carl heneghan bm, bch, ma, mrcgp deputy director centre for evidence-based medicine university of...
TRANSCRIPT
Carl Heneghan BM, Bch, MA, MRCGP
Deputy Director Centre for Evidence-Based MedicineUniversity of Oxford
I am here to learn EBM Because?
• I wanted a day of work • Formulate an answerable questions
• Two acronyms PICO - RAMbo
• Right to Wrong,•Wrong to Right, •Wrong to Wrong
Rapid appraisal of RCTs
Always bring your book Do not volunteer in a teaching
session Use the GATE appraisal tool Randomization pink & blue bunnies Maintenance Blinding or Objective
Five steps in EBM
1. Formulate an answerable question2. Track down the best evidence 3. Critically appraise the evidence for:
Validity Impact (size of the benefit) Applicability
4. Integrate with clinical expertise and patient values
5. Evaluate our effectiveness and efficiency keep a record; improve the process
Participants
Intervention Group (IG) & Comparison Group (CG)
Outcome
IG
CG
+ -+- DC
BA
Representative?
Allocation?
Selection?
Maintenance of allocation?
VALIDITY
comparable groups?treated equally?compliant?
Maintenance?
Measurementsblind subjective? ORobjective?
QUESTION:
Randomizedconcealed Allocation?
Measurement of outcomes?
DESIGN:
No maths
Validity for an intervention study - 10 seconds
Two ways to summarize results of studies that compare groups
Ratio Difference
No maths
Potter’s where to buy www.thinknatural.com
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
Half the time I don’t know what I am doing
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
Systematic Reviews
Mother’s Kiss
Café Rule
FAST
Group Summary
Changes in the past 12 months
A Worldwide survey of 43 EBM practitioners
0- 1 2 3 4 to 5 6 to 8 >80%
5%
10%
15%
20%
25%
30%
35%
40%
Changes in the last 12 months
Questions that people have looked at this week
Paul, Ulf, Rossalyn, Jennifer, Mark, Tricia, Helen, Mark, Robyn, Krishna
Group 1 Aspirin for the primary thrombosis
prevention in the antiphospholipd syndrome
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
Questions that people have looked at this week
Matthew, Miriam, Amitava, Daniel, Matt, Julia, David, Barbara, Gregory,
Narayana Group 2 In diabetic patients does aspirin
prevent CVD 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
Questions this weekMike, Clare, Murtala, Mogamat, Haren,
Anee, Daniel, Nuno, Eve Lena, Dini
Group 3 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
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 Antibiotics versus placebo for
postoperative infection after appendicectomy
Anaesthesia awareness and the Bispectral Index
Predicting functional impairment with aging
Anticoagulation Treatment in Central Venous Thrombosis
Questions his weekDan, Iben, Annabel, Robert, Nastiti, Chidimma, Annette, Katherine, Richard
Group 5 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
Does sugar make children hyperactive
Does socioeconomic status determine caesarean rate Does CPAP improve mortality in pulmonary odema What is the evidence goserelin reduces chronic pelvic pain Does C section reduce perinatal mortality in breech presentation
Questions this weekKaren, Su-May, LakshimiSiobhan, Norita, Sridhar, Rowena, Mia, Bijay Group 6 When searching does Google or
Pubmed produce higher quality evidence
Is aspirin effective in primary prevention of CVD in diabetics
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
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
ResourcesResource How many of you
Up to date 14
Clinical Evidence 6
Trip database 10
Google All!
Google scholar 20
Pubmed central 9
Bandolier 11
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 more 14. Join CEBM mailing list/discussion list
2. Read EBM journal 15. Try to translate things into lay terms
3. Set up journal club 16. Teach others EBM skills
4. Keep book of questions 17. Use PICO and RAAMBO to design research
5. Start blog (see Ami’s on CEBM site!)
18. Better reviewer for journals
6. What is I2? Look up heterogeneity
19. Use pubmed clinical queries…with patient in the room…demonstrate to colleague
7. Try BMJ updates/Evidence updates
20. Increase understanding of EBM in Prosthetics…and other specialties.
8. Keep record of changes to practice
21. 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 designs 24. 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 NEJM
26. 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 Prove colleagues
wrong Keeps coming up Risk of patient
harm Want to do better Anxiety Avoid litigation Internet informed
patient
AwayTimeWe already know the
answerFatigueAccessInferiority complex-
anxiety-afraid of admitting knowledge gaps
CynicalLazinessLack of supportPrevious failure at
searchingLack of resourcesNoone else does itFear of change
The Real ‘Three R’s’ of Learning
Resilient
Reflective
Resourceful
FAQ: How Long … ? Proficient?
Quickly Mastery?
Lifetime
Human expertise takes >10,000 hours, >10 years
→Deliberate practice