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Evidence-Based Practice

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.

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Evidence-Based Practice

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  1. Evidence-Based Practice Paul Glasziou University of Queensland & Oxford

  2. 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

  3. JASPA*(Journal associated score of personal angst) J: Are you ambivalent about renewing your JOURNALsubscriptions? A: Do you feel ANGER towards prolific authors? S: Do you ever use journals to help you SLEEP? P: Are you surrounded by PILESof PERIODICALS? A: Do you feel ANXIOUS when journals arrive? 0 (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions) * Modified from: BMJ 1995;311:1666-1668

  4. Rule 31 – Review the World Literature Fortnightly* *"Kill as Few Patients as Possible" - Oscar London 5,000? per day 1,400 per day 55 per day

  5. The Airline industry Boeing 777 manuals 24 binders 10 feet shelf space Conversion to CD Reduced search by 60% The Health Industry Memorize “the manuals” Exams, audits, etc to check Managing Information

  6. Systematic review of bed rest after medical procedures • 10 trials of bed rest after spinal puncture • no change in headache with bed rest • Increase in back pain • Protocols in UK neurology units - 80% still recommend bed rest after LPSerpell M, BMJ 1998;316:1709–10 • …evidence of harm available for 17 years preceding... Allen, Glasziou, Del Mar. Lancet, 1999

  7. 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.

  8. 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 arise • EBM Steps: Question; search; appraise; apply

  9. 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

  10. “Just in Time” learning:Intern’s information needs • Setting: 64 residentsat 2 New Haven hospitals • Method: Interviewed after 401 consultations • Questions • Asked 280 questions (2 per 3 patients) • Pursued an answer for 80 questions (29%) • Not pursued because • Lack of time • Forgot the question • Sources of answers • Textbooks (31%), articles (21%), consultants (17%) Green, Am J Med 2000

  11. 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

  12. Your Clinical Questions • Write down one recent patient problem • What was the critical question? • Did you answer it? If so, how?

  13. Information “pull”Steps in EBM process • Formulate an answerable question • Track down the best evidence • Critically appraise the evidence • Integrate with clinical expertise and patient values

  14. 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?

  15. 1. The question • Does a normal ECG rule out a serious elevation of potassium? • Population - In suspected hyperkalemia • Indicator - does a normal ECG • Comparator - • Outcome - rule out hyperkalemia?

  16. 1. The question • Does a normal ECG rule out a serious elevation of potassium? • Population – hyperkal* • Indicator – ECG OR EKG • Comparator - • Outcome – hyperkal* • Underline keywords; think of synonyms

  17. PubMed via Google Diagnosis button “OR” synonyms * Means any letters

  18. Diagnosis button

  19. Sensitivity of 62% or 55%

  20. Step 2:The “best” evidence depends on the type of question • What are the phenomena/problems? • Observation (e.g., qualitative research) • What is frequency of the problem? (FREQUENCY) • Random (or consecutive) sample • Does this person have the problem? (DIAGNOSIS) • Random (or consecutive) sample with Gold Standard • Who will get the problem? (PROGNOSIS) • Follow-up of inception cohort • How can we alleviate the problem? (INTERVENTION/THERAPY) • Randomised controlled trial

  21. Treating hyperkalemia • She refused to go to hospital • Resonium A, but it is around $100 (RPBS but not PBS) which she could not afford. • My search had mentioned albuterol as a treatment.

  22. Dave Sackett “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

  23. The Barriers to EBP • Attitude of question & inquiry • Know-how in finding, appraising, and applying evidence • Information Resources on tap • Lack of Time

  24. EBP in Teams • Question focused journal clubs • Structure: • Appraise & apply “homework” article • New questions? Discuss & assign • Plan and monitor changes • Are there barriers to the change? • Can we measure the change?

  25. EBP for Teams: example • Initial “EBP lunch” questions on annual check • TRIGGER: Is blood monitoring better than urine monitoring in NIDDM? – No; give patients option • Session 1: formulate questions • Should all diabetics be on aspirin? – Most; audit • Are aerobic or resistance exercises helpful for diabetic control? – Both improve control; audit; purchased 12 pedometers • (Subsequent sessions) • Who needs to see the podiatrist? – High risk • What is the best test for neuropathy? - Monofilament • How can we improve compliance? • When should oral medications be started?

  26. Using evidence for prioritising • Q: Which diabetics need podiatry? • PLAN • Current wait time is 3 Months • About half workload is diabetics • Cohort study shows 2% ulcers/yr with 5 risk factors • Current ulcer • Past ulcer • Neuropathy • Deformity • Poor pulses Abbot. Diab ed 2002: 377-84

  27. 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

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