Carl Heneghan BM, Bch, MA, MRCGP Deputy Director Centre for Evidence-Based Medicine University of Oxford

I am here to learn EBM Because? I wanted a day of work I wanted a day of work Formulate an answerable questions Formulate an answerable questions Two acronyms PICO - RAMbo Two acronyms PICO - RAMbo Right to Wrong, Right to Wrong, Wrong to Right, Wrong to Right, Wrong to Wrong Wrong to Wrong

Rapid appraisal of RCTs Always bring your book Always bring your book Do not volunteer in a teaching session Do not volunteer in a teaching session Use the GATE appraisal tool Use the GATE appraisal tool Randomization pink & blue bunnies Randomization pink & blue bunnies Maintenance Maintenance Blinding or Objective Blinding or Objective

Five steps in EBM Formulate an answerable question Track down the best evidence 3. Critically appraise the evidence for: Validity Validity Impact (size of the benefit) Impact (size of the benefit) Applicability Applicability Integrate with clinical expertise and patient values Evaluate our effectiveness and efficiency keep a record; improve the process

Participants Intervention Group (IG) & Comparison Group (CG) Outcome IGIGIGIG CGCGCGCG DC BA Representative? Allocation? Selection? Maintenance of allocation? VALIDITY comparable groups? treated equally? compliant? Maintenance? Measurements blind subjective? OR objective? QUESTION: Randomized concealed Allocation? Measurement of outcomes? DESIGN:

No maths Validity for an intervention study - 10 seconds Validity for an intervention study - 10 seconds Two ways to summarize results of studies that compare groups Two ways to summarize results of studies that compare groups Ratio Difference

No maths Potters where to buy The first question: Has the result happened by chance The more information - the more certain we are

Diagnosis Who is this have you met him before Who is this have you met him before Half the time I dont know what I am doing Half the time I dont know what I am doing Specificity is no good to me given a positive test Specificity is no good to me given a positive test Is It unreasonable to ask what happens if you have a positive test think false positive rate Is It unreasonable to ask what happens if you have a positive test think false positive rate

Systematic Reviews Mothers Kiss Mothers Kiss Café Rule Café Rule FAST

Group Summary

Changes in the past 12 months A Worldwide survey of 43 EBM practitioners

Questions that people have looked at this week Paul, Ulf, Rossalyn, Jennifer, Mark, Tricia, Helen, Mark, Robyn, Krishna Group 1 Group 1 Aspirin for the primary thrombosis prevention in the antiphospholipd syndrome Aspirin for the primary thrombosis prevention in the antiphospholipd syndrome Rovustatin to prevent vascular events in men and women with elevated CRP Rovustatin to prevent vascular events in men and women with elevated CRP The accuracy of single serum progesterone measurement in the diagnosis if ectopic pregnancy The accuracy of single serum progesterone measurement in the diagnosis if ectopic pregnancy

Questions that people have looked at this week Matthew, Miriam, Amitava, Daniel, Matt, Julia, David, Barbara, Gregory, Narayana Group 2 Group 2 In diabetic patients does aspirin prevent CVD In diabetic patients does aspirin prevent CVD In elderly patients does MD intervention therapies reduce the incidence of falls In elderly patients does MD intervention therapies reduce the incidence of falls In patients with suspected heart failure does BNP accurately predict disease compared to the gold standard In patients with suspected heart failure does BNP accurately predict disease compared to the gold standard

Questions this week Mike, Clare, Murtala, Mogamat, Haren, Anee, Daniel, Nuno, Eve Lena, Dini Group 3 Group 3 Does Steroid Treatment improve renal recovery in patients with induced acute interstitial nephritis Does Steroid Treatment improve renal recovery in patients with induced acute interstitial nephritis Is early compared to late haemodialysis better for survival in critically ill patients with ARF Is early compared to late haemodialysis better for survival in critically ill patients with ARF Does pre operative compared to post operative chemo and radiotherapy improve survival in rectal cancer patients with resectable disease Does pre operative compared to post operative chemo and radiotherapy improve survival in rectal cancer patients with resectable disease

Questions that people have looked at this week Carl, Kamlesh, Albin, Mark, Noran, Angel, Orla, Vicky, Robert, Roopa, Sashidar Group 4 Group 4 Antibiotics versus placebo for postoperative infection after appendicectomy Antibiotics versus placebo for postoperative infection after appendicectomy Anaesthesia awareness and the Bispectral Index Anaesthesia awareness and the Bispectral Index Predicting functional impairment with aging Predicting functional impairment with aging Anticoagulation Treatment in Central Venous Thrombosis Anticoagulation Treatment in Central Venous Thrombosis

Questions his week Dan, Iben, Annabel, Robert, Nastiti, Chidimma, Annette, Katherine, Richard Group 5 Group 5 Does a statin reduce CVD in Middle aged men with no IHD, but a high cholesterol Does a statin reduce CVD in Middle aged men with no IHD, but a high cholesterol What is the evidence that every pregnant women needs to have folic acid to reduce neural tube defects What is the evidence that every pregnant women needs to have folic acid to reduce neural tube defects Does sugar make children hyperactive Does sugar make children hyperactive Does socioeconomic status determine caesarean rate Does socioeconomic status determine caesarean rate Does CPAP improve mortality in pulmonary odema Does CPAP improve mortality in pulmonary odema What is the evidence goserelin reduces chronic pelvic pain What is the evidence goserelin reduces chronic pelvic pain Does C section reduce perinatal mortality in breech presentation Does C section reduce perinatal mortality in breech presentation

Questions this week Karen, Su-May, Lakshimi Siobhan, Norita, Sridhar, Rowena, Mia, Bijay Group 6 Group 6 When searching does Google or Pubmed produce higher quality evidence When searching does Google or Pubmed produce higher quality evidence Is aspirin effective in primary prevention of CVD in diabetics Is aspirin effective in primary prevention of CVD in diabetics Is vitamin c effective for the symptoms of the common cold Is vitamin c effective for the symptoms of the common cold In patients with FH of thalassaemia does using a risk counselling tool increase number going to screening In patients with FH of thalassaemia does using a risk counselling tool increase number going to screening

Introduction of new ideas Presenting new material and concepts Practice and consolidation Using real examples, real language Debriefing and Reflection Evidence Learning cycle

Developing your EBM skills What resources might you use How are you going to develop your EBM skills What are you going to differently after this workshop

Resources ResourceHow many of you Up to date14 Clinical Evidence6 Trip database10 GoogleAll! Google scholar20 Pubmed central9 Bandolier11 Cochrane (abstracts free, full text maybe not) including DARE Athens EMBASE BestBets (Emergency Dept)12 Drug Infozone E medicine Info retriever Essential Evidence Plus

What things are you going to differently 1. Use GATE tool more14. Join CEBM mailing list/discussion list 2. Read EBM journal15. Try to translate things into lay terms 3. Set up journal club16. Teach others EBM skills 4. Keep book of questions17. Use PICO and RAAMBO to design research 5. Start blog (see Amis on CEBM site!)18. Better reviewer for journals 6. What is I 2 ? Look up heterogeneity19. Use pubmed clinical queries…with patient in the room…demonstrate to colleague 7. Try BMJ updates/Evidence updates20. Increase understanding of EBM in Prosthetics…and other specialties. 8. Keep record of changes to practice21. More questioning at work 9. Do a systematic review….22. Librarians to use more pre-appraised resources 10. Engage colleagues in implementing changes 23. Look back at studies we are using to see if they are really valid/how big is benefit 11. Research designs24. Do MSc in EBM 12. Try different study designs eg observational 25. Apply for grants to do course/systematic review 13. Write a letter about an article to NEJM26. Influence journal editors to present things better.

Postcards: What three things are you going to do differently

Questions Recognize: your questions Select: which questions to pursue Guide: how to ask and answer Assess: how well & what to improve

What Pushes Us … ? Toward curiosity curiosity Prove colleagues wrong Prove colleagues wrong Keeps coming up Keeps coming up Risk of patient harm Risk of patient harm Want to do better Want to do better Anxiety Anxiety Avoid litigation Avoid litigation Internet informed patient Internet informed patient Away Time We already know the answer Fatigue Access Inferiority complex-anxiety- afraid of admitting knowledge gaps Cynical Laziness Lack of support Previous failure at searching Lack of resources Noone else does it Fear of change

The Real Three Rs of Learning Resilient Reflective Resourceful

FAQ: How Long … ? Proficient? Quickly Proficient? Quickly Mastery? Lifetime Mastery? Lifetime Human expertise takes >10,000 hours, >10 years Human expertise takes >10,000 hours, >10 years Deliberate practiceDeliberate practice