Evidence Based Medicine & Critical Appraisal & Professional Reading

1. Evidence Based Medicine&Critical Appraisal&Professional Reading Dr Richard de Ferrars February 2012

2. Evidence Based Medicine&Critical Appraisal&Professional Reading Dr Richard de Ferrars February 2012

3. Professional Reading Dr Richard de Ferrars February 2012

4. Professional Reading • Browsing • Flicking papers & journals • Has value, BUT time is limited... • Targeted Reading • Using the EBM resources to answer a question • Knowing the good resources

5. Why Bother? My Regular Literature Pulse GP BMJ BJGP Prescriber Newspapers (Post & Email) InnovAIT New NICE guidelines Other national guidelines Local/ PCT guidelines Hospital updates Daily Mail... Thousands of pages, hundreds of hours....

6. What Skills Do I Need? • Speed reading • Ability to critically appraise (appreciate)

7. Critically Appraisal? Critical(adjective) skillful judgment as to truth & merit Appraisal(noun) the act of estimating or judging the nature or value of something or someone. More than just knowing how “believable” the contents of some research & papers are. Also an element of judging the value & relevance, in practical terms, for your own work.

8. What Skills Do I Need? • Speed reading • Ability to critically appraise (appreciate) In pairs: • pick some reading material • 10 minutes to find something you think is good • present it back to the rest of us

9. What Skills Do I Need? • Speed reading • Critical appraisal (being accurately selective) In pairs: • pick some reading material • 5 minutes to find something of value • present it back to the rest of us

10. Speed Reading...

11. Speed Reading... Top level: Be very selective over what you even start to read: Read titles Look for summaries Abstracts of papers NICE Quick Reference Guides Lower level: If you are a slow reader then consider speed reading “course”

12. What Skills Do I Need? • Speed reading • Critical appraisal (being accurately selective) In pairs: • pick some reading material • 5 minutes to find something of value • present it back to the rest of us

13. Realistic Goals What’s realistic in under 1 hour? Helping you to judge: Q U Quality Utility, Usefulness, Usability

14. What is Good Quality? • My GPR (who has just passed his MRCGP) says thiazides are good anti-hypertensives • The NICE guidelines say first choice BP drug for over 55’s is thiazide or CCB • I read a review in the BMJ last week that showed that showed thiazides gave better outcomes that ACEi in the elderly • Most people that I see in my surgery who have high BP seem to be on medication that includes a thiazide • That drug rep last week showed my some impressive graphs for his new CCB-thiazide combination drug • Rate these 5 fonts of wisdom in order of “good & sound”

15. What is Good Quality? • The NICE guidelines say first choice BP drug for over 55’s is thiazide or CCB • My GPR (who has just passed his MRCGP) says thiazides are good anti-hypertensives • I read a review in the BMJ last week that showed that showed thiazides gave better outcomes that ACEi in the elderly • Most people that I see in my surgery who have high BP seem to be on medication that includes a thiazide • That drug rep last week showed my some impressive graphs for his new CCB-thiazide combination drug • Rate these 5 fonts of wisdom in order of “good & sound”

16. What is Good Quality? • The NICE guidelines say first choice BP drug for over 55’s is thiazide or CCB • I read a review in the BMJ last week that showed that showed thiazides gave better outcomes that ACEi in the elderly • My GPR (who has just passed his MRCGP) says thiazides are good anti-hypertensives • Most people that I see in my surgery who have high BP seem to be on medication that includes a thiazide • That drug rep last week showed my some impressive graphs for his new CCB-thiazide combination drug • Rate these 5 fonts of wisdom in order of “good & sound”

17. What is Good Quality? • The NICE guidelines say first choice BP drug for over 55’s is thiazide or CCB • I read a review in the BMJ last week that showed that showed thiazides gave better outcomes that ACEi in the elderly • That drug rep last week showed my some impressive graphs for his new CCB-thiazide combination drug • Most people that I see in my surgery who have high BP seem to be on medication that includes a thiazide • My GPR (who has just passed his MRCGP) says thiazides are good anti-hypertensives • Rate these 5 fonts of wisdom in order of “good & sound”

18. What is Good Quality? • The NICE guidelines say first choice BP drug for over 55’s is thiazide or CCB • I read a review in the BMJ last week that showed that showed thiazides gave better outcomes that ACEi in the elderly • That drug rep last week showed my some impressive graphs for his new CCB-thiazide combination drug • My GPR (who has just passed his MRCGP) says thiazides are good anti-hypertensives • Most people that I see in my surgery who have high BP seem to be on medication that includes a thiazide • Rate these 5 fonts of wisdom in order of “good & sound”

19. What is Good Quality? • The NICE guidelines say first choice BP drug for over 55’s is thiazide or CCB • I read a review in the BMJ last week that showed that showed thiazides gave better outcomes that ACEi in the elderly • That drug rep last week showed my some impressive graphs for his new CCB-thiazide combination drug • My GPR (who has just passed his MRCGP) says thiazides are good anti-hypertensives • Most people that I see in my surgery who have high BP seem to be on medication that includes a thiazide • Rate these 5 fonts of wisdom in order of “good & sound”

20. What is Good Quality? Good Studies & Bad studies – Study Hierarchy Meta-analysis & systematic review – aggregation of several similar studies Double-blind randomised placebo controlled studies Larger, generic products, paid for by neutral body Double-blind randomised placebo controlled studies Smaller, branded products, paid for by the manufacturer Observational studies Case reports Anecdotal experience Big is Beautiful!

21. What is Good Quality? Big is Beautiful!

22. Strength of Recommendation A Based directly on category 1+ evidence. B Based directly on category 2++ evidence or extrapolated from category 1 C Based directly on category 2 +/- evidence or extrapolated from category 2++ D Based on category ¾ or extrapolated from category 2+ 1++ Meta-analysis of randomised controlled trials. 1- Randomised controlled studies 2++ Systematic reviews of case-control & cohort studies 2+/- Case-control studies & cohort studies 3 Non-analytical studies (comparitive studies, case reports) 4 Expert opinions, clinical experience of respected authorities

23. Sources of Information? Sources of information: Where do you go to get information, advice & recommendations? What sources & resources do you use? Discuss in pairs for 5 minutes

24. Quality and believability Accessibility Sources of Information? • Overall quality – a compromise between quality of information and accessibility National bodies – NICE, NPC, CKS (Prodigy), SIGN, Cochrane Publications - Journals Local Guidelines – PCT, hospital, department Trainer, registrar, consultant Your patients????

25. What is Good Quality? • Remember the hierarchy of studies • Take into account practicalities • availability & accessibility • time constarints

26. What About Utility? What kind of factors determine utility & usefulness of what you are reading?

27. What About Utility? How relevant is it to your own practice? How likely to change your own practice? Will you need to get others on-board? How easy to apply & implement changes? What are the cost/ resource implications?

28. Quality & Utility Quality Meta-analysis & systematic review Double-blind randomised placebo controlled studies Observational studies Case reports Anecdotal experience Utility How relevant is it to your own practice? How likely to change your own practice? Will you need to get others on-board? How easy to apply & implement changes? What are the cost/ resource implications? Return to your selected material Score 0-1-2 on each of Quality & Utility Anyone got a 4? Anyone got a 0?

29. The End