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Please sit beside someone from whom you would like help in solving a problem related to practicing evidence-based health care. Joint 7th International Shared Decision Making (ISDM) Conference and the 4th International Society for Evidence-Based Health Care (ISEHC) Conference 2015.

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Please sit beside someone from whom you would like help in solving a problem related to practicing evidence-based health care
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Joint 7th International Shared Decision Making (ISDM) Conference and the 4th International Society for Evidence-Based Health Care (ISEHC) Conference 2015

To register your interest in attending, sponsoring, exhibiting or presenting at the conference visit:

www.isdm-isehc2015.org

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How To Practice and TeachEvidence Based Health Care:An Attempt at a Tantalizing Introduction to the WorkshopGordon Guyatt

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Plan

EBHC

know best evidence – staying updated

process of answering clinical questions

introduce a patient

apply process

review an EBM principle

demonstrate I’m with it

ebhc know best evidence
EBHC - Know best evidence

staying up to date

journals

secondary journals

push services

solving a clinical dilemma

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Evidence Arc

Ask

Act

Acquire

Patient

Patient

Apply

Appraise

background to our patient
Background to our patient

Type 2 diabetes epidemic

occurs in older, often obese and sedentary individuals

associated with macrovascular (MI, CV death, stroke) and microvascular (neuropathy, retinopathy, nephropathy) complications

diagnosis by fasting glucose (> 125 mg/dl, 7 mm/l), GTT, increasingly HbA1C

our patient s presentation
Our patient’s presentation

57 year old man, + family history of CV disease, doesn’t smoke, moderate regular exercise, not obese, balanced diet

routine testing shows no hypertension, lipid profile normal, FBG 117/6.5

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Evidence Arc

any questions about

patient management?

Ask

Act

Acquire

Patient

Patient

Apply

Appraise

our patient s presentation1
Our patient’s presentation

57 year old man, + family history of CV disease, doesn’t smoke, moderate regular exercise, not obese, balanced diet

routine testing shows no hypertension, lipid profile normal, FBG 117/6.5

question
Question
  • patient
    • middle-aged man with borderline sugar
  • intervention
    • rosiglitazone
  • comparator
    • no rosiglitazone
  • outcome?
slide12

Evidence Arc

Ask

Act

Acquire: what sort of study and source?

Patient

Patient

Apply

Appraise

slide14

DREAM

Warning: You will be asked to summarize

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> 80% meds taken

over 17 days

oral GTT

fasting glucose > 6.1, < 7.0 mmol/l

2 hr > 7.8, < 11.1

all participants received

healthy diet and lifestyle advice

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Evidence Arc

Ask

Act

Acquire

Patient

Patient

Apply

Appraise - risk of bias, results

validity likelihood of bias
Validity (likelihood of bias)
  • randomization
    • concealed
  • blinding
    • patients
    • caregivers
    • data collectors
    • adjudicators
    • data analysts
  • loss to follow-up
validity likelihood of bias1
Validity (likelihood of bias)
  • randomization
    • concealed
  • blinding
    • patients
    • caregivers
    • data collectors
    • adjudicators
    • data analysts
  • loss to follow-up
validity likelihood of bias2
Validity (likelihood of bias)

randomization

concealed

blinding

patients

caregivers

data collectors

adjudicators

data analysts

loss to follow-up

validity risk of bias
Validity – risk of bias

hopeless

perfect

0

100

assignment
Assignment
  • using evidence in practice
    • 30 second teaching opportunity
  • issue of whether to give rosiglitazone to patient arises in outpatient clinic
  • summarize the study
  • educational goals
    • remind resident of risk of bias criteria
    • summarize results using approximate numbers
      • include notion of confidence intervals
    • applicability to our patient
an indispensable skill study synopsis
An Indispensable Skill:Study Synopsis

The Problem:

  • immediately after reading an article few learners can provide a synopsis.
  • several days after reading an article, hardly any clinicians can do this.
  • some EBM teachers can’t do this either.

The Solution:

  • clinicians and teachers need to practice creating the verbal study synopsis of an article.
what is the authors message
What is the authors’ message?

rosiglitazone to prevent diabetes:

strong indication (for all)

weak indication (for some)

not indicated

doctor what do i gain by taking rosiglitazone
Doctor, what do I gain by taking rosiglitazone?

Doc: less chance of diabetes

Pt: what happens if I get diabetes

Doc: you have to take a drug

Pt: the same drug I’m taking to prevent diabetes?

Doc: I could give you a drug with less problems

Pt: I’ll take a drug every day for 3 years to lower my risk of taking the same or a less toxic drug from 25 to 10%???

modelling exercise
Modelling exercise
  • 10,000 patients with pre-diabetes
  • what would happen if:
    • lifestyle advice only, drugs when they develop diabetes
    • rosiglitazone for 3 years, stop, resume drug if develop diabetes
what is your view
What is your view?

rosiglitazone to prevent diabetes:

strong indication (for all)

weak indication (for some)

not indicated

investigators very smart people

what has gone wrong here?

what went wrong
What went wrong?
  • development of diabetes is a surrogate
  • surrogate for:
    • mortality
    • cardiovascualar events (stroke, MI)
    • renal failure
    • visual impairment and blindness
    • anxiety
    • inconvenience
patient important and surrogtes
Patient-important and surrogtes

patient important outcomes

surrogate outcomes

associated with patient-important

change in surrogate leads to change in pt-important

often biologically compelling

association suggests causal relationship

often practically compelling

markedly ↓ duration, sample size, cost of RCTs

often misleading

surrogate or patient important
Surrogate or patient-important?

blood pressure

(stroke, MI, death)

heart failure exacerbation

cardiac output

(qol, exacerbations, death)

hip fracture

vertebral fracture

(pain, deformity)

development/increase in albuminuria

(dialysis)

asymptomatic DVT

(symptomatic DVT, PE)

development of diabetes

conclusion
Conclusion
  • beware surrogate outcomes
  • if intervention harmless, no cost, can rely on surrogate
  • if intervention has harms or costs, demand evidence of effect on patient-important outcomes
suggestions for the course
Suggestions for the course
  • clarify your learning objectives
  • take responsibility for ensuring objectives met
  • have an awesome time