1. Evidence-Based Practice Paul Glasziou University of Queensland & Oxford

2. What evidence-based medicine is: Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values - Sackett, et al 2001

3. JASPA* (Journal associated score of personal angst) J: Are you ambivalent about renewing your JOURNAL subscriptions? A: Do you feel ANGER towards prolific authors? S: Do you ever use journals to help you SLEEP? P: Are you surrounded by PILES of PERIODICALS? A: Do you feel ANXIOUS when journals arrive? * Modified from: BMJ 1995;311:1666-1668 0 (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions)

4. Rule 31 – Review the World Literature Fortnightly* *"Kill as Few Patients as Possible" - Oscar London 5,000? per day 1,400 per day 55 per day

5. Managing Information The Airline industry Boeing 777 manuals 24 binders 10 feet shelf space Conversion to CD Reduced search by 60% The Health Industry Memorize the manuals Exams, audits, etc to check

6. Systematic review of bed rest after medical procedures Allen, Glasziou, Del Mar. Lancet, 1999 10 trials of bed rest after spinal puncture no change in headache with bed rest Increase in back pain Protocols in UK neurology units - 80% still recommend bed rest after LP Serpell M, BMJ 1998;316:1709–10 …evidence of harm available for 17 years preceding...

7. Getting Evidence in to Practice How do you do EBP? What EBP do you do/help with? What other EBP do you know of? Compare with you neighbour Teaching Tip: Special background for activities.

8. Managing Information Push and Pull methods Push - alerts us to new information Just in Case learning Use ONLY for important, new, valid research Pull – access information when needed Just in Time learning Use whenever questions arise EBM Steps: Question; search; appraise; apply

9. Bimonthly just in case journal Valid, Relevant & (almost) No Effort! 80 journals scanned Is it valid? Intervention: RCT Prognosis: inception cohort Etc Is it relevant? GPs & specialists ask: Will this change your practice? www.evidence-basedmedicine.com

10. Just in Time learning: Interns information needs Setting: 64 residents at 2 New Haven hospitals Method: Interviewed after 401 consultations Questions Asked 280 questions (2 per 3 patients) Pursued an answer for 80 questions (29%) Not pursued because Lack of time Forgot the question Sources of answers Textbooks (31%), articles (21%), consultants (17%) Green, Am J Med 2000

11. Interns information needs Most of our questions are NEVER answered When answered, the information is likely to be neither the best nor up-to-date

12. Your Clinical Questions Write down one recent patient problem What was the critical question? Did you answer it? If so, how?

13. Information pull Steps in EBM process 1.Formulate an answerable question 2.Track down the best evidence 3.Critically appraise the evidence 4.Integrate with clinical expertise and patient values

14. An example: the first sign of hyperkalaemia is death An anxious laboratory technician phoned about a potassium of 7.3 mmol/l (Ref Range 3.5-5.0) found on a routine blood test of a 50 year old woman. I arranged an urgent repeat of the electrolytes (to rule out a spurious elevation) and an ECG. The latter was reassuringly normal, but left me asking: Does a normal ECG rule out a serious elevation of potassium?

15. 1. The question Does a normal ECG rule out a serious elevation of potassium? Population - In suspected hyperkalemia Indicator - does a normal ECG Comparator - Outcome - rule out hyperkalemia?

16. 1. The question Does a normal ECG rule out a serious elevation of potassium? Population – hyperkal* Indicator – ECG OR EKG Comparator - Outcome – hyperkal* Underline keywords; think of synonyms

17. Diagnosis button * Means any letters OR synonyms PubMed via Google

18. Diagnosis button

19. Sensitivity of 62% or 55%

20. Step 2: The best evidence depends on the type of question 1.What are the phenomena/problems? Observation (e.g., qualitative research) 2.What is frequency of the problem? (FREQUENCY) Random (or consecutive) sample 3.Does this person have the problem? (DIAGNOSIS) Random (or consecutive) sample with Gold Standard 4.Who will get the problem? (PROGNOSIS) Follow-up of inception cohort 5.How can we alleviate the problem? (INTERVENTION/THERAPY) Randomised controlled trial

21. Treating hyperkalemia She refused to go to hospital Resonium A, but it is around $100 (RPBS but not PBS) which she could not afford. My search had mentioned albuterol as a treatment.

23. Just in Time learning The EBM Alternative Approach Shift focus to current patient problems (just in time education) Relevant to YOUR practice Memorable Up to date Learn to obtain best current answers Dave Sackett

24. The Barriers to EBP 1.Attitude of question & inquiry 2.Know-how in finding, appraising, and applying evidence 3.Information Resources on tap 4.Lack of Time

25. EBP in Teams Question focused journal clubs Structure: Appraise & apply homework article New questions? Discuss & assign Plan and monitor changes Are there barriers to the change? Can we measure the change?

26. EBP for Teams: example Initial EBP lunch questions on annual check TRIGGER: Is blood monitoring better than urine monitoring in NIDDM? – No; give patients option Session 1: formulate questions Should all diabetics be on aspirin? – Most; audit Are aerobic or resistance exercises helpful for diabetic control? – Both improve control; audit; purchased 12 pedometers (Subsequent sessions) Who needs to see the podiatrist? – High risk What is the best test for neuropathy? - Monofilament How can we improve compliance? When should oral medications be started?

27. Using evidence for prioritising Q: Which diabetics need podiatry? PLAN Current wait time is 3 Months About half workload is diabetics Cohort study shows 2% ulcers/yr with 5 risk factors Current ulcer Past ulcer Neuropathy Deformity Poor pulses Abbot. Diab ed 2002: 377-84

28. Summary Is there an information deluge? Yes – 5,000 articles per day Does CME help? Maybe a little Can EBM (patient-centred learning) help? Yes, it uses the more effective methods of CME What are the barriers? Evidence resources, skills, inquiring attitude