the epidemiology of ignorance - gimbe€¦ · the epidemiology of ignorance the leaky pipeline from...
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The Epidemiology of Ignorance The leaky pipeline from research to patient care
Professor Paul Glasziou Centre for Evidence Based Medicine University of Oxford
www.cebm.net
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The Epidemiology of Ignorance and Knowledge in Health Care Prevalence & Incidence Causes / Etiology Prognosis Prevention & Treatment
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Prevalence
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Is bed rest ever helpful? A systematic review of trials*
*Allen, Glasziou, Del Mar. Lancet, 1999
10 trials of bed rest after spinal puncture no change in headache with bed rest Increase in back pain
Protocols in UK neurology units - 80% still
recommend bed rest after LP Serpell M, BMJ 1998;316:1709–10
…evidence of harm available for 17 years preceding...
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Bed-rest leads to non-significant increase in preterm delivery
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GP beliefs and intentions for preventive procedures in 52 yr male
0 20 40 60 80 100
*Screen for colon cancer
*Tetanus immunisation
Screen for lung cancer
Screen for prostate cancer
*Measure cholesterol
Measure glucose level
*Advise heavy drinkers
*Advise smokers to quit
*Measure blood pressure
Really DoShould Do
EUROPREV Network Europe.Prev Med. 2005:595-601 Croatia Estonia Georgia Greece Ireland Malta Poland Slovakia Slovenia Spain Sweden
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Why? The Etiology/Pathogensis The “Leaks” from research & practice
Aware Accept Target Doable Recall Agree Done
Valid Research
If 80% achieved at each stage then 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21
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Evidence-Awareness Gap Etiology
1. Too much information 2. Too much information 3. Too much information
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Size of Medical Knowledge
NLM MetaThesaurus 875,255 concepts 2.14 million concept names
Diagnosis Pro 9,200 diseases 20,000 abnormalities (symptoms, signs, lab,
X-ray,) 3,200 drugs (cf FDAs 18,283 products)
1 per day for 25 years
Quant’e Informazioni?
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Rule 31 – Review the World Literature Fortnightly* *"Kill as Few Patients as Possible" - Oscar London
0
500000
1000000
1500000
2000000
2500000
Biomedical MEDLINE Trials Diagnostic?
Med
ical
Art
icle
s pe
r Yea
r
5,000? per day
1,500 per day
55 per day
Quant’e Informazioni?
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PROCESS 120+ journals scanned
50,000 articles Is it valid? (<5%)
Intervention: RCT Prognosis: inception cohort Etc
Is it relevant? 6-12 GPs & specialists asked:
Relevant? Newsworthy?
< 0.5% selected
www.evidence-basedmedicine.com
Filtered knowledge How much is valid AND relevant?
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Prevention & Treatment
EVIDENCE
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Prevention: The push & pull of Evidence-Based Practice
Read an evidence-based abstraction journal
Keep a logbook of your own clinical questions (and answer some!!)
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“Just in Time” learning: Intern’s information needs
Setting: 64 residents at 2 New Haven hospitals Method: Interviewed after 401 consultations Questions Asked 280 questions (2 per 3 patients) Pursued an answer for 80 questions (29%) Not pursued because
Lack of time Forgot the question
Sources of answers Textbooks (31%), articles (21%), consultants (17%)
Green, Am J Med 2000
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Prevention: “Just in Time” learning Shift focus to current patient problems
(“just in time” education) Relevant to YOUR practice Memorable – and behaviour changed! Up to date
Skills and resources for best current answers
Dave Sackett
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Treatment of a specific Ignorance
Difficult and expensive No magic bullets Local opinion leaders Academic detailing Audit and Feedback Reminder systems
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Dissemination and diffusion What do we know?
Roger’s work in rural sociology Greenhalgh T, et al. A systematic
review of the literature on diffusion, dissemination and sustainability of innovations in health service delivery and organisation. London, NHSSDO Programme, 2004 EPOC reviews
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Aware Accepted Applicable Able Acted on Agreed Adhered to
Studies
(primary research studies: sound & unsound)
Systems (bottomline +/- ref)
Synopses (user summary of research)
Systematic Reviews & CATs (search; appraise; synthesis)
Quality Improvement • Skills • Systems
Evidence-Based Medicine • Questioning • Skills in EBM • Evidence Resources • Time (substitution)
Patient Choice • Decision Aids • Education • Compliance aids
Research Synthesis, Guidelines, EBJs, …
Myth, opinion, poor
research
Glasziou, Haynes, EBM 2005
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Summary Prevalence: Ignorance is common
Causes: 560,000 research articles/year
Prevention & Treatment - no “magic bullets” Prevention: EBM skills Treatment: interactive education, academic detailing, …
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GIMBE® 3rd EBHC Conference GIMBE® 4th EBHC Conference 2007