The Culture of Health Care

2. The Culture of Health Care Evidence-Based Practice Lecture b This material (Comp 2 Unit 5) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

3. Evidence-Based PracticeLearning Objectives • Define the key tenets of evidence-based medicine (EBM) and its role in the culture of health care (Lectures a, b). • Construct answerable clinical questions and critically appraise evidence answering them (Lecture b). • Explain how EBM can be applied to intervention studies, including the phrasing of answerable questions, finding evidence to answer them, and applying them to given clinical situations (Lecture c). • Describe how EBM can be applied to key clinical questions of diagnosis, harm, and prognosis (Lectures d, e). • Discuss the benefits and limitations to summarizing evidence (Lecture f). • Describe how EBM is used in clinical settings through clinical practice guidelines and decision analysis (Lecture g).

4. Making Evidence-Based Clinical Decisions (Mulrow, 1997) 5.1 Figure: Adapted from Mulrow, Cook, & Davidoff, 1997

5. Best Resources for EBM • Three major books: • Evidence-Based Medicine: How to Practice and Teach It, 4th edition, Straus, Richardson, Glasziou, and Haynes (2010) • Informally known as the “Sackett Book” for original author David Sackett • Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 3rd edition, Guyatt, Rennie, Meade, and Cook (2015) • Encyclopedic guide to principles and applications of EBM • Users’ Guides to the Medical Literature: Essentials of Evidence-Based Clinical Practice, 3rd edition, Guyatt, Rennie, Meade, and Cook (2015) • Handbook of the most clinically relevant content of the larger manual • Web sites: • Centre for Evidence-based Medicine: http://www.cebm.net • Centre for Health Evidence: http://www.cche.net • http://www.nettingtheevidence.org.uk

6. The Changing Nature of EBM (Hersh, 1999) • Initial approach ( “first generation”) was for clinician to find and critically appraise evidence • Too time consuming; clinicians lack expertise • More recent approach ( “next generation”) is synthesis and synopsis of evidence for clinician • Access to online, up-to-date information makes easier • Slawson & Shaughnessy (2005) argue for more emphasis on teaching information management (seeking) than on techniques of EBM

7. Another Viewpoint Concerning Evidence (Haynes, 1999) • Can it work? • Efficacy studies take place under “ideal” circumstances • This unit looks mainly at such studies • Does it work? • Effectiveness studies ascertain whether something works in the “real world” • Sometimes called “outcomes research” (Clancy & Eisenberg, 1998) • Is it worth it? • Cost-benefit or cost-effectiveness studies determine whether benefits worthwhile in relation to cost or other resources

8. Hierarchy of Evidence—The 4S Model (Haynes, 2001) Subsequently updated to 5S (Haynes, 2005) and 6S (DiCenso, 2009) models, but 4S is preferred 5.2 Figure: adapted from Haynes’s “4S” model of the Hierarchy of Evidence, 2001

9. Where the Evidence Comes From 5.3 Figure: Adapted from Haynes’s “S4” model of the Hierarchy of Evidence, 2001 with types and sources of evidence

10. Studies • Accessed (usually) in literature databases such as Medline • Most common and freely available system for accessing medical literature is PubMed, available at http://pubmed.gov • Retrieved from journals • Many now available electronically • Application of critical appraisal and formulas • For example, relative risk, number needed to treat, sensitivity, odds ratio

11. Syntheses • Systematic reviews • Exhaustive, systematic review of data on a topic • Not a simple literature review or overview of papers one knows about • Application, where appropriate, of meta-analysis, the combination of results from multiple studies in a single analysis • Studies must be appropriately similar, and there are methodological means to assess that • Available in PubMed or in specialized Pubmed Health http://www.ncbi.nlm.nih.gov/pubmedhealth

12. Synopses and Systems • Synopses—Highly summarized information appropriate for clinical setting, such as • Critically appraised topics (CATs) • Clinical Evidence, InfoPOEMS, PIER • Clinical practice guidelines • Systems—Decision support within electronic health record systems • Best way to provide evidence to clinicians at point of clinical decision making

13. Overview of the Application of EBM • Steps include • Phrasing a clinical question that is pertinent and answerable • Identifying evidence to address the question • Critically appraising the evidence to determine whether it applies to the patient

14. Phrasing the Clinical Question • Background vs. foreground questions • Background questions ask for general knowledge about a disorder • Usually answered with textbooks and classical review articles • Foreground questions ask for knowledge about managing patients with a disorder • Usually answered using EBM techniques

15. Background Questions • General information not specific to a given patient • Examples • What causes pneumonia? • When do complications of type I diabetes usually occur? • Distinction from foreground questions can be blurry • New etiologies of disease • Level of training (e.g., specialist vs. student)

16. Foreground Questions • Have three or four essential components (PICO) • Patient and/or problem • Intervention • Comparison intervention (if appropriate) • Outcomes • Example • In an elderly patient with congestive heart failure, are beta blockers helpful in reducing morbidity and mortality without excess side effects?

17. Four Categories of Foreground Questions • Intervention (or therapy)—Benefit of treatment or prevention • Diagnosis—Test diagnosing disease • Harm—Etiology or cause of disease • Prognosis—Outcome of disease course

18. Questions to Ask about the Results from Any Study • Are the results valid? • Are the results important? • Can the results be applied to patient care? Specific sub-questions depend on type of question and study

19. Evidence-Based PracticeSummary – Lecture b • There are many easily accessible resources for EBM • Approach has changed over the years • Can be best viewed from the 4S model demonstrating the hierarchy of evidence, based on a foundation of studies, brought together where possible by syntheses, summarized in synopses, and implemented in systems that make it actionable • When seeking evidence, it is critical to appropriately phrase the clinical question

20. Evidence-Based PracticeReferences – Lecture b References Centre for Evidence-Based Medicine. (n.d.). Retrieved from http://www.cebm.net Centre for Health Evidence. (n.d.). Retrieved from http://www.cche.net Clancy, C., & Eisenberg, J. (1998). Outcomes research: Measuring the end results of health care. Science, 282, 245–246. DiCenso, A., Bayley, L., & Haynes, R. (2009). ACP Journal Club. Editorial: Accessing preappraised evidence: Fine-tuning the 5S model into a 6S model. Annals of Internal Medicine, 151(6), JC3-2, JC3-3. Netting the Evidence. (2009, November 11). [Web blog]. Evidence-based medicine. Retrieved from http://www.nettingtheevidence.org.uk Guyatt, G., et al. (2015). Users’ guides to the medical literature: A manual for evidence-based clinical practice, 3rd ed. American Medical Association Guyatt, G., et al. (2015). Users' guides to the medical literature: Essentials of evidence-based clinical practice, 3rd ed. New York: McGraw-Hill. Haynes, R. (1999). Can it work? Does it work? Is it worth it? British Medical Journal, 319, 652–653. Haynes, R. (2001). Of studies, syntheses, synopses, and systems: The "4S" evolution of services for finding current best evidence. ACP Journal Club, 134, A11–A13. Haynes, R. (2006). Of studies, syntheses, synopses, summaries, and systems: The "5S" evolution of information services for evidence-based healthcare decisions. Evidence-Based Medicine, 11, 162–164.

21. Evidence-Based PracticeReferences – Lecture b Continued References Hersch, W. (2009). Information retrieval: A health and biomedical perspective. New York: Springer Verlag. Mulrow, C., Cook, D., & Davidoff, F. (1997). Systematic reviews: Critical links in the great chain of evidence. Annals of Internal Medicine, 126, 389–391. Slawson, D., & Shaughnessy, A. (2005). Teaching evidence-based medicine: Should we be teaching information management instead? Academic Medicine, 80, 685–689. Straus, S., & Glasziou, P. (2011). Evidence-based medicine: How to practice and teach it, 4th edition. Edinburgh: Elsevier Churchill Livingstone. U.S. National Library of Medicine. (n.d.). PubMed Health. For Researchers. Retrieved from https://www.ncbi.nlm.nih.gov/pubmedhealth/researchers/ U.S. National Library of Medicine. (n.d.). PubMed. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed

22. Evidence-Based PracticeReferences – Lecture b Continued 2 Charts, Tables, Figures 5.1 Figure: Adapted from Mulrow, C., Cook, D., & Davidoff, F. (1997). Systematic reviews: Critical links in the great chain of evidence. Annals of Internal Medicine, 126, 389–391. 5.2 Figure: Adapted from Haynes’s “4S” model of the Hierarchy of Evidence: Haynes, R. (2001). Of studies, syntheses, synopses, and systems: The "4S" evolution of services for finding current best evidence. ACP Journal Club, 134, A11–A13. 5.3 Figure: Adapted from Haynes’s “4S” model of the Hierarchy of Evidence with types and sources of evidence: Haynes, R. (2001). Of studies, syntheses, synopses, and systems: The "4S" evolution of services for finding current best evidence. ACP Journal Club, 134, A11–A13.

23. The Culture of Health CareEvidence-Based PracticeLecture b This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002.