveness)

Evidence generation

Evidence synthesis

Decision-making

Evidence-Based Practice

Luce BR et al. Milbank Q. 2010;88:256-76.

Can it work?(Efficacy)

Does it work?(Effectiveness)

Is it worth it?(Cost-Effectiveness)

Evidence generation

Evidence synthesis

Decision-making

Clinicalguidelines

Clinicaltrials

Clinicalpractice

Healthpolicy

Regulatoryapproval

Systematicreviews

EBP - Current View

Variousmethods

Modified from: Luce BR et al. Milbank Q. 2010;88:256-76.

Can it work?(Efficacy)

Does it work?(Effectiveness)

Is it worth it?(Cost-Effectiveness)

Evidence generation

Evidence synthesis

Decision-making

Clinicalguidelines

Clinicaltrials

Clinicalpractice

Healthpolicy

Regulatoryapproval

Systematicreviews

Comparativeeffectiveness

research

Healthtechnologyassessment

EBP - Ideal View

Epidemiology,Registries

Modified from: Luce BR et al. Milbank Q. 2010;88:256-76.

Cost data

Comparative Effectiveness Research

Aspirin for Primary Prevention in the Elderly

BMJ. doi:10.1136/bmj.38456.676806.8F (published 20 May 2005)

Aspirin for Primary Prevention in the Elderly

BMJ. doi:10.1136/bmj.38456.676806.8F (published 20 May 2005)

Aspirin for Primary Prevention in the Elderly

Health Technology Assessment

dominated

dominant

net health gain

net health loss

net positive costs

net negative costs

(cost saving)

x

incremental cost-effectiveness ratio= net cost/net health effect

Cost-Effectiveness Plane

Aspirin in At-Risk Groups

Cardiovasc Ther. 2011. doi: 10.1111/j.1755-5922.2011.00291.x.

Summary

• beyond efficacy, EBP should

encompass effectiveness and cost-

effectiveness

• ‘practice-based evidence’: 2-way

street between research and practice

• rich source of relevant data available

in hospital settings

© Copyright The University of Melbourne 2008

Aspirin for Primary Prevention

Ann Intern Med. 2002;136:161-72.

McKeon Review

total years lived

quality-adjusted life years (QALYs) lived

Summary Health Measures

current best practice

new intervention

Statins for Primary Prevention in Korea

Clin Ther. 2009;31:2919-30.

Heart Lung Circ. 2009;18:388-92.

Application of Evidence in Practice

Health Services Research

Health servicesevaluation*

Can it work?(Efficacy)

Does it work?(Effectiveness)

Is it worth it?(Cost-Effectiveness)

Evidence generation

Evidence synthesis

Decision-making

Clinicalguidelines

Clinicaltrials

Clinicalpractice

Healthpolicy

Regulatoryapproval

Systematicreviews

Comparativeeffectiveness

research

Healthtechnology

assessment*

EBP - Ideal View

Epidemiology,Registries

*Health services research = HTA + HSE + other

Modified from: Luce BR et al. Milbank Q. 2010;88:256-76.

Cost data