7521 Evidence Based Medicine. Part I

Evidence Based Medicine www.bradfordvts.co.uk Part I What I’ve done / do/don’t do Done: I’ve gotten out of date and retrained in Internal Medicine twice  Do: I run an in-patient General Medicine service (all comers) at a UK DGH:  » 208 admissions last month » strive to use evidence at the bedside  Don’t: I’ve cancelled my journal subscriptions (and give away the JCI and BMJ) Centre for Evidence-Based Medicine The Problems: We need evidence (about the accuracy of diagnostic tests, the power of prognostic markers, the comparative efficacy and safety of interventions, etc.) about 5 times for every in-patient (and twice for every 3 out-patients).  We get less than a third of it  Centre for Evidence-Based Medicine The Problems: To keep up to date in Internal Medicine, I need to read 17 articles a day, 365 days a year  Need to read  Don’t  Nor does anyone else  Centre for Evidence-Based Medicine Median minutes/week spent reading about my patients: Self-reports at 17 Grand Rounds:       Medical Students: House Officers (PGY1): SHOs (PGY2-4): Registrars: Sr. Registrars Consultants: » Grad. Post 1975: » Grad. Pre 1975: 90 minutes 0 (up to 70%=none) 20 (up to 15%=none) 45 (up to 40%=none) 30 (up to 15%=none) 45 (up to 30%=none) 30 (up to 40%=none) Centre for Evidence-Based Medicine Performance deteriorates, too Determinants of the clinical decision to treat some, but not other, hypertensives: 1 Level of blood pressure. 2 Patient’s age. 3 The physician’s year of graduation from medical school. 4 The amount of target-organ damage. Centre for Evidence-Based Medicine No wonder, then, that CME is growing Big, and getting huge.  Usually instructionally (fact) oriented.  Several randomised trials have shown that it does not improve clinical performance.  Centre for Evidence-Based Medicine Three solutions Clinical performance can keep up to date: 1 by learning how to practice evidencebased medicine ourselves. 2 by seeking and applying evidencebased medical summaries generated by others. 3 by applying evidence-based strategies for changing our clinical behaviour. Centre for Evidence-Based Medicine When did EBM begin ?  Certainly in post-revolutionary Paris.  Arguably in B.C China.  Some late-comers named it in 1992. Centre for Evidence-Based Medicine What evidence-based medicine is: The practice of EBM is the integration of  individual clinical expertise with the  best available external clinical evidence from systematic research. and  patient’s values and expectations Centre for Evidence-Based Medicine I.Individual Clinical Expertise: Clinical skills and clinical judgement  Vital for determining whether the evidence (or guideline) applies to the individual patient at all and, if so, how  Centre for Evidence-Based Medicine II. Best External Evidence: From real clinical research among intact patients.  Has a short doubling-time (10 years).  Replaces currently accepted diagnostic tests and treatments with new ones that are more powerful, more accurate, more efficacious, and safer.  Centre for Evidence-Based Medicine III. Patients’ Values & Expectations Have always played a central role in determining whether and which interventions take place  We’re getting better at quantifying and integrating them  Centre for Evidence-Based Medicine What EBM is not:  EBM is not cook-book medicine » evidence needs extrapolation to my patient’s unique biology and values  EBM is not cost-cutting medicine » when efficacy for my patient is paramount, costs may rise, not fall Centre for Evidence-Based Medicine Evidence-Based Medicine: The Practice When caring for patients creates the need for information: 1 Translation to an answerable question (patient/manoeuvre/outcome). 2 Efficient track-down of the best evidence » secondary (pre-appraised) sources e.g., Cochrane; E-B Journals » primary literature Centre for Evidence-Based Medicine Evidence-Based Medicine: The Practice 3 4 5 Critical appraisal of the evidence for its validity and clinical applicability  generation of a 1-page summary. Integration of that critical appraisal with clinical expertise and the patient’s unique biology and beliefs  action. Evaluation of one’s performance. Centre for Evidence-Based Medicine We needn’t always carry out all 5 steps to provide E-B Care  Asking an answerable question. Searching for the best evidence. Critically-appraising the evidence.  Integrating the evidence with our expertise and our patient’s unique biology and values  evaluating our performance Centre for Evidence-Based Medicine We’ve identified 3 different modes of practice  “Searching & appraising” » provides E-B care, but is expensive in time and resources  “Searching only” » much, quicker, and if carried out among EB resources, can provide E-B care  “Replicating” the practice of experts » quickest, but may not distinguish evidencebased from ego-based recommendations Centre for Evidence-Based Medicine Even fully EB-trained clinicians work in all 3 modes  “Searching & appraising” mode for the problems I encounter daily.  “Searching only” mode among E-B resources for problems I encounter once a month.  “Replicating” the practice of experts mode for problems I encounter once a decade(and crossing my fingers!). Centre for Evidence-Based Medicine Patients can benefit Even if <10% of clinicians are capable of practicing in the “searching & appraising” mode (5% of GPs)  As long as most of them practice in a “searching” mode within high-quality evidence sources (70-80% of GPs):  » Cochrane Library, E-B Journals, E-B Guidelines, etc Centre for Evidence-Based Medicine Three solutions Clinical performance can keep up to date: 1 by learning how to practice evidencebased medicine ourselves. 2 by seeking and applying evidencebased medical summaries generated by others. 3 by applying evidence-based strategies for changing our clinical behaviour. Centre for Evidence-Based Medicine Information required within seconds Systematic reviews, periodically updated, of randomised trials of the effects of health care (from all sources, and in all languages): The Cochrane Collaboration. Centre for Evidence-Based Medicine Cochrane Systematic Reviews (522; another 500 in preparation) Database of Abstracts of Reviews of Effectiveness (1895) Registry of Randomised Controlled Trials (218,355) Information required within seconds CD-Evidence-based journals of 2º publication:  screen 50-70 clinical journals per week for clinical articles that pass critical appraisal quality filters  conclusions likely to be true.  select the subset that are clinically relevant.  summarise as “more-informative” abstracts.  add commentaries from clinical experts.  introduce with declarative titles. Centre for Evidence-Based Medicine Centre for Evidence-Based Medicine 2. Seeking and Applying EBM generated by others Evidence-Based Medicine is published in:  English  French  German  Italian  Portuguese  Spanish Centre for Evidence-Based Medicine 2. Seeking and Applying EBM generated by others New Evidence-based journals of 2º publication:  E-B Cardiovascular Medicine  E-B Health Policy & Management  E-B Nursing  E-B Mental Health And as new departments in 1º journals. Centre for Evidence-Based Medicine 2. Seeking and Applying EBM generated by others E-B Textbooks:  E-B Pain Relief  E-B Cardiology includes icons for levels of evidence  “E-B On-Call” includes > 1300 CATs Centre for Evidence-Based Medicine Can you really practice EBM?  Is there any “E” for EBM ? Centre for Evidence-Based Medicine Conventional Wisdom  “only about 15% of medical interventions are supported by solid scientific evidence” (BMJ Editorial) Centre for Evidence-Based Medicine Even on the U.S. Talk-Shows: (“Health Outrage of the Week”)  “..... this would put 80 to 90 per cent of accepted medical procedures in this country under the heading of quackery!” Centre for Evidence-Based Medicine Problems with Conventional Wisdom uses clinical manoeuvres, rather than patients, as the denominator.  tends to focus on high-technology, “big ticket” items.  relies on simple literature searches that miss over half of the most rigorous types of evaluations.  conducted from armchairs.  Centre for Evidence-Based Medicine Performed an empirical study on a busy in-patient service on the general medicine in-patient service of the Nuffield Department of Medicine at the Oxford-Radcliffe NHS Hospital Trust (“The John Radcliffe”)  all our admissions arise from urgent referral from local GPs or via the Emergency Room  Centre for Evidence-Based Medicine