evidence-based practice: providing best care for our patients mark c. wilson, md, mph associate...
TRANSCRIPT
![Page 1: Evidence-Based Practice: Providing Best Care for Our Patients Mark C. Wilson, MD, MPH Associate Dean, Graduate Medical Education Associate Program Director,](https://reader035.vdocuments.mx/reader035/viewer/2022062519/56649e375503460f94b27a40/html5/thumbnails/1.jpg)
Evidence-Based Practice: Providing Best Care for Our
Patients
Mark C. Wilson, MD, MPHAssociate Dean, Graduate Medical Education
Associate Program Director, Internal MedicineCarver College of Medicine – University of Iowa
Process of Integrating Evidence July 9, 2015
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The Disclaimer …
• I’m a General Internist• I’m an EBM Enthusiast
• Since 1992, I’ve Been a Member of the International EBM Working Group
• Teach at McMaster University• Co-Author of Users’ Guides to Medical Literature
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Disclosures
• I have no financial conflicts of interest
• I periodically lapse into substandard English language, honed in West Texas public schools
• Over past 25yrs, my passion is to educate next generation of physicians to be better than their faculty
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Welcome to
IOWA!
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How Do You Spell Iowa?
a) Illinoisb) Idahoc) Iowad) Ohio
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How Do You Spell Iowa?
a) Illinoisb) Idaho
c) Iowad) Ohio
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Raygun Unpaid Advertisement
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Today’s RoadMap Objectives
1. Explore Just What ‘EBM’ Is, including Why Bother?
2. Gain Insights from Actual Patient Care
3. Encourage Your Investment to Grow these Enduring Clinical Skills
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Chat with Your Neighbor(s)
1. What attracted you to travel to this conference? … aside from it being in Iowa!
2. What perceptions/experiences have you had regarding ‘Evidence-based Clinical Practice’?
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Some UI Resident Perspectives on ‘EBM’
• It’s just Up-to-Date (electronic text)
• Evidence applied as a blunt hammer• Difficult
• Too time consuming to get any helpful info• Overwhelming jargon
• Hindrance• Painful• Is not consistent with local practice preferences
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A Quick Tour Thru the Evolution of ‘Evidence-Based
Medicine’
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EBM: It’s a Paradigm Shift• “When defects in an existing paradigm accumulate
to the extent that the paradigm is no longer tenable, the paradigm is challenged and replaced by a new way of looking at the world”
• “A new paradigm for medical practice is emerging”
• “Evidence-based medicine requires new skills of the physician”
JAMA 1992; 268:2420-5
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EBM: What it is• “Evidence-Based Medicine is the conscientious,
explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”
• “Practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”
EBM: What it is and what it isn’t. Br Med J 1996; 312:71-72
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EBM: What it is
• “Evidence-Based Medicine is about solving clinical problems.”
Users’ Guides to the Medical Literature:A Manual for Evidence-Based Clinical Practice 3rd
ed, 2015
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Core Principles ofEvidence-Based Medicine
1. The better the overall research, the more confident our clinical decisions
2. Evidence alone is never sufficient to make clinical decisions
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Core Principles ofEvidence-Based Medicine
1. The better the overall research, the more confident our clinical decisions
2. Evidence alone is never sufficient to make clinical decisions
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EBM is a Process
It’s an explicit approach to solving clinical problems …
It’s a philosophy of patient care
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A Process to Become Better Faster Clinicians
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Ask
Acquire
AppraiseApply
Action
Patient Dilemma
Evidence Cycle of EBM
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Why Do We Need this Process?
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“A Major Problem with Medical Knowledge …
It Doesn’t Smell When It’s Wrong or Becomes Out of Date”
Brian Haynes, MD, PhDEditor, ACP Journal Club
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1960
1965
1970
1975
1980
1985
1990
0.5 1.0 2.0
Odds Ratio of Death (Log Scale)
Favors Tx Favors Ctrl
4 316 7 1783
1 23
2 65
3 143
67 4753167 48154
Ro
uti
ne
Sp
ecif
ic
Rar
e/N
ever
Exp
erim
enta
l
No
t M
en
tio
ne
d
21
6
111281
2
6
510
878
1243 1 5
15
1 1 2
87
2
153929
22 545223 5767
17 3311
26511110 2544 p < 0.01
65 47185
27 612530 634633 657143 2105954 22051
p < 0.001
p < 0.0001
Antman. JAMA 1992; 268: 240
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Hoot Groups• Get into pairs (or 3)• Identify a Couple of
Reasons Why Docs were Slow to Adopt Thrombolytics in Acute MI
• Report in 3 minutes
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Why Docs Use Ineffective Rx
• Clinical Experience and Belief Structure• Love of Pathophysiological Model• Over-Reliance on Surrogate Outcomes• Ritual and Mystique• Patients’ Expectations (real or assumed)• A Need to Do Something
(Errors of Omission Worse that Errors of Commission)
• Nobody Asks the Question
Doust J, Del Mar C. BMJ 2004; 328:474
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Ask
Acquire
AppraiseApply
Action
Patient Dilemma
Evidence Cycle of EBM
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Let’s Venture onto My Ward Team(Take 1)
Mrs. Jones was transferred out to us from CVICU after urgent cath for severe CP & anterior ST elevations; normal cath and repeat EKG had diffuse ST elevations …
Resident: In addition to NSAID, I plan to start colchicine
Me: Hmmm … why don’t you bring the best evidence about this tomorrow for the team
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Let’s Venture onto My Ward Team(Take 2)
Mrs. Jones was transferred out to us from CVICU after urgent cath for severe CP & anterior ST elevations; normal cath and repeat EKG had diffuse ST elevations …
Resident: In addition to NSAID, I plan to start colchicine
Me: Really… I don’t recall anything about colchicine & pericarditis
Resident: It’s common practice to use colchicine to prevent recurrence
Me: Really … Wow, do you recall any specifics about the added benefit?
Resident: Well, we always use it on Cardiology …
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What If Our Cupboard Is Bare?(i.e. we don’t know everything …
like answers to their questions!)
• Affective Responses & Losing Control
• Or … Ego Stable & Shift into a Cognitive Response
• Embrace that c/w ‘Adaptive Expertise’• Allows experts to continuously learn during
the process of problem-solving
• Unanticipated challenges become opportunities for learning
Academic Medicine 87: 1-5, 2012
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Not All Clinical Research Evidence is Created Equal
1st Core Principle:The better the research evidence, the more confident our clinical decisions
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BIASBIAS
Hierarchy of Evidence
1. Systematic Reviews of RCTs
2. Randomized Controlled Trials
3. Cohort studies
4. Case-Control studies
5. Case series
6. Case reports
7. Unsystematic observations
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Ask
Acquire
AppraiseApply
Action
Patient Dilemma
Evidence Cycle of EBM
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Applying Evidence
“Knowing is not enough. We must apply. Willing is not enough, we must do.”
Johann Wolfgang von Goethe1749 – 1832
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If EBM is about Using Evidence …
How Should We Treat Deep Venous Thrombosis?
1. Traditional: Admit to hospital 7d for IV heparin while wait for warfarin to take effect
2. Alternative: Use 7days of SQ LMWH as outpatient while wait for warfarin to take effect
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Ahh, … The Best Evidence
• RCT at 15 Centers in Canada• 500 patients with acute proximal DVT• Enoxaparin 1mg/kg SQ bid versus
Standard continuous heparin infusion• Equal rates of recurrent VTE (5-6%)
& major bleeding rare (1-2%)• 50% of LMWH group never hospitalized
Levine, et al. NEJM 1996; 334:677-81
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How Would You Treat These Patients With New DVTs?
• 43 y/o truck driver whose husband is a nurse
• 68 y/o man 2wks after knee replaced who participates in rehab program 3X/week
• 75 y/o woman with metastatic ovarian cancer who is non-communicative after stroke 2yrs ago and has no advance directives & no family
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So We Wrestled with the 2nd Core Principle . . .
Evidence Alone
NEVER
Makes Clinical Decisions
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Evidence-Based Clinical Practice
• Specific Circumstances
• Research Evidence
• Patient Values & Preferences
Clinical Expertise
Haynes, Devereaux, & Guyatt. BMJ 2002; 324: 1350
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Ask
Acquire
AppraiseApply
Action
Patient Dilemma
Evidence Cycle of EBM
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You’re Getting Ready to Start the Day in Clinic with the Ambulatory
Block Resident
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Cochrane Database of Systematic Reviews
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Cochrane Database of Systematic Reviews
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This Feels Complicated … Do We All Need Advanced EBCP Skills?
A) ‘Evidence-Based Practitioners’• Adept at using the entire evidence-based cycle• Advanced critical appraisal skills; can use original
literature if needed• Can be leaders
B) ‘Evidence Users’• Have appreciation for strong evidence• Can seek out and use pre-appraised summaries
Guyatt, BMJ 2000; 320:954-5
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Consider …
Aiming to steadily get further in your skills.There are great tools & resources to help you.
Ultimately, You have to decide what to aim for …
1.Evidence-based practitioner (a.k.a. enthusiast) with broad capabilities
2.Evidence User with focused abilities to use pre-appraised evidence-based summaries
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Core Principles ofEvidence-Based Medicine
1. The better the research evidence, the more confident our clinical decisions
2. Evidence alone is never sufficient to make clinical decisions