Hello. My name is Ken and I have an information problem

1. An Introduction to EBM Hello. My name is Ken and I have an information problem Is Evidence-Based Medicine the answer?

2. My Problem • My 50 y/o patient has had a cough for 2 weeks but no fever or rales • Should I treat with an antibiotic?

3. Starts with clinical questions • Physicians generate 5 questions for every inpatient and 2 questions for every 3 outpatients • For each day of 25 patients, generate about 15 questions

4. Our Problem? • They tend to underestimate their uncertainty • They usually don’t look for the answers • When they do the sources may not be evidence-based Ely: BMJ, 319(7206):358-361

5. What is happening to medical information? • >30,000 new citations added to Medline every month • Volume of medical information doubles every 19 years

6. The inevitable consequence: On average, the clinically-important knowledge of physicians deteriorates rapidly after we complete their training.

7. The Slippery Slope r = -0.54 p<0.001 . .. . . .... . knowledge of current best care ... ... ... ... .. .... .... years since graduation

8. How sure are we?Expert estimates of breast implant rupture rates 0% 0.2% 0.5% 1% 1% 1% 1.5% 2% 3% 3% 4% 5% 5% 5% 5% 5% 5% 5% 5% 6% 6% 6% 8% 10% 10% 10% 10% 13% 13% 15% 15% 18% 20% 20% 20% 25% 25% 25% 30% 30% 40% 50% 50% 50% 62% 70% 73% 75% 75% 75% 75% 80% 80% 80% 80% 80% 80% 100%

9. 0% 25% 50% 75% 100% Experts estimates of the effect of colon cancer screening on chance of dying Source David Eddy

10. In fact we are not very good at converting facts into accurate beliefs and actions • Complexity of medical practice • Complexity of research • Limitations of the human mind • Personal & professional biases

11. Which leads to • Wide variation in perceptions • Wide variation in practice • Much higher rates of inappropriate care than any of us would like to admit Any alternative to evidence as the bedrock for medicine must account for these

12. Summary thus far • Clinicians need information, but most needs are never met. • Consequently, knowledge and performance deteriorate. • Traditional instructional CME doesn’t improve performance. • Our unaided minds are fallible, even when we know the evidence.

13. How can clinical performance can keep up to date? • Appreciate the limitations of judgements, beliefs and biological models • Learn how to practice evidence-based medicine • Seek and apply evidence-based medical summaries generated by others. • Accept evidence-based practice protocols developed by our colleagues.

14. Publication to ImplementationAntman EM, Lau J, Kupelnick B, Mosteller F, and Chalmers TC.JAMA, 268:240-8, 1992

15. Lag time from time of “knowing” to time of implementation • 13 yrs for thrombolytic therapy. • 10 yrs for corticosteroids to speed fetal lung maturity.

16. Fact • New types of evidence are now being generated which, when we know and understand them, create frequent, major changes in the way we care for our patients.

17. What Are We Doing? • CME • Guidelines • Experts • Reading

18. Does CME Work? • Davis D A, et al. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995; 274: 700-1. • Sibley J C, A randomized trial of continuing medical education. N Engl J Med 1982; 306: 511-5. • Conclusion • Traditional CME in a nice place with pleasant after lecture diversions is, unfortunately, completely ineffective in changing our behavior.

19. What About Guidelines? • Guidelines can be very useful • Problems • Surprise! They don’t all agree. • Which ones do we use? (Determining validity) • How do we implement? (How do we remember to do what they say?) • Once validity is established they can be an excellent resource

20. The Experts ? • Remember, they’re in the same position we are with information overload. • They often look at a patient and a disease in a fundamentally different way because they deal with a selected patient population. • Excellent resource once reliability has been established.

21. Do We Read ? • Self-reported reading time per week. (University setting) • Medical students 60 min. • Interns none • Senior residents 10 min. • Fellows 45 min. • Attendings graduating • Post 1975 60 min. • Pre 1975 30 min.

22. Do We Read? • University of Virginia • Mailing to primary care physicians • 50% had not read a medical journal article in the last year. • The most commonly sited source of information was pharmacutical representatives.

23. Why Don’t We Read ? • We’re lazy? • The fact of the matter is that none of us likes feeling out of date. We like it so little in fact that we are willing to work at night and on weekends in an effort to stay current. • Frustration. • Conflicting information • No one taught us HOW or WHAT to read.

24. The Magic Bullet ?

25. What evidence-based medicine is: “Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” David Sackett

26. What evidence-based medicine is:a practical definition • Where there is evidence of benefit and value, do it • Where there is evidence of no benefit, harm, or poor value, don’t do it. • When there is insufficient evidence to know for sure, be conservative David Eddy

27. Clinical Judgement Best Evidence What evidence-based medicine is: Patient Preference

28. What does evidence-based mean? • A comprehensive, systematic, open minded review of all the evidence • The evidence determines the conclusion, not vice versa • Not, the citation of papers supporting a preformed conclusion (and trashing of those that don’t) • Not, the use of evidence when it is ‘positive’ but judgement when it isn’t

29. What is “good evidence” • Directly or indirectly demonstrates treatment effect on health outcomes • beware of biological outcomes • Includes good controls • “beyond any reasonable bias”

30. EBM is not new • “First do no harm” • The scientific tradition • Informed decision making • The Pure Food and Drug Act; FDA’s approval to market • Common sense: do what works, don’t do what doesn’t

31. But EBM is not “old hat” • Clinicians vary in their application of data to patient care (“doctor-bashing studies”) • inhaled steroids, beta blockers, ACE inhibitors • Reading habits and traditional CME not very effective • Variation in guideline recommendations • PSA, mammography, pap smear frequency

32. EBM is not impossible to practice • Front line inpatient clinical teams in: • general medicine • psychiatry • surgery have provided evidence-based care to the vast majority of their patients.

33. Evidence-based medicine is not “cookbook” medicine: • EBM requires that the best external evidence be integrated with individual clinical expertise and patient-choice in a bottom-up approach • External evidence can only inform clinical expertise and patient preference. • It is necessarily limited in its ability to predict individual patient outcome

34. The Process of EBM Convert information needs into answerable questions Track down, with maximum efficiency, the best evidence to answer questions Critically appraise the evidence for validity Apply the results in practice Explain evidence Evaluate performance

35. Step #1Developing an answerable Clinical Question

36. Getting through the information jungle The Key The answerable question

37. Good questions • Important to your practice • Important to your patients • Specific • Answerable!

38. Good Questions • Which patients is this question about? • What is the main intervention? • Is there an alternative intervention? • What can I hope to accomplish?

39. Examples of good questions • In patients with insulin-dependent diabetes mellitus • receiving current standard insulin therapy • will an intensive insulin regime • reduce the risk of developing microvascular complications

40. Examples of good questions • In patients with COAD • does self-initiated antibiotic use • as compared with physician initiated antibiotic prescriptions • reduce the number of admissions to hospital or the number of days spent in hospital?

41. Examples of good questions • Among women in premature labour expected to deliver before thirty weeks of gestation • does an intensive corticosteroid regime • compared with the standard regime • reduce the risk of RDS in their babies?

42. Examples of good questions • Amongst patients with pre-existing coronary heart disease • does the use of supplementary folic acid in breakfast cereals • as compared with the use of ordinary cereals • reduce the plasma homocysteine levels?

43. “Hunting” questions - “PICO”: • “P” - patient or problem • “I” - intervention (e.g., diagnostic test, treatment, cause, prognostic factor) • “C” - comparison intervention (if necessary) • “O” - outcome

44. “PICO” • P - Adult maturity onset diabetic • I - Use of ACE-inhibitor • C - Randomised controlled trial • O - Reduced micro-albuminuria

45. Step #2Efficiently track down the best evidence to answer clinical questions

46. Searching for the best evidence Once you have an answerable question, then you need to search for the “ best” evidence – that which will help you to decide on the most appropriate approach

47. Tools to efficiently obtain the best available evidence • The Cochrane Library • Evidence-based online journals • Internet databases • Evidence-based clinical practice guidelines • Evidence-based text books

48. Searching for the best evidence • Pre-digested” - eg Cochrane Library • Databases – eg MEDLINE • WWW – general /specific

49. The Cochrane Database of Systematic Reviews • Rapidly expanding database • 795 completed reviews / 738 in progress • explicit, meticulous methodology • international effort, updated quarterly • Limitations • incomplete • frequently data from RCT’s is inadequate to make strong recommendations

50. EBM Journals • Available online and in text format • Include: • ACP Journal Club • Clinical Evidence • Evidence-Based Practice