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Using evidence in practice

Using evidence in practice. Nick Price 4 th April 2006. Objectives. To have an overall understanding of the concept of evidence based practice. To critique how ‘evidence’ is presented in journals and by journalists. Raise awareness of other factors that influence clinical decision making.

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Using evidence in practice

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  1. Using evidence in practice Nick Price 4th April 2006

  2. Objectives • To have an overall understanding of the concept of evidence based practice. • To critique how ‘evidence’ is presented in journals and by journalists. • Raise awareness of other factors that influence clinical decision making. • To be able to apply simple statistics in practice. • To be able to present these to patients, minimising bias. • To develop some of the skills in this area required to pass the MRCGP.

  3. Schedule 1400-1500 Overview of EBP Panorama programme on Herceptin . 1515-1530 Tea 1530-1615 Group work Critically appraising an editorial. Working out some numbers Practice explaining risk to patients 1615-1630 Summary and evaluation (plenary)

  4. What is evidence based practice?

  5. Evidence based medicine? Maybe it is the application of the best available scientific knowledge to the patient’s or population’s clinical problem? Or ‘Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values’ Sackett et al (2000)

  6. Arts and humanities Ethics Adaptability, broad perspective Humane Judgement A model of influences inclinical decision making Science Social Science Scientific Method Counting differences Understanding differences Technical judgement Clinical Judgement

  7. Principles of a health care system Systematic review Meta-analysis • equity • effectiveness • efficiency • appropriateness • accessibility • responsibility • humanity RCT Cohort studies Case control studies Descriptive studies quantitative qualitative

  8. Panorama

  9. ‘Should I sell my house to pay for Herceptin, Doctor?’How would you gather evidence?

  10. First define your questionPICO • Population • Intervention(s) • Comparison • Outcome.

  11. Levels of evidence • (I-1) a well done systematic review of 2 or more RCTs • (I-2) a RCT • (II-1) a cohort study • (II-2) a case-control study • (II-3) a dramatic uncontrolled experiment • (III) respected authorities, expert committees, etc.. (Good Old Boys Sitting Heroically At Tables?) • (IV)....someone once told me...

  12. Thorough Practical Medline search SR and Meta-analyses RCTs Review articles Observational Studies Clinical Evidence Cochrane Bandolier DTB MeReC RCGP/RCPsych guidelines NICE guidelines NSF Local Guidelines Ask the consultant or others? Gathering evidence

  13. What I actually did for Herceptin • Medline – got nowhere really • www.scholar.google.com – got nowhere really • Asked my mates a bit. • www.bmj.com – editorial and then references from that. Could have done what?

  14. Making sense of numbers • Relative risk • Absolute risk • Absolute risk reduction / harm • NNT • NNH • Hazard Ratio • Cost per case / QALY

  15. So lies damn lies and statistics? • Absolute risk / benefits often sound small • Relative risk / benefits can sound big e.g. • Your chance of winning the lottery with 2 tickets as opposed to one is increased by 1 in 14million • Your chance of winning the lottery with 2 tickets as opposed to one is increased by 100%

  16. Numbers Needed to Treat The average number of people from a defined population you would need to treat with a specific intervention for a given period of time to achieve one beneficial outcome. NNT = 1 / ARR Can you calculate this for winning the lottery jackpot? Assume chance of winning is 1 in 14m per ticket per draw.

  17. NNTs 2 ARI = 1/14m per ticket per draw = 1/14m x 2 per week with 1 ticket for each draw = 1/14m x2 x52 x5 for 5 years = 520/14m NNT = 14m/520 = 27,000 approx i.e. 27,000 people have to buy 2 tickets a week for 5 years for one person to win the jackpot

  18. Summary • Trials are there to inform clinical decision making. • Identifying appropriate literature needs to consider quality / rigour but also practicality. • Some stats are really quite easy but need to be used with care if you are to be honest. • I suggest that risks and benefits should be expressed in both absolute terms and relative terms and DON’T mix them up!

  19. Some reading / resources: • Greenhalgh T (2000) How to Read a Paper: The basics of evidence based medicine.London BMJ Publishing • McGovern D P B, Summerskill W S M, McManus R (2001) Evidence-based medicine in General Practice. Oxford BIOS Scientific. OR • Sackett DL, Strauss S, Richardson WS, Rosenberg W, Hayes RB (2000) Evidence-based Medicine: How to practice and Teach EBM. Edinburgh Churchill Livinstone

  20. Tea time Then: Reviewing the editorial and doing some sums. Back here for 1615 for close and evaluation

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