Evidence-based medicine. Converting the knowledge gap into an answerable question

Evidence-based medicine Converting the knowledge gap into an answerable question

Learning Objectives To understand the meaning of evidence-based medicine. To be able to ask a focussed/answerable question. To be aware that there are many different sources of health information and how to access and assess them

Evidence based medicine Introduction What is EBM? Why EBM? Steps of EBM. Conclusion.

What is Evidence-based medicine: "Evidence based clinical practice is an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best". Muir Gray JA. (1997) Evidence-based healthcare: how to make health policy and management decisions. London: Churchill Livingstone.

What is Evidence-based medicine? EBM is an approach to practice and teaching that integrates pathophysiological rationale, caregiver experience, and patient preferences with valid and current clinical research evidence. (Ellrodt, G. Evidence-based disease management, JAMA 1997, 278, 20)

What is Evidence Based Medicine (EBM ) Is the integration of best research evidence with clinical expertise and patient values. 6

Evidence-based medicine A process of turning clinical problems into questions......and then systematically locating, appraising and using contemporaneous research findings as the basis for clinical decisions. Rosenberg W and Donald A. Evidence-based medicine: an approach to clinical problemsolving. British Medical Journal; 310: 1122-1127. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2549505/

Why EBM? Need for valid information about diagnosis, prognosis.etc. The inadequacy of traditional sources for information because they are: out of date (textbook) frequently wrong (expert), or too overwhelming in volume & too variable in validity (journals ). 8

Evidence: the whats and whys Not all evidence is of equal value; Hierarchies of research design are considered to have different strengths; Therefore they have different values in the final conclusions we can draw from the literature; http://phpartners.org/tutorial/04-ebph/2-keyconcepts/4.2.7.html

Hierarchy of evidence 1

The Five Steps of EBHC 1. To convert the knowledge gap into an answerable question 2. To search for and locate the best evidence 3. To critically appraise the evidence 4. To apply evidence 5. Evaluate your performance audit and reflect

1. How to convert the knowledge gap into an answerable question? How to ask clinical question that you can answer?

Learn how to recognize, classify, and prioritize important patient or policy problems. Construct clinical questions that facilitate an efficient search for evidence. Gather important and convincing evidence from high-quality repositories of the health literature. Systematically check best available evidence for indications of validity, importance, and usefulness. Interpret the applicability of evidence to specific problems, given patient preferences and values.

PI(E)COT Participant/Population Intervention or Exposure Control/Comparison Outcomes Time

Components of Clinical Questions Patient/ Population Intervention/ Exposure Comparison Outcome In postmenopausal women Treatment with HRT Placebo/no treatment Increase the Risk of breast cancer 15

2. How to search for and locate the best evidence? Colleagues Summaries of the primary evidence Clinical Evidence emedicine FPIN Clinical Inquiries UpToDate Databases MEDLINE Cochrane Library Electronic textbooks and libraries ACP Medicine Harrisons MD Consult Stat!Ref Meta-Search Engines SUMSearch TRIP Plus: Turning Research into Practice

Other EBM Resources : Michigan State University, An Introduction to Information Mastery: http://www.poems.msu.edu/infomastery/ University of Virginia Health Sciences Library, Navigating the Maze: Obtaining Evidence-Based Medical Information: http://www.healthsystem.virginia.edu/internet/library/col lections/ebm/index.cfm NHS Research and Development Centre for Evidence- Based Medicine http://www.cebm.net/ Netting the Evidence - A ScHARR Introduction to Evidence Based Practice on the Internet: http://www.nettingtheevidence.org.uk/ 17

3. How to Critically appraise the evidence: It has 3 steps : 1. Is it valid? 2. Is it important? 3. Is it applicable? 18

4. Applying the evidence Can you apply this valid, important evidence in caring for your patient?

5. How to evaluate your performance Evaluate your effectiveness & efficiency in steps 1-4 and seek ways to improve them.

Barriers to EBM approach Culture change hard to initiate; Leap in the dark ; May require increased resources, therefore may be easier not to ask the difficult questions; Lies, Damned Lies and Statistics mindset; Practical difficulties of getting the evidence to where it is needed most: the medical decision-making front line.

Next up......the challenge of asking answerable questions!

Clinical questions 1 ABNORMALITY: is the patient well or unwell? DIAGNOSIS: how reliable are the tests used to diagnose disease? FREQUENCY: how often does a disease occur? RISK: what factors are associated with an increased risk of disease?

Clinical questions 2 PROGNOSIS: what are the consequences of having a disease? TREATMENT: how does treatment change the course of a disease? PREVENTION: does an intervention on well people keep the disease from developing? Do early detection and early treatment improve the course and outcome of the disease?

Clinical questions 3 CAUSE: What conditions lead to disease? What are the pathogenic mechanisms of the disease? What are the triggers for the disease? COST: how much will care for an illness cost?

Asking Answerable Questions Why? Focus Provides search terms Inclusion/Exclusion criteria Type of evidence/information

A poorly formulated question Does insulin do any good in diabetes?

Refining the question Too many hits on literature search Nothing in the literature

This is the trouble with internet research, in my experience. The proportion of what s useful to what s dross dwindles very quickly and suddenly it s like searching for something dropped down the back of a sofa and coming up with handfuls of old coins, buttons, fluff and sucked sweets. What s important is to ask the right question. Robert Harris The Ghost

Broad Too many concepts Difficulty to determine search strategy Non-comparable studies Search taking too much time Hard to draw conclusions Narrow Are the results generalisable Biased conclusions Inclusion/exclusion criteria

PI(E)COT Participant/Population Intervention or Exposure Control/Comparison Outcomes Time

A focused Question P Diabetic Patients with Type I diabetes who experience severe hypoglycaemia I Continuous subcutaneous insulin infusion C Multiple daily insulin injections O Reduction in hypoglycaemic rate

The role of Health Intelligence in Evidence Based Health Care Converting the knowledge gap into an answerable question

Evidence-based medicine

Evidence-based medicine Together, the two twinned units satisfy the vision of the HI Department; taken from HSE website: The work of the team brings a heightened specialisation in regard to the analysis of health information, a refreshed approach to using the evidence base of health, and support and leadership in research and development

What is Health Intelligence? It is responsible for capturing, utilising and developing knowledge to improve health outcomes for the population. Use of data sources to drive health policy.

Health intelligence provides Health information including HIPE analysis and commentary Demographic data Mapping services Evidence based Health Care Support Teaching Advice on research projects and applications Health Technology Assessment (HTA) and Health Impact Assessment (HIA) Knowledge Management

Some Tools and Data Sources for EBM

Health Atlas Open source application developed to bring health related datasets, statistical tools and GIS together in a web environment to add value to existing health data; Enables joined up thinking with and between agencies.

Health Atlas

Health Atlas

Health Atlas

Health Atlas

Health Atlas

Health Atlas

Health Atlas

Health Atlas

Health Atlas

Health Atlas

Health Atlas

Some questions answered by EBM within Health Intelligence: Primary care resource allocation. Emergency Services provision. Road traffic accidents. Lower Extremity Amputations in Diabetic Patients Rise in COPD mortality and in-patient admissions in women Trends in paediatric hospital admissions and prescribing for asthma in Ireland over a ten year study period. The epidemiology of assault-related hospital in-patient admissions and emergency department attendances.

Thank you! anne ofarrell@hse.ie