(First Annual)Learning to Practice and Teach

Evidence-based Health CareAn Intensive Workshop

Introductions

• Robert Wild & Dave Thompson

• Susan Hollingsworth

• Speakers

• Facilitators

• Participants

A true story

• A randomized trial of treating high blood pressure on the jobsite (a steel mill) vs. referral for treatment to primary care doctor

• Primary outcome: treatment compliance• No difference in compliance between the

groups• Some patients who were referred with

documented hypertension did not get treated

Determinants of the clinical decision to treat some, but not other, high blood pressure patients:

1 The level of diastolic blood pressure.2 The patient’s age.3 _4 The amount of target-organ damage.

Determinants of the clinical decision to treat some, but not other, hypertensive patients:

1 The level of diastolic blood pressure.2 The patient’s age.3 The physician’s year of graduation from

medical school.4 The amount of target-organ damage.

How we “know”• observations in the world

• clinical experience

– open to bias• specious causal connections• vividness and immediacy• small samples

• laboratory and physiological research– systematic but generalization dangerous

• observational studies– non-comparable groups

What we (did) know that ain’t so:

• HRT to decrease cardiovascular risk– observational studies consistently suggest

decreased risk– RCTs show increased risk

• High flow oxygen for RDS– My 6th grade pen-pal was in the “gifted

children” class at the Ohio state school for the blind

• Anti-arrythmics post-MI

Contrasting Reasoning

• Patho-physiologic reasoning– Depends on logic and

knowledge of pathophysiology

– This leads to a decision to prescribe flecainide to patients after heart attack

• Evidence from systematic studies in human subjects:– Randomized trial of

flecainide after MI:• 7.7% dead on

flecainide• 3.0% dead on placebo

– Leads to a decision NOT to prescribe flecainide after MI

Hierarchy of Evidence

Meta-analysis of RCTssystematic review of RCTs

Individual RCT

Observational studiespatient-important outcomes

Basic researchtest tube, animal, human physiology

Clinical experience

Why don’t we practice EBM?

• Exploding information supply

• Textbooks are out of date

• No time to read

• Traditional CME doesn’t work

Asking questions

• Practice identifying information needs:

– Routinely question decisions

– Question routine decisions

• Identify the specific issue at hand

• Do you need background or foreground information?

Identify the type of information that is needed

• Background information: What IS myelomonocytic leukemia?? Best source of information for background questions is recent textbooks or recent general review articles.

• Foreground information: Should patients with myelomonocytic leukemia be treated with methotrexate? The best information for foreground questions comes from original research in human subjects.

Asking Questions

• Design a focused clinical question that addresses the information need– Patient/population– Intervention– Comparison if relevant– Outcome

• The “PICO question”

• PCOS

Why bother with EBM?

• without EBM we are helpless in the face of– misguided experts– overenthusiastic experts– drug company hype

• without EBM our ability is limited– to understand difficult tradeoffs – to help our patients make difficult decisions

• with EBM comes– understanding and power – greater effectiveness in helping our patients

Seven Alternatives to Evidence Based Medicine

• Eminence Based Medicine (marked by radiance of white hair)

• Vehemence Based Medicine • Eloquence Based Medicine• Providence Based Medicine• Diffidence Based Medicine• Nervousness Based Medicine• Confidence Based Medicine

– (Isaacs and Fitzgerald, BMJ 1999;319:1618)

Structure of the Workshop• Breakfast at 8:00am both days• First plenary at 9:15 am on Friday and 9:00am Saturday• Small group sessions

– 10:15-11:40 am Friday, 1:30-3:30 pm Friday– Saturday 10:15-11:30 adjourn Sat 11:30 am

• Box Lunches Friday and Saturday • Lunchtime registrants hands - on searching session

today – Sign up at registration table, limited space -

• facilitators go to room 251 Provost Conference PM • Reception this afternoon after last plenary 4:45PM• Please turn in your evaluations. CME can be obtained

for an additional $25 , slide presentations, and the library resource guide with links to many, many helpful websites will be posted on URL http://moon.ouhsc.edu/dthompso/cdm/ebhc1/ … in your packet

Goals of the workshop

• To learn and practice skills of critical appraisal of the research literature

• To learn techniques for teaching EBM

Your own goals

• You will have come with your own objectives for the workshop– Please share them with your group

Ground Rules

• Facilitators are there to facilitate and demonstrate

• Please arrive on time and prepared for each session

• Have a good time!