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(First Annual) Learning to Practice and Teach Evidence-based Health Care

Welcome!. (First Annual) Learning to Practice and Teach Evidence-based Health Care. An Intensive Workshop. Introductions. Robert Wild & Dave Thompson Susan Hollingsworth Speakers Facilitators Participants. A true story.

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(First Annual) Learning to Practice and Teach Evidence-based Health Care

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  1. Welcome! (First Annual)Learning to Practice and Teach Evidence-based Health Care An Intensive Workshop

  2. Introductions • Robert Wild & Dave Thompson • Susan Hollingsworth • Speakers • Facilitators • Participants

  3. A true story • A randomized trial of treating high blood pressure on the jobsite (a steel mill) vs. referral for treatment to primary care doctor • Primary outcome: treatment compliance • No difference in compliance between the groups • Some patients who were referred with documented hypertension did not get treated

  4. Determinants of the clinical decision to treat some, but not other, high blood pressure patients: • The level of diastolic blood pressure. • The patient’s age. • _ • The amount of target-organ damage.

  5. Determinants of the clinical decision to treat some, but not other, hypertensive patients: • The level of diastolic blood pressure. • The patient’s age. • The physician’s year of graduation from medical school. • The amount of target-organ damage.

  6. How we “know” • observations in the world • clinical experience • open to bias • specious causal connections • vividness and immediacy • small samples • laboratory and physiological research • systematic but generalization dangerous • observational studies • non-comparable groups

  7. What we (did) know that ain’t so: • HRT to decrease cardiovascular risk • observational studies consistently suggest decreased risk • RCTs show increased risk • High flow oxygen for RDS • My 6th grade pen-pal was in the “gifted children” class at the Ohio state school for the blind • Anti-arrythmics post-MI

  8. Patho-physiologic reasoning Depends on logic and knowledge of pathophysiology This leads to a decision to prescribe flecainide to patients after heart attack Evidence from systematic studies in human subjects: Randomized trial of flecainide after MI: 7.7% dead on flecainide 3.0% dead on placebo Leads to a decision NOT to prescribe flecainide after MI Contrasting Reasoning

  9. Hierarchy of Evidence Meta-analysis of RCTs systematic review of RCTs Individual RCT Observational studies patient-important outcomes Basic research test tube, animal, human physiology Clinical experience

  10. Why don’t we practice EBM? • Exploding information supply • Textbooks are out of date • No time to read • Traditional CME doesn’t work

  11. Asking questions • Practice identifying information needs: • Routinely question decisions • Question routine decisions • Identify the specific issue at hand • Do you need background or foreground information?

  12. Identify the type of information that is needed • Background information: What IS myelomonocytic leukemia?? Best source of information for background questions is recent textbooks or recent general review articles. • Foreground information: Should patients with myelomonocytic leukemia be treated with methotrexate? The best information for foreground questions comes from original research in human subjects.

  13. Asking Questions • Design a focused clinical question that addresses the information need • Patient/population • Intervention • Comparison if relevant • Outcome • The “PICO question” • PCOS

  14. Why bother with EBM? • without EBM we are helpless in the face of • misguided experts • overenthusiastic experts • drug company hype • without EBM our ability is limited • to understand difficult tradeoffs • to help our patients make difficult decisions • with EBM comes • understanding and power • greater effectiveness in helping our patients

  15. Seven Alternatives to Evidence Based Medicine • Eminence Based Medicine (marked by radiance of white hair) • Vehemence Based Medicine • Eloquence Based Medicine • Providence Based Medicine • Diffidence Based Medicine • Nervousness Based Medicine • Confidence Based Medicine • (Isaacs and Fitzgerald, BMJ 1999;319:1618)

  16. Structure of the Workshop • Breakfast at 8:00am both days • First plenary at 9:15 am on Friday and 9:00am Saturday • Small group sessions • 10:15-11:40 am Friday, 1:30-3:30 pm Friday • Saturday 10:15-11:30 adjourn Sat 11:30 am • Box Lunches Friday and Saturday • Lunchtime registrants hands - on searching session today • Sign up at registration table, limited space - • facilitators go to room 251 Provost Conference PM • Reception this afternoon after last plenary 4:45PM • Please turn in your evaluations. CME can be obtained for an additional $25 , slide presentations, and the library resource guide with links to many, many helpful websites will be posted on URL http://moon.ouhsc.edu/dthompso/cdm/ebhc1/ … in your packet

  17. Goals of the workshop • To learn and practice skills of critical appraisal of the research literature • To learn techniques for teaching EBM

  18. Your own goals • You will have come with your own objectives for the workshop • Please share them with your group

  19. Ground Rules • Facilitators are there to facilitate and demonstrate • Please arrive on time and prepared for each session • Have a good time!

  20. ENJOY!

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