Evidence Based Practice Workshop with Dr. Carl Heneghan

Evidence Based Practice Workshop with Dr. Carl Heneghan
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Join Dr. Carl Heneghan, Director of CEBM at the University of Oxford, for a 3-day workshop on Evidence Based Practice. Learn how to apply evidence to clinical decisions and improve patient care. Also, attend a one day program on EBP. Register now at www.cebm.net.

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Slide1www.cebm.net3-Day workshop on Evidence-Based Practice March 26 th  2012 Dr Carl Heneghan Director CEBM Clinical Reader, University of Oxford

Slide2 www.cebm.netOne-Day EBP Workshop Program

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Slide4 www.cebm.netI  am  here  because? I  am  here  because? What  do  you  hope  to  achieve by  the  end  of  3  days? What  do  you  hope  to  achieve by  the  end  of  3  days?

Slide5 www.cebm.netThe aim of Day 1 1. To understand what is EBP 2. To recognize questions 3. To develop focussed clinical questions 4. To find answers to your clinical questions 5. To assess the validity of an RCT

Slide6 www.cebm.netWhat is Evidence-Based Medicine? “ Evidence-based medicine is the  integration  of best research evidence with clinical expertise   and patient values”

Slide7 www.cebm.netThe 5 steps of EBM 1. Formulate an answerable question 2. Track down the best evidence 3. Critically appraise the evidence for validity, clinical relevance and applicability 4. Individualize, based clinical expertise and patient concerns 5. Evaluate your own performance

Slide8 www.cebm.net“Just  in  Time”  learning The  EBM  Alternative  Approach “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 Dave Sackett

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Slide11 www.cebm.netWhy do we need EBM? A more detailed account of the MRC patulin trial is available in: Chalmers I, Clarke M. The 1944 patulin trial: the first properly controlled multicentre trial conducted under the aegis of the British Medical Research Council. International Journal of Epidemiology 2004;32:253-260

Slide12 www.cebm.netWhy do we need RANDOMIZED CONTROLLED TRIALS ? In the early   1980s newly introduced antiarrhythmics were found to be   highly successful at suppressing arrhythmias. Not   until a RCT was performed was it realized that, although   these drugs suppressed arrhythmias, they actually increased   mortality. The CAST trial revealed    Excess mortality of 56/1000. By the time the results of this trial were published, at least   100,000 such patients had been taking these drugs.

Slide13 www.cebm.netThe 5 steps of EBM 1. Formulate an answerable question 2. Track down the best evidence 3. Critically appraise the evidence for validity, clinical relevance and applicability 4. Individualize, based clinical expertise and patient concerns 5. Evaluate your own performance

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Slide18 www.cebm.netGetting Evidence in to Practice How do  you  “do” EBP? • What Evidence based practice do you do/help with? • What other EBP do you know of?

Slide19 www.cebm.netJASPA* (Journal associated score of personal angst) J:  Are you ambivalent about renewing your  JOURNAL   s ubscriptions? 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) *  Modified from: BMJ 1995;311:1666-1668 0 (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions)

Slide20 www.cebm.netMedian minutes/week spent reading about my patients: Self-reports at 17 Grand Rounds: • Medical Students:    90 minutes • House Officers (PGY1): 0    (up to 70%=none) • SHOs (PGY2-4): 20  (up to 15%=none) • Registrars: 45  (up to 40%=none) • Sr. Registrars  30  (up to 15%=none) • Consultants: • Grad. Post 1975: 45  (up to 30%=none) • Grad. Pre   1975: 30  (up to 40%=none)

Slide21 www.cebm.netHow many randomized trials are published each year

Slide22 www.cebm.netChanges in the past 12 months A Survey of  EBM practitioners at 2012 EBM  practice workshop  

Slide23 www.cebm.netChanges in the past 12 months A Survey of 43 EBM practitioners at 2009 EBM  practice workshop  

Slide24 www.cebm.netManaging 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

Slide25 www.cebm.netKeeping up to Date by “Just in Time” Education • Shift focus to  your  current problems • Relevant  to YOUR practice • More m emorable  (and practice changed) • Up to date • But Four Barriers • Admitting we don’t know • Skills in obtaining current best evidence • Evidence Resources at the point of care • Time

Slide26 www.cebm.netYour Clinical Questions • Write down one recent patient problem • What was the critical question?

Slide27 www.cebm.netAngela  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. She has been hospitalized twice within the last 6 months for worsening of heart failure and has a venous leg ulcer. 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. She is mobile and lives alone with several cats but reports sometimes she forgets certain things. She also tells you she is a bit hard of hearing, has a slight cough, is an ex- smoker  of 20 cigs a day for 40 years. Her BP today is 170/90, her ankles are slightly swollen and her ulcer is painful and her pulse is 80 and slightly irregular . What are your questions ?

Slide28 www.cebm.net‘Background’ Questions • About the disorder, test, treatment, etc. 2 components: a. Root*   + Verb :    “What causes …” b. Condition:        “… SARS?” • * Who, What, Where, When, Why, How

Slide29 www.cebm.net‘Foreground’ Questions • About patient care decisions and actions 4 (or 3) components: a.  P atient, problem, or population b.  I ntervention, exposure, or maneuver c.  C omparison (if relevant) d. Clinical  O utcomes (including time horizon)

Slide30 www.cebm.netBackground & Foreground

Slide31 www.cebm.netPatient or Problem Intervention Comparison intervention Outcomes Tips for Building Describe a group of patients similar to your own What intervention are you considering What is the main alternative to the intervention What do you hope to accomplish with the intervention Example “In elderly patients with congestive heart failure … …does treatment with spirinolactone… …when compared with standard therapy alone… …lead to a decrease in hospitalization  ”

Slide32 www.cebm.netExample 1 Jean is a 55 year old woman who quite often crosses the Atlantic to visit her elderly mother. She tends to get swollen legs on these flights and is worried about her risk of developing deep vein thrombosis (DVT), because she has read quite a bit about this in the newspapers lately. She asks you if she would wear elastic stockings on her next trip to reduce her risk of this. P I C O

Slide33 www.cebm.netHow it   happens in practice?

Slide34 www.cebm.netBackground & Foreground

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Slide37 www.cebm.net‘Foreground’ Questions • About patient care and interventions 4 (or 3) components: a.  P atient, problem, or population b.  I ntervention, exposure, or maneuver c.  C omparison (if relevant) d. Clinical  O utcomes (including time horizon)

Slide38 www.cebm.netBackground & Foreground

Slide39 www.cebm.net‘Foreground’ Questions • About patient care decisions and actions 4 (or 3) components: a. In  P atients with Bell’s Palsy b.  Do ( I ) corticosteroids c.  C ompared to placebo d. Improve facial function ( O ) at 3  months

Slide40 www.cebm.netThe 5 steps of EBM 1. Formulate an answerable question 2. Track down the best evidence 3. Critically appraise the evidence for validity, clinical relevance and applicability 4. Individualize, based clinical expertise and patient concerns 5. Evaluate your own performance

Slide41 www.cebm.netMyocardial infarction How common is the problem? Who gets it Is this diagnostic test accurate? Diagnosis What will happen if we do nothing? Prognosis Does  this intervention help? Treatment  benefits What are the common harms  of treatment? Treatment Harms What are the  rare harms Treatment Harms Is this early detection test worthwhile? Screening Bells Palsy What type of question

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Slide46 www.cebm.netYour Clinical Questions • Write down one recent patient problem • What is the PICO of the problem?

Slide47 www.cebm.netQuestions • Recognize:   your  questions • Select:   which questions to pursue • Guide:   how to ask and answer • Assess:   how well & what to improve

Slide48 www.cebm.netFAQ: How Long … ? • Proficient?  Quickly • Mastery?    Lifetime • Human expertise takes >10,000 hours, >10 years → Deliberate practice

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