EBayesMet conference October 2011 e-Learning Evidence-based Medicine Katrien Oude Rengerink Academic Medical Center Dept. of Obstetrics and Gynaecology.

EBayesMet conference October 2011

e-LearningEvidence-based Medicine

Katrien Oude Rengerink

Academic Medical CenterDept. of Obstetrics and Gynaecology

The Netherlands

Contents

What is Evidence-based Medicine? Why e-learning modules EBM? e-learning basic principles EBM e-learning modules Teach-the-Teacher EBM

What is EBM?

Dave Sackett BMJ 1996: “Good doctors use individual clinical expertise, the best available external evidence as well as patient preferences, and neither alone is enough.”

Reduction Number Needed to Read

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

Number Needed to Read

is 200+

Why EBM?

Exponential growth knowledge Integration research into clinical practice slow

evidence summaries important

skills for knowledge translation important

5 steps of EBM

Theory of the Stork vs Theory of Sexual Reproduction

R2 0.49, p<0.05

Evidence supporting Theory of Stork

Storks exist Unexplained features fetal development Sexual intercourse without delivery Correlation birth rate - stork population Storks not seen in hospitals: apparently medical

interventions may replace storks

EBM: hierarchy in evidence sources

Organisation of evidence

Parachute use to prevent death: systematic review of RCTs

Parachutes used to prevent death and major injury due to gravitational challenge

Free fall studies: no 100% mortality No RCT: basis use purely observational. Apparent

efficacy potentially explained by a ‘healthy’ cohort effect. No evidence do not use intervention

Some effects not need RCT

Why e-learning EBM?

Clinical professionals value EBM important, but slow integration and application in practice

Huge variation EBM content and education Europe Interactive, clinically integrated education best way

learning and applying EBM

Current available courses useful, but: - minimum integration clinical practice- low flexibility

Leonardo IAn European e-learning course in

Evidence Based Medicine

Partners

UK • University of Birmingham/Birmingham Womens’ Hospital• CASP International

Germany - Agency for Quality in Medicine Poland - CASPolska Spain - CASPe Hungary - TUDOR Italy - Universita Cattolica del Sacro Cuore Switserland - Basel Institute for Clinical Epidemiology The Netherlands - AMC

Independent steering commitee

Aim

Familiarise participants with EBM basics to help incorporate evidence from systematic reviews on therapeutic interventions into daily clinical practice

Harmonise EBM teaching across Europe

Short, individual e-learning sessions On-the-job training

Course content

1. Defining clinical questions

2. Searching the evidence

3. Appraisal of the systematic review

a. Validity of RCTs

b. relative risk and 2x2 table

4. Applying evidence to patient

5. Implementation of evidence into practice

Instruments for evaluating education in EBM

4 EBP domains:

1. Knowledge

2. Skills

3. Attitude

4. Behavior• enacting EBP steps in practice• permorning evidence-based clinical manoevers• affecting patient outcomes

Course evaluation

101 participants from Switserland, Germany, Hungary, Spain, UK

Pre- and postcourse assessment• Knowledge/skills: modelled Berlin Questionnaire• Attitudes: questionnaire by Taylor L. et al.

Results

Across all countries, knowledge scores improved from pre- to post-course for all five modules (p<0.001) (paired Wilcoxon signed ranks test)

After completing course participants felt more confident that they can assess research evidence

E-learning at least equally effective as regular teaching

Leonardo II

Evidence Based Medicine: Training the Trainers across the healthcare sector

Background

During Leonardo I & Sicily EBM conference: need support teaching EBM in practice • low level EBM teaching in clinical practice possibly

due to lack of confidence to teach EBM in workplace

Complementary to existing EBM programmes: exploit learning opportunities in clinical setting

Leonardo II

Partners

England (lead): • University of Birmingham/Birmingham Women’s Hospital• J&B Associates

Italy – Universita Cattolica del Sacro Cuore

Poland - CASPolska

Hungary - TUDOR

Switserland - Basel institute of clinical epidemiology

Netherlands – AMC

Germany – AzQ

Aim

Train trainers to teach EBM through on-the-job training, by demonstration of applied EBM, to encourage clinically relevant teaching of EBM in post-graduate education

Develop European standard in EBM education

Target: clinical teachers who teach EBM in clinical practice to postgraduates

Course contents

Based on teaching opportunities modules developed for 6 clinical settings:• Learner-centered (e-learning)• Problem-based• Video clip incorporated• Applicable in Europe

Teaching opportunities in clinical practice

Learning Opportunities

5 EBM stepsFormulating questions

Searching for

evidence

Critical appraisal

Integrating evidence

with clinical

scenario

Bringing change to practice

Ward round +++ (+) + ++ +

Journal club + + +++ + +Clinical teaching and assessment

++ (+) ++ +++ +

Outpatient clinic +++ (+) ++ ++ +

Formal clinical meeting

+++ (+) + ++ +

Audit ++ (+) ++ + +++

Example: Teaching and learning EBM during ward rounds

Outline: Learning objectives Pre-requisites to undertake the module Learning opportunities EBM steps Example Video clip (3 min) Teaching and learning lesson Conclusion

Course evaluation

5 countries: about 10 clinical teachers who teach EBM to postgraduates per country piloted

Pre- and postcourse assessment using ‘Basel questionnaire’

e-learning course on how to teach EBM in various settings is feasible and effective.

Barriers EBM teaching

120 clinical EBM teachers from 11 countries completed questionnaire regarding barriers for EBM teaching

Barriers: • lack of time in busy practice

• lack of requirements for EBM skills

• pyramid hierarchy in health care management structure.

Teaching EBM in clinical settings is most successful where EBM principles are culturally embedded and form part and parcel of everyday clinical decisions and medical practice.

Availability

Free available in:

English German French Polish

Hungarian

Accessible through: www.ebm-unity.org

References

1. Sackett, BMJ 1996 EBM what is it and what isn’t it?

2. Höfer T, Przyrembel H, Verleger S. New evidence for the Theory of the Stork. Paediatric and perinatal epidemiology. 2004(18):88-92.

3. Smith GCS, Pell JP. Parachute use to prevent dath and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ 2003.

4. Khan AT, Mehr MN, Gaynor AM, Bowcock M, Khan KS. Is general inpatient obstetrics and gynaecology evidence-based? A survey of practice with critical review of methodological issues. BMC Women’s Health 2006(6):5.

5. Khan KS, Coomarasamy A. A hierarchy of effective teaching and learning to acquire competence in evidence-based medicine. BMC Med Educ 2006:15(6):59.

6. Coppus SFPJ, Emperanza JI, hadley J et al. A clinically integrated curriculum in Evidence-based medicine for just-in-time learning through on-the-job training: The EU-EBM project. BMC Medical Education 2007(7):46.

7. Shaneyfelt T, Baum KD. Instruments for evaluating education in evidence-based practice: a systematic review. JAMA 2006;296(9):1116-1127.

8. Kulier R, Hadley J, Weinbrenner S et al. Harmonising Evidence-based medicine teaching: a study of the outomes of e-learning in five European countries. BMC Medical Education 2008(8):27.

9. Taranganitam S, Barnfield G et al. Teaching trainers to incorporate evidence-based medicine (EBM) teaching in clinical practice: the EU-EBM project.

10. Oude Rengerink K, Thangaratinam S. How can we teach EBM in clinical practice? An analysis of barriers to implementation of on-the-job EBM teaching and learning.

Thanks to

Leonardo IRegina KulierJulie HadleySusanne WeinbrennerBerrit MeyerroseTamas DecsiAndrea HorvathEva NagyJose EmparanzaSjors CoppusTheodoris ArvantisAmanda BurlsJuan CabelloMarcin KaczorGianni ZanreiKaren PiererKatarzyna Stawiarz Regina KunzBen Willem MolKhalid Khan

Steering committee

Leonardo IIShakila Thangaratinam Gemma Barnfield Theodoros ArvanitisSusanne WeinbrennerKhalid Khan Berit Meyerrose Andrea Horvath Gianni Zanrei Regina Kunz Katja Suter Jacek WalczakAnna Kaleta Javier ZamoraHarry Gee Ben Willem Mol Maciej NogasBernard BurnandChantal Arditi

Katrien Oude Rengerink: [email protected]

www.ebm-unity.org