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Why bother with Evidence-Based Practice?

Why bother with Evidence-Based Practice?. Professor Paul Glasziou Centre for Evidence-Based Medicine University of Oxford. I am here to learn EBM because …. I am working in clinical practice I am working on evidence resources (reviews, guidelines, reports , …)

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Why bother with Evidence-Based Practice?

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  1. Why bother with Evidence-Based Practice? Professor Paul Glasziou Centre for Evidence-Based Medicine University of Oxford

  2. I am here to learn EBM because …. • I am working in clinical practice • I am working on evidence resources (reviews, guidelines, reports , …) • I will help others use evidence • I plan to teach EBM • My boss told me I had to attend

  3. EBP Workshop – Program Day 1 • Plenary: What is Evidence-based practice? • Small group Tutorial: Asking well-formulated Questions • Coffee • Plenary: Rapid Critical Appraisal of intervention studies • Small group tutorial: Critical Appraisal of intervention studies • LUNCH • Lab Tutorial: Efficient Searching for Evidence (hands-on) • Plenary: Finding the best studies (searching basics) • Tea • Small Group Tutorial: Reading papers

  4. Introductory Lecture: Objectives 1. What • What is evidence-based medicine? • What does it look like in practice? 2. How • Formulate Clinical Questions • Search for Evidence • Appraisal of research • Apply to clinical problem

  5. Patient Concerns Best research evidence Clinical Expertise EBM What is evidence-based medicine? “Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” - Dave Sackett

  6. A dilemma • You are very ill …

  7. Which doctor do you want? Smart young doctor William Osler, 1900

  8. Which doctor do you want? Wise & experienced smart young doctor

  9. Life long learning The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not … a medical course, but a life course, for which the work of a few years under teachers is but a preparation. • Sir William Osler (1849-1919), from: The Student of Medicine

  10. Worse with “duration in practice” The Prognosis of Ignorance is Poor

  11. Do we know the right things? GP beliefs about prevention for a 52 yr male Effective Effective Effective Probable Effective Ineffective Ineffective Probable Effective EUROPREV Network Europe.Prev Med. 2005:595-601 Croatia Estonia Georgia Greece Ireland Malta Poland Slovakia Slovenia Spain Sweden

  12. Page 9 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

  13. Rule 31 – Review the World Literature Fortnightly**"Kill as Few Patients as Possible" - Oscar London 5,000? per day 1,500 per day 95 per day Medical Articles Per Year

  14. Is keeping up to date Mission Impossible? Bluegreenblog 2006

  15. Coping with the overload: three possible things you might try A. Read an evidence-based abstraction journal(and cancel other journals) B. Keep a logbook of your own clinical questions C. Run a case-discussion journalclub with your practice

  16. Some variants of Evidence-Based Practice Brian Haynes, physician McMaster ACP journal club Bob Phillips, Oncology, Leeds Patients in Trials Kevin Mackway Jones A&E Manchester BestBets Yaser Faden, Neonatology, Jeddeh “PICO” rounds

  17. Part 2: The 4 steps of “pull” EBM • Formulate an answerable question • Track down the best evidence • Critically appraise the evidence • Individualise, based clinical expertise and patient concerns

  18. Step 1Formulate an answerable clinical question Structure of researchable questions – PICO-T • Population/Patients • Intervention • Comparison • Outcome • Time

  19. What are your clinical questions? • A 35 year old man says his brother recently died of a ruptured cerebral aneurysm. He is worried about whether he might have one and what the chances are that it would rupture. -> PICO Table

  20. CT Scan Cross Sectional Study Types of question: stroke Cohort Study Inception Cohort Study Survey Frequency Prognosis Risk Factors Treatments Randomised Trial Treatment Effect Symptoms Signs, Tests Cause(s) Past current future

  21. What are the … outcomes (PO?) Patients Outcomes ? Qualitative Research Page 24

  22. The “best” evidence depends on the type of question

  23. The “best” evidence depends on the type of question

  24. 2. Searching: finding good answers?

  25. Should I ask a colleague? • 12 occupational therapy questions • E.g., Is a 38-year old sewage worker subject to a higher risk of contracting Hepatitis A as a result of occupational exposure? (No) • Obtain advice from 2 professionals on 3 cases each. • 37% wrong answers • 17% wrong if based on literature • 65% wrong if not Schaafsma BMC Health Services Research 2005

  26. Impact of searching on correctness of answers to clinical questions

  27. Impact of searching on correctness of answers to clinical questions

  28. Searching made easy 

  29. 3. Rapid Critical Appraisal It’s peer-reviewed, therefore it must be OK?

  30. What do the results mean on average? What do they mean for this individual? Step 4: Applying to the individual

  31. What are the alternatives to EBM? Isaacs, BMJ

  32. Where to now? • Small Group - Room on Group sheet • Hobbs – right • Hamlin – left • Wordsworth/Board 1st floor • 10:45 TEA/COFFEE

  33. Step 3: Appraise the evidence Did you find good quality studies? • Two steps • PICO • RAMMbo

  34. Early Trial in K-L

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