Evidence-Based Practice April 8th 2013
Dr Carl Heneghan
Clinical Reader, University of Oxford Director CEBM


Developing Evidence-Based Practice?

Carl Heneghan MA, MRCGP
Centre for Evidence Based Medicine

University of Oxford

Practice of Evidence-Based Health Care

Day One (Monday)
Registration from 08:15 in Reception Coffee in the Common Rm

Day Two (Tuesday)

Day Three (Wednesday)

Session One 09:00 – 10:30

Welcome & Plenary: Intro into EBP (CH)

Plenary: Critical Appraisal of RCTs (KM) COFFEE
in the Common Room

Plenary: Appraising Diagnostic Studies (MT) COFFEE
in the Common Room

10:30 – 11:00

in the Common Room

Session Two 11:00 – 12:30 12:30 – 13:30

Small Group Work Qs & Abstracts LUNCH
In the Dining Room

Small Group Work

Small Group Work

In the Dining Room

In the Dining Room

Session Three 13:30 – 15:00

Plenary: Study Designs (JH)

Plenary: Systematic Reviews (SM)

Plenary: Ethical Issues and Critical thinking in EBHC (JH) COFFEE
in the Tawney Room

15:00 – 15:30 Session 4 15:30 – 17:00

13 Banbury Road

in the Common Room

Plenary: Searching Followed by computer lab (Nia)

Small Group Work

Developing Evidence Based Practice (CH)

16:30 Close 18:30 GALA DINNER Queens College

David Nunan & Sadeesh Srinathan .Small groups • Group 1 (Room 012) – Carl Heneghan & Khamis Elissi • Group 2 (Room 018) – Sharon Mickan & Claire Friedemann • Group 3 (Room 310) – Kamal Mahtani.

I am here because? •I wanted 3 days of work •Formulate an answerable questions www.cebm.net .

To develop focussed clinical questions . To recognize questions 3. To understand what is EBP 2.cebm.net 1.The aim of this session www.

net medicine is the integration of best research evidence with clinical expertise and patient values” .What is Evidence-Based Medicine? “Evidence-based www.cebm.

cebm.“Just in Time” learning The 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 www.net Dave Sackett .

cebm.net .www.

www.cebm.net .

cebm.net Would any of you have agreed to participate in a placebo controlled trial of prophylactic antibiotics for colorectal surgery after 1975? .www.

net .Reduction of perioperative deaths by antibiotic prophylaxis for colorectal surgery www.cebm.

net Would you ever have put babies to sleep on their tummies? .cebm.www.

cebm.www.net .

cebm.www.net .

they actually increased mortality. Not until a RCT was performed was it realized that. By the time the results of this trial were published. at least 100.Why do we need RANDOMIZED CONTROLLED TRIALS ? www. The CAST trial revealed Excess mortality of 56/1000. . although these drugs suppressed arrhythmias.net In the early 1980s newly introduced antiarrhythmics were found to be highly successful at suppressing arrhythmias.000 such patients had been taking these drugs.cebm.



What does CEBM do?





net 1. clinical relevance and applicability 4. Formulate an answerable question 2. Critically appraise the evidence for validity.cebm. Individualize.The 5 steps of EBM www. Track down the best evidence 3. Evaluate your own performance . based clinical expertise and patient concerns 5.

Getting Evidence in to Practice How do you “do” EBP? www.cebm.net • What Evidence based practice do you do/help with? • What other EBP do you know of? .

at risk for polythenia gravis and related conditions) * Modified from: BMJ 1995.311:1666-1668 .net J: Are you ambivalent about renewing your JOURNAL subscriptions? A: Do you feel ANGER towards prolific authors? S: Do you ever use journals to help you SLEEP? P: Are you surrounded by PILES of PERIODICALS? A: Do you feel ANXIOUS when journals arrive? YOUR SCORE? (0 TO 5) 0 (?liar) 1-3 (normal range) >3 (sick.cebm.JASPA* (Journal associated score of personal angst) www.

cebm. Registrars Consultants: 90 minutes 0 (up to 70%=none) 20 (up to 15%=none) 45 (up to 40%=none) 30 (up to 15%=none) www. Post 1975: • Grad.Median minutes/week spent reading about my patients: Self-reports at 17 Grand Rounds: • • • • • • Medical Students: House Officers (PGY1): SHOs (PGY2-4): Registrars: Sr.net • Grad. Pre 1975: 45 (up to 30%=none) 30 (up to 40%=none) .

200 drugs (cf FDAs 18. X-ray. signs.000 abnormalities (symptoms.283 products) To cover the vast field of medicine in four years is an impossible task.Size of Medical Knowledge www.255 concepts • 2. . lab.000 diseases • 30.net • NLM MetaThesaurus • 875.) • 3.cebm.William Olser .14 million concept names 1 disease per day for 30 years • Diagnosis Pro • 11.

cebm.net .How many randomized trials are published each year www.

Changes in the past 12 months A Survey of 43 EBM practitioners at 2009 EBM practice workshop www.cebm.net Changes in the last 12 months 40% 35% 30% 25% 20% 15% 10% 5% 0% 01 2 3 4 to 5 6 to 8 >8 .

But we are (currently) poorly equipped to tell good from bad research • BMJ study of 607 reviewers • 14 deliberate errors inserted www.22% Poor response rate .47% Not intention-to-treat analysis .cebm. accepted for Clinical Trials .net • Detection rates • • • • On average <3 of 9 major errors detected Poor Randomisation (by name or day) .41% Schroter S et al.

search. new.cebm. appraise.Managing Information “Push” and “Pull” methods • “Push” .alerts us to new information • “Just in Case” learning • Use ONLY for important. valid research www.net • “Pull” – access information when needed • “Just in Time” learning • Use whenever questions arise • EBM Steps: Question. apply .

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

net : Asking well-formulated questions In your books .www.cebm.

net At the present time she reports she is extremely diligent about taking her medications (lisinopril and aspirin) and wants desperately to stay out of the hospital. www.cebm. What are your questions? . has a slight cough. is an exsmoker of 20 cigs a day for 40 years. her ankles are slightly swollen and her ulcer is painful and her pulse is 80 and slightly irregular. She is mobile and lives alone with several cats but reports sometimes she forgets certain things.Angela is a new patient who recently moved to the area to be closer to her son and his family She is 69 years old and has a history of congestive heart failure brought on by a recent myocardial infarctions. Her BP today is 170/90. She has been hospitalized twice within the last 6 months for worsening of heart failure and has a venous leg ulcer. She also tells you she is a bit hard of hearing.

test. When. Root* + Verb: “What causes …” b.cebm.net • About the disorder. Condition: “… SARS?” • * Who. 2 components: a. Why. Where.„Background‟ Questions www. How . What. treatment. etc.

Comparison (if relevant) d.„Foreground‟ Questions www. Patient. exposure.cebm. or population b. Clinical Outcomes (including time horizon) . Intervention.net • About patient care decisions and actions 4 (or 3) components: a. problem. or maneuver c.

Background & Foreground www.cebm.net .

cebm.www.net .

cebm.net .www.

cebm.net .net www.www.cebm.

net .www.cebm.net www.cebm.

www.cebm.net .

‘Foreground’ Questions About patient care decisions and actions • 4 (or 3) components: • a. Compared to placebo • d. Do (I) corticosteroids • c. Improve facial function (O) at 3 months . In Patients with Bell’s Palsy • b.

net .www.cebm.net www.cebm.

net .cebm.www.net www.cebm.

net www.cebm.cebm.net For every 100 people with Bell’s palsy at 3 months • 83 in the corticosteroid group will have recovered facial function • 64 in the placebo group will have recovered facial function • Risk difference = 19% • Relative Risk Reduction = 23% • Number Needed to Treat = 6 .Does this intervention help? o www.

net P I C O . She tends to get swollen legs on these flights and is worried about her risk of developing deep vein thrombosis (DVT).cebm. www. She asks you if she would wear elastic stockings on her next trip to reduce her risk of this. because she has read quite a bit about this in the newspapers lately.Example 1 Jean is a 55 year old woman who quite often crosses the Atlantic to visit her elderly mother.

cebm. however. A friend if his . a smoker of more than 30 years. has come to see you about something unrelated .net Jeff. successfully quit with acupuncture.Example 2 www. He tells you he has tried to quit smoking unsuccessfully in the past. Should he try it? Other interventions you know about are nicotine replacement therapy and antidepressants P I C O . You ask him if he is interested in stopping smoking.

Lisa is very concerned that the same thing may happen again this time. a colleague told you that needle length can affect local reactions to immunisation in young children but you can‟t remember the precise details P I C O .cebm. Lisa. Recently.net At a routine immunisation visit.Example 3 www. the mother of a six-month-old tells you that her baby suffered a nasty local reaction after her previous immunisation.

net .cebm.www.

cebm.net .www.

P I C O Aetiology and risk factors .Example 4 www. if so. She has been reading about the potential benefits and harms of giving newborn babies vitamin K injections. what the risk for her baby will be.cebm. She is alarmed by reports that vitamin K injections in newborn babies may cause childhood leukaemia. She asks you if this is true and.net Susan is expecting her first baby in two months.

The test was negative but it was not a good experience.Example 5 www. You winder if this combination of tests is as reliable as a conventional amniocentesis .cebm. because she did not get the result until she was 18 weeks pregnant. The local hospital offers serum biochemistry plus nuchal translucency ultrasound screening as a first trimester test for Down syndrome. She had her first baby when she was 33 and had amniocentesis to find out if the baby had Down Syndrome. and asks if she can have a test that would give her an earlier result. She is now 35 and 1 month pregnant.net Julie is pregnant for the second time.

cebm. He visits you for confirmation of his diagnosis and information about the consequences. .net Mr Thomas. and the man asks „How likely is that?‟ You reply „pretty unlikely‟ (which is as much as you know at the time) but say that you will try to find out more precisely. who is 58 years old. has correctly diagnosed his inguinal lump as a hernia. You mention the possibility of strangulation.Example 6 www.

cebm.net • Write down one recent patient problem • What is the PICO of the problem? .Your Clinical Questions www.

net • • • • Recognize: your questions Select: which questions to pursue Guide: how to ask and answer Assess: how well & what to improve .cebm.Questions www.

net • Resilient • Reflective • Resourceful .The Real ‘Three R’s’ of Learning www.cebm.

cebm.FAQ: How Long … ? • Proficient? Quickly • Mastery? Lifetime • Human expertise takes >10. >10 years →Deliberate practice www.net .000 hours.

www.cebm.net Any questions? .

Sign up to vote on this title
UsefulNot useful