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What is.. Evidence Based Health Care ? Craig Mellis University of Sydney

What is.. Evidence Based Health Care ? Craig Mellis University of Sydney . Objectives: 1. Traditional (“Mark 1”) EBHC. Objectives: 1. ‘Traditional’ EBHC 2. ‘New’ (“Mark 2”) EHBC. Objectives: 1. ‘Traditional’ EBHC 2. ‘New’ EHBC 3. What Y OU ..‘Need-to-Know’.. …to practice EBHC.

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What is.. Evidence Based Health Care ? Craig Mellis University of Sydney

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  1. What is.. Evidence Based Health Care ?Craig MellisUniversity of Sydney

  2. Objectives: 1. Traditional (“Mark 1”) EBHC

  3. Objectives: 1. ‘Traditional’ EBHC 2. ‘New’ (“Mark 2”) EHBC

  4. Objectives: 1. ‘Traditional’ EBHC 2. ‘New’ EHBC 3. What YOU ..‘Need-to-Know’.. …to practice EBHC

  5. .. EBHC is all about optimalclinical decision making

  6. EBM & CLINICAL DECISION MAKING Brian Haynes

  7. Assess the Patient Ask Q..? Acquire Act Apply Appraise

  8. Assess Patient Ask Q..? Acquire Act Apply Appraise

  9. Assess Patient Ask Q Acquire the Evidence Act Apply Appraise

  10. Assess Patient Ask Acquire Act Apply Appraise the evidence

  11. Assess Patient Ask Acquire Action Applicable..? Appraise Steps involved in ‘traditional’ EBHC

  12. Jack.. aged 16 months

  13. History … Jack, 16 months • Viral URTI .. 2-3 days • Cough & Wheeze .. 24 hours • Woke up this am with.. “Loud Wheeze & difficulty breathing” -> ED…

  14. History … Jack, 16 months • Viral URTI .. 2-3 days • Cough & Wheeze .. 24 hours • Woke up this am with.. “Loud Wheeze & difficulty breathing” -> ED… • No prior wheeze / atopy • No FH asthma / atopy

  15. Physical Examination: + Moderate Resp Distress + Audible Wheeze + Signs of U.R.T.I

  16. Physical Examination: + Moderate Resp Distress + Audible Wheeze + Signs of U.R.T.I + Chest wall retractions + Mild nasal flaring

  17. Physical Examination: + Moderate Resp Distress + Audible Wheeze + Signs of U.R.T.I + Chest wall retractions + Mild nasal flaring + Resp Rate = 42 / min + Pulse Rate = 102 / min + SaO2 (air) = 90%

  18. Most likely Diagnosis..?

  19. Dx: Viral Induced Wheeze …Moderate resp distress

  20. -> ED.. Progress • Dx: Viral Induced Wheeze …Moderate resp distress • Initial Tmt: * Oxygen via face mask -> SaO2 > 95% * Salbutamol ..4 puffs (via puffer+spacer) -> ?..Minimal response

  21. -> ED.. Progress • OE: Viral Induced Wheeze … Mild-moderate resp distress • Initial Tmt: Oxygen ->SaO2 > 95% ‘Ventolin’..4 puffs via puffer+spacer -> ?..Minimal response ?? Q… Add oral Corticosteroids

  22. Background Information • Oral C’steroids E ffectiveschool-age children & adults with Asthma …ie, reduces need hospital admission

  23. Background Information • Oral C’steroids =effective older children & adults w acute mod-severe asthma 2) Most infants & preschoolerswho wheeze ONLY with Viral URTI (Viral Associated Wheeze) DO NOT have asthma

  24. Background Information 3) Genuine concern re Adverse Effects w repeated courses… ( espGrowth, weight gain, HPA axis)

  25. You are in ED.. ? Will YOU… give Jack oral C’steroids: • YES • NO • UNSURE

  26. How will YOU get answer..? • Phone a friend • Textbook • Medline (‘Pubmed’ / ’Ovid’) • “UptoDate” / “Clinical Evidence”

  27. WHAT..is the Evidence ?& HOW ..will you find it ?

  28. ‘P I C O’ / ‘P I C O T’ …. • French word (re lace & embroidery) • Prefix for one trillionth ( 10-12 ) • Mnemonic for framing clinical questions • Spanish word for… ‘ a little bit’ • All of the above

  29. Use PICO (T) to… Frame YOUR Clinical Questions

  30. P I C O ( T ) format: • P opulation (disease group) • I ntervention • C omparator • O utcome • T ype Study

  31. P I C O ( T ) format: • P opulation“..Among ..Pts w ‘Dis’ • I nterventionDoes… ‘Tmt A’ • C omparatorCompared to.. ‘Tmt B’ • O utcomeAffect… (eg, QoL).. ? ” • T ypeStudy< Ideal study type >

  32. Jack’s Clinical Question..? • Population ? • Intervention ? • Comparator ? • Outcome ? • Type of Study ?

  33. Jack’s Clinical Question • Population….. Viral Wheeze • Intervention… Oral C’steroid • Comparator… Placebo • Outcome… Length of Stay • Type of Study… Systematic Review -> RCT -> Cohort

  34. Generating the search terms P = Viral Wheeze I = Oral C’steroids (C=placebo) (O=outcome) T = SystReview .. -> RCT

  35. ACQUIRE…research Evidence • Use appropriate Electronic databases • Use Efficient SEARCH strategy

  36. -> PubMed www.ncbi.nlm.nih.gov/pubmed/ -> “ Clinical Queries ”

  37. Search Terms: viral wheeze AND oral corticosteroids

  38. Search Terms: viral wheeze AND oral corticosteroids

  39. Appraisal • VALID Study ? • IMPORTANTResults ? • APPLICABLE to your patient ?

  40. … VALIDITY of the Evidence Use Checklist* …Depends on Type Question: • Therapy ( S/R or RCT) • Diagnosis • Prognosis • Harm * Users Guide

  41. ?...IMPORTANT RESULTS: ie, Effect size & 95% Confidence Interval ? Statistically significant ? Clinically Important

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