ebhckt ksu edu sa Ebhckt ksu edu sa

ebhc-kt. ksu. edu. sa Ebhc-kt. ksu. edu. sa Evidence-Based Health Care (EBHC): The Basics

ebhc-kt. ksu. edu. sa Aims/Objectives What is EBM/ EBHC? Why the sudden interest in EBM/EBHC? How to do it? ü 5 steps üStep 1 - PICO formulation The way forwards. . .

ebhc-kt. ksu. edu. sa Pause for Thought For three minutes • Why this session is important? • What is EBM • What are the • Benefits ? ? First alone then 2 -3 in group

ebhc-kt. ksu. edu. sa What Is EBM? • EBM is a style of practice in which doctors manage problems by reference to valid and relevant information.

ebhc-kt. ksu. edu. sa What Is EBM? • EBM is the conscientious, conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients. (Sackett, et al 1992)

ebhc-kt. ksu. edu. sa What Is EBM? Best research evidence Clinical expertise Patient’s values & expectations (Sackett, et al 1996)

The patient should be involved in all important decisions But this isebhc-kt. ksu. edu. sa NOT always an easy task! Ebhc-kt. ksu. edu. sa And conflicts WILL occur!

No salt? Lose weight? Forget it! Just give me a pill! I WON’T take that medicine… The side effects are INTOLERABLE! ebhc-kt. ksu. edu. sa Ebhc-kt. ksu. edu. sa And conflicts WILL occur! But doctor, I DO want to have children!

No salt? Lose weight? Forget it! Just give me a pill! I WON’T take that medicine… The side effects are INTOLERABLE! But doctor, I DO want to have children! ebhc-kt. ksu. edu. sa Education about current alternatives and risks is often needed… for both the Patient and the Doctor!

Wow… I never knew that high blood pressure could be so dangerous at my age! Yes, I’d like to try that new medication! I’ll discuss those risks with my husband. ebhc-kt. ksu. edu. sa Education about current alternatives and risks is often needed… for both the Patient and the Doctor!

EBM, EBCP & EBHC ebhc-kt. ksu. edu. sa EBM EBCP EBHC

ebhc-kt. ksu. edu. sa Is It Something New? ü The term ü Formalization of the process ü The systems and technology X THE ACTIVITIES

Some milestones in the history of EBM ebhc-kt. ksu. edu. sa James Lind publishes review & clinical trial in Treatise on Scurvy 900 AD Bradford-Hill publishes Principles of Medical Statistics & MRC trial of streptomycin 1780 Al-Rhazi For I once saved one group by it, while I intentionally neglected another group. By doing that, I wished to reach a conclusion. Pierre Louis Develops his “numerical method” and changes blood letting practice in France 1840 1937/48 1967 Alvan Feinstein publishes his book Clinical Judgement 1970’s

Unexpected Bad Effects ebhc-kt. ksu. edu. sa

Hoped-For Effects That Don’t Materialise ebhc-kt. ksu. edu. sa HRT and heart attacks

ebhc-kt. ksu. edu. sa T The Cochrane Collaboration Logo It shows how pooling data reveals the significance of treatment effect

ebhc-kt. ksu. edu. sa Our daily need for valid information . 1 Diagnosis Therapy Prognosis Prevention

ebhc-kt. ksu. edu. sa The inadequacy of traditional sources of information • • Textbooks - out of date Experts - frequently wrong Didactic CME - ineffective Didactic CME Medical journals – Medical journals Overwhelming in volume Variable in validity . 2

Medical Articles Per Year ebhc-kt. ksu. edu. sa 5, 000? per day 1, 500 per day 95 per day

Where’s the Meat in Clinical Journals? Top 20 Journals Contributing to ACPJC in 1992 ebhc-kt. ksu. edu. sa Journal N Engl J Med JAMA Ann Intern Med Lancet Arch Intern Med BMJ J Intern Med # articles with abstract % articles meeting criteria 254 303 246 410 262 283 157 16. 9 12. 2 13. 4 7. 3 10. 3 8. 5 10. 8

ebhc-kt. ksu. edu. sa Our inability to set aside time to find & assimilate the evidence

Our inability to set aside time to find assimilate the evidence ebhc-kt. ksu. edu. sa Median minutes/week spent reading about ‘my patients’*: patients • • • House officers (PGY 1): SHOs (PGY 2 -4): Registrars: Sr. registrars Consultants Post 1975: Consultants Pre 1975: 0 20 45 30 (up to 70%=none) (up to 15%=none) (up to 40%=none) (up to 15%=none) (up to 30%=none) (up to 40%=none) *Self-reports at 17 Grand Rounds (Internal Medicine)

ebhc-kt. ksu. edu. sa 23 L. Al-Ansary: EB-CPGs

5 Steps of EBM: 5 As ebhc-kt. ksu. edu. sa • • • Asking Accessing Appraising Applying Assessing

ebhc-kt. ksu. edu. sa Now That I Know What I Am Supposed to Do, How Do I Actually Do It? 25 L. Al-Ansary: EB-CPGs

ebhc-kt. ksu. edu. sa • Asking 5 Steps of EBM: 5 As

Background and Foreground ebhc-kt. ksu. edu. sa Questions

Background and Foreground Qs ebhc-kt. ksu. edu. sa Foreground Qs Background Qs Novice Expert A 28 B Experience with Condition C

Foreground Questions ebhc-kt. ksu. edu. sa PICO 1. Patient and/or problem. 2. Intervention/indicator. 3. Comparison intervention (if relevant). 4. Clinical outcomes.

Clinical Scenario ebhc-kt. ksu. edu. sa Mrs. FATMA is an educated patient who presents with a complaint of fatigue and loss of interest in her usual activities. She denies any suicidal ideation, and has a normal history and physical examination. After diagnosing her with minor depression, you are preparing to write a prescription for a serotonin specific reuptake inhibitor (SSRI). She asks, what about St. John’s Wort? You wonder: “Is St. John’s Wort a reasonable choice for this patient? ” Blossom of St. John’s Wort (Hypericum perforatum)

Clinical Scenario ebhc-kt. ksu. edu. sa • Patient/problem Adults with minor depression • Intervention St. John’s Wort • Comparison intervention SSRI • Outcome(s) Relief of symptoms “In adults with minor depression, is St. John’s Wort or an SSRI more effective at relieving symptoms? ”

ebhc-kt. ksu. edu. sa To formulate clinical questions: – Population – Intervention – Comparison – Outcome

Why Bother Formulating Qs Clearly? ebhc-kt. ksu. edu. sa cus our scarce learning time on evidence that: § Is directly relevant to our patient needs. § Directly addresses our particular knowledge needs. To suggest high yield search strategies § PICO § Study design

Why Bother Formulating Qs Clearly? ebhc-kt. ksu. edu. sa To communicate clearly with colleagues when sending or receiving patients in referral To suggest the forms that useful answers might take To help learners understand the content of what we teach Personal satisfaction

5 Steps of EBM: 5 As ebhc-kt. ksu. edu. sa • • • Asking Accessing Appraising Applying Assessing

Problems in Posing Answerable Questions ebhc-kt. ksu. edu. sa 1. When we‘re puzzled by a patient but don’t know where to start. Therapy Diagnosis Prognosis

Problems in Posing Answerable Questions ebhc-kt. ksu. edu. sa 2. When we have trouble articulating the question.

Examples where POE does not ebhc-kt. ksu. edu. sa confirm DO (surrogate) end points Disease and intervention DOE Ventricular arrhythmia after MI and use of lidocaine prophylaxis Decreased risk of ventricular arrhythmia Heart failure and use of digoxin Increase in exercise tolerance Blood lipid lowering and clofibrate Lowered lipid concentration POE Increase in mortality No effect on mortality Increased non-cardiac mortality

Problems in Posing Answerable Questions ebhc-kt. ksu. edu. sa 3. When we have more questions than time. Prioritize Qs !

The best evidence for different types of question ebhc-kt. ksu. edu. sa Level Treatment Prognosis Diagnosis I Systematic Review of … II Randomised trial Inception Cohort Cross sectional III

Types of Studies ebhc-kt. ksu. edu. sa Question Best study design Intervention RCT Aetiology & risk factors Frequency & rate RCT/ Cohort/ Case-control Cohort / Cross-sectional Diagnosis Cross-sectional with random or Prognosis Phenomena Cohort/ survival Qualitative consecutive sample In each case, a systematic review of all available studies is better than an individual study

Steps to Improve Your Ability to ebhc-kt. ksu. edu. sa Ask and Answer Questions • The educational prescription/Logbook.

Steps to Improve Your Ability to Ask and Answer Questions ebhc-kt. ksu. edu. sa • Create a culture of inquiry Inquire, don’t advocate “What do you think? ” “Should I keep doing this? ” “I wonder whethere is a better way? ”

Steps to Improve Your Ability to Ask and Answer Questions ebhc-kt. ksu. edu. sa • Feel good about not knowing everything. Only 2% of the medical literature is POEMs

Steps to Improve Your Ability to Ask and Answer Questions ebhc-kt. ksu. edu. sa • Let someone else do the heavy lifting Secondary literature:

ebhc-kt. ksu. edu. sa THANK YOU