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The Protocol

The Protocol. At the time of discharge, death, or month’s end, each patient was reviewed and consensus reached on: ¶ The primary diagnosis: the disease, syndrome or condition most responsible for the patient’s admission to hospital. The Protocol (cont.). · The Primary Intervention

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The Protocol

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  1. The Protocol At the time of discharge, death, or month’s end, each patient was reviewed and consensus reached on: ¶The primary diagnosis: • the disease, syndrome or condition most responsible for the patient’s admission to hospital

  2. The Protocol (cont.) ·The Primary Intervention • the treatment or other manoeuvre that constituted our most important attempt to cure, alleviate, or care for the primary diagnosis • traced into the literature to determine its basis in evidence • the Consultant’s “Instant Resource Book” • bibliographic data base searches

  3. Primary Interventions were Classified by Level: • Evidence from Randomised Control Trials (better yet: systematic reviews of all relevant, high-quality RCTs) • Convincing non-experimental evidence (unnecessary & unethical to randomise) • Interventions without substantial evidence

  4. Conclusions from E-B oriented General Medicine: • 82% of our patients received evidence-based care. • treatments for 53% were justified by RCTs or systematic reviews of RCTs. • Of 28 relevant RCTs and SRs, 21 were accessible within seconds. • treatments for 29% were justified by convincing non-experimental evidence

  5. Evidence from RCTs (53%) • 36% had Cardiovascular diagnoses: • Ischaemic heart disease 17% • Heart failure 6% • Arrhythmia 2% • Thromboembolism 3% • Cerebrovascular 8%

  6. Evidence from RCTs (53%) • 7% had taken poison • 5% received chemotherapy or analgesia for cancer • 3 % had gastrointestinal disorders • 2% had obstructive airways disease

  7. Convincing non-experimental evidence (29%) • Infections 15% • Cardiac disorders 7% • Miscellany (non-compliance, drug reactions, bowel or bladder neck obstruction, dehydration, micturition syncope) 7%

  8. Interventions without substantial evidence (18%) • Specific symptomatic and supportive care for mild poisoning, non-cardiac chest pain, viral (non-herpetic) meningitis, terminal CNS disease, confusion, and food poisoning.

  9. Better Outcomes for Patients When EBM Is Practised • E-B practise vs. Outcome in stroke (US): • When cared for by E-B neurologists, patients were 44% more likely to receive warfarin, and much more likely to be placed in a stroke care unit, • And were 22% less likely to die in the next 90 days. (Mitchell et al: stroke 1996;27:1937-43)

  10. Centres for Evidence-Based Surgery • E-B General/Vascular Unit in Liverpool: • 95% received evidence-based Rx • 24% Level 1 • 71% Level 2 • E-B Paediatric Unit in Liverpool: • 77% received evidence-based Rx • 11% Level 1 • 66% Level 2

  11. Worse Outcomes for Patients When EBM Is Not Practised: • In a city-wide study of E-B practise vs. Outcome in carotid stenosis: • Generated E-B indications for endarterectomy and reviewed 291 pts. • Found the surgical indications: • Appropriate in 33% • Questionable in 49% • Inappropriate in 18%

  12. Worse Outcomes for Patients When EBM Is Not Practised • Stroke or death within the next 30 days: • Expected (if left alone): 0.5% • Expected (if properly selected and operated): 1.5% • Observed among operated patients (2/3 operated for questionable or inappropriate reasons): >5% Wong et al. Stroke 1997;28: 891-8.

  13. Evidence-Based Ambulatory Paediatrics • 54% of manoeuvres were evidence-based (“experts” had predicted <20%) • 77% of diagnostic manoeuvres • 67% of treatments • 59% of health promotion

  14. Centres for Evidence-Based Psychiatry • In-Patients (Oxford) • 67% treated on the basis of RCTs • Out-Patient • >80% received evidence-based Rx

  15. Evidence-Based General Practice 122 consecutive consultations in a suburban (Leeds, UK) practice. • 81% evidence-based: • 31% based on RCTs or overviews • 50% based on convincing non-experimental evidence • 19% without substantial evidence (Gill et al, BMJ 1996;312:819-21)

  16. Can we get evidence to the bedside? • Need it within seconds if it is to be incorporated into busy clinical rounds • Our initial attempts to bring the best evidence to a busy clinical team caring for 200+ admissions per month

  17. Searching for Evidence in the Month Before the Cart: • Expected searches = 98 • Identified searching needs = 72 • Only 19 searches (26%) carried out.

  18. Contents of the Cart: • Infra-red simultaneous stethoscope with 12 remote receivers. • Physical diagnosis text book and reprints (JAMA Rational Clinical Exam). • Notebook computer, computer projector, and pop-out screen. • Rapid printer.

  19. Contents of the Cart(cont):Library Round-Trip = 7 min • 125 summaries (1-3 pp) of evidence previously appraised and summarised by Side A teams (in the form of “Redbook” entries or Critically-Appraised Topics : “CATs”). Access Time to the “bottom line” = 12 sec.

  20. Contents of the Cart(cont):Library Round-Trip = 7 min • CD of Best Evidence Access Time to the “bottom line” = 26 sec. • CD of WinSPIRS (5-year clinical subsets) Access Time to useful abstract = 90 sec. (so used for filling Educational Rx after rounds) • CD of the Cochrane Library (used for filling Educational Rx after rounds)

  21. Usefulness of the Cart: • 81% of searches were for evidence that could affect diagnostic and/or treatment decisions. • 90% of these searches were successful in finding useful evidence. *

  22. Of the successful searches(from the perspective of the most junior responsible team member): • 52% confirmed diagnostic and/or management decisions • 23% led to changes in existing decisions • 25% led to additional decisions

  23. Searching for Evidence in a 3-day period after the Cart: • Expected searches = 10 • Identified searching needs = 41 • Only 5 searches (12%) carried out.

  24. Can we get evidence to the bedside? • Yes, and it will improve patient care. • But can we provide it in a less cumbersome form?

  25. EBM and Purchasing In harmony: Ê When we clinicians stop doing things that are useless or harmful ËWhen we use just-as-good but less expensive treatments, carers, and sites for care.

  26. What we could save in Oxford by switching from: LASIX ê frusemide: £ 90,000 simvastatin ê cerivastatin: £ 500,000 TENORMIN ê atenolol: £ 700,000 diclofenac ê ibuprofen: £ 1,000,000 Total: £ 2,290,000 • how many hips would these savings purchase?

  27. EBM and Purchasing Still in harmony: Ì When we spend now to save later.

  28. EBM and Purchasing In grudging collaboration: Í Waiting lists, once we understand the opportunity costs of shortening them: • it’s not about money • it’s about what else we won’t be able to do if we shorten them

  29. EBM and Purchasing In conflict: Î When we identify so strongly with a dying patient’s short-term goals that we use resources that we know would “add more QALYs” if used for other patients.

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