Getting evidence into practice

Fiona Godlee

Editor, BMJ

International Clinical Librarian Conference

Birmingham 13 June 2011

Why are health professionals slow to adopt evidence-based practice?

• The story behind preventing neonatal distress syndrome in premature babies

Surfactant treatment Prenatal steroid treatment

Perception of mechanism Corrects a surfactant deficiency disease

Ill-defined effect on developing lung tissue

Timing of effect Minutes Days

Impact on prescriber Views effect directly (has to stand by ventilator)

Sees effect as statistic in annual report

Perception of side effects Perceived as minimal Clinicians’ and patients’ anxiety disproportionate to actual risk

Conflict between two patients

No (paediatrician’s patient will benefit directly)

Yes (obstetrician’s patient will not benefit directly)

Pharmaceutical industry interest

High (patented product; huge potential revenue)

Low (product out of patent; small potential revenue)

Trial technology “New” (developed in late 1980s)

“Old” (developed in early 1970s)

Widespread involvement of clinicians in trials

Yes No

Factors influencing implementation of evidence to prevent neonatal respiratory distress syndrome (Dr V Van Someren, personal communication)

What is Evidence Based Medicine?

"the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

David Sackett, et al. BMJ 312, no. 7023 (1996)

What is Evidence Based Medicine?

“ the integration of best research evidence with clinical expertise and patient values."

David Sackett, et al. Evidence-Based Medicine: How to Practice and Teach EBM (New York: Churchill Livingstone, 2000), 1.

What is Evidence Based Medicine?

Patient preferences

Evidence Clinical experience

What do we know about doctors’ information needs? Smith R. BMJ

• Information needs do arise regularly when doctors see patients• Questions are most likely to be about treatment, particularly drugs.• Questions are often complex and multidimensional• The need for information is often much more than a question about

medical knowledge. Doctors are looking for guidance, psychological support, affirmation, commiseration, sympathy, judgement, and feedback.

What do we know about doctors’ information needs? Smith R. BMJ

• Most of the questions generated in consultations go unanswered• Doctors are most likely to seek answers to their questions from

other doctors• Most of the questions can be answered - but it is time consuming

and expensive to do so• Doctors seem to be overwhelmed by the information provided for

them

The information paradox

“Doctors are overwhelmed with information yet cannot find the information they need”

Dr Muir Gray Dr Muir Gray

Director of the UK’s National Library of MedicineDirector of the UK’s National Library of Medicine

The poet’s view

“Where is the wisdom we have lost in knowledge?

And where is the knowledge we have lost in information?”

T S Eliot

Many necessary stages between research and practice

• Are doctors aware of the evidence?• Do they accept it?• Is it targeted correctly at their patients?• Is the necessary change in practice doable?• Is the information recalled at the right moment? (does

the doctor remember what to do?) • Does the patient agree with the doctor’s

recommendation?• Does it actually happen?

Many “leaks” between research & practice

Aware Accept Target Doable Recall Agree Done

ValidResearch

Glasziou, Haynes, ACP Journal Club 2005

Many “Leaks” from research & practice

Aware Accept Target Doable Recall Agree Done

ValidResearch

Even if 80% is achieved at each stage then0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21

Glasziou, Haynes, ACP Journal Club 2005

“The application of what we know already will have a bigger impact on health and disease than any drug or technology likely to be introduced in the next decade” 1

1. Tikki Pang,Muir Gray,Tim Evans. A 15th grand challenge for global public health. The Lancet - 28 January 2006 ( Vol. 367, Issue 9507, Pages 284-286 ) DOI: 10.1016/S0140-6736(06)68050-1 .

2. Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts: treatments for myocardial infarction. JAMA 1992;268(2):240-248..

3. Crowley, P. Prophylactic corticosteroids for preterm labour. The Cochrane Library 2000, Issue 1 (CDSR) Update software..

Evidence into Practice

• It took 200 years before the Royal Navy routinely used lemon juice to prevent scurvy. First study 1601 1

• The first RCT that showed the benefit of thrombolytic therapy was in acute MI late 1950s – not in routine use until 1990s 2

• International guidelines first recommended antenatal corticosteroid use in preterm labour 22 years after first evidence 3

• On average it takes 17 years for 14% of clinical research to become routine practice 4

1. Mosteller, F. Innovation and evaluation. Science 1981,211,881–86.4. Westfall, J. M., Mold, J., & Fagnan, L. (2007). Practice based research - "Blue Highways" on the NIH roadmap. JAMA, 297(4), p. 403.

Patient Safety

• Adverse event rate in UK hospitals as high as 10.8% 1

• 190,000 deaths from adverse events in US annually 2

• Cost to the NHS £500m annually

• Caused by slips, lapses, mistakes and non-uniform or poorly evidenced care

• Results in increased mortality, morbidity and a higher cost of care

1. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ (Clinical research ed.). 2001;322(7285):517-9.

2. HealthGrades Quality Study. Patient Safety in American Hospitals; 2004 http://www.healthgrades.com/media/english/pdf/hg_patient_safety_study_final.pdf

What can we do?

• Errors and mistakes• Poor quality healthcare• Waste• Variations in practice• Poor patient experience• The adoption of interventions with low value• Failure to get new evidence into practice

The application of what we know can prevent and minimise the seven main healthcare problems:

Steps to the solution as proposed in 1998 1

• Generating evidence from research

• Synthesising the evidence

• Creating evidence based clinical policies

• Applying the policies

1. Brian Haynes, Andrew Haines. Education and debate: Getting research findings into practice: Barriers and bridges to evidence based clinical practice. BMJ 1998;317:273-276.

Systems

Summaries

Synopses

Syntheses

Studies

Examples

Computerized decision support

Evidence-based textbooks

Evidence-based journal abstracts

Systematic reviews

Original journal articles

The evolution of Evidence-Basedinformation systems

Data

Information

Know About

Know How

Action

Integrating evidence to help organisations:

Deliver high quality, safe and more efficient healthcare.

For better patient outcomes.

Resources to support CPD, appraisal, re-

validation and exam preparation.

Over 30 titles supporting research

across multiple clinical specialties.

Group

Content and services for healthcare organisationsContent and services for healthcare organisations

Evidence based products to support clinicians in decision

making

Evidence based products to support clinicians in decision

making

Over 30 titles supporting research

across multiple clinical specialties

Resources to support CPD, appraisal,

revalidation and exam preparation

Systematic reviews of 3300 interventions

First published in 1999

Reaches more than a million clinicians worldwide in seven languages

Updated monthly

Evidence, expert opinion and guidelines

Designed to fit the medical model

Assessment, diagnosis, treatment, management

Web interface designed to be used at the Point of Care

COPD

Can also be integrated into an Electronic Patient Record

This allows clinicians to answer their clinical questions while using their clinical systems

There is evidence to support the effectiveness of this approach

Successful Decision Support

• BMJ 2005, Kawamoto et el, systematic review of CDSS1

• Included 70 studies, 6000 clinicians acting as study subjects treating 130,000 patients

• 75% of interventions succeeded when the decision support was provided to clinicians automatically in the clinical workflow

• Systems that were integrated into order entry systems were significantly more likely to succeed than stand alone systems

1. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ (Clinical research ed.). 2005;330(7494):765. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15767266.

The 4 critical predictors of clinical decision support success

Table 1 - Features of CDSS associated with improved clinical practice

Order sets designed for use in electronic orders systems

Based on clinical evidence and organised into care protocols

Our content covers up to 80% of acute admissions

Evidence based reduction in mortality, cost and complication rate

The Problem of Acute Chest Pain is recorded in the

patient record

We are now in the orders section of Mr Hamilton’s electronic health record

A list of Action Sets is displayed relevant to Acute

Chest Pain

Nursing requests

Medication and i.v. fluid requests

Including dose instructions

Pathology tests

Radiology and other tests

Specialist Referrals

Some other things we could talk about

• How good is the evidence?• How important is open access, and what can librarians

do to support it?