8/18/10 1 Evidence Based Medicine, Family Physicians, and Knowledge Translation (KATIE) David Gardner PharmD, MSc Michael Allen MD Dalhousie Refresher February 2010 2 Disclosure David Gardner Michael Allen Research/ development projects: Department of Health, NS NSHRF Pfizer Department of Health, NS Health Canada Honouraria (expert/ speaker): AstraZeneca Canadian Pharmacists Association Mental Health Commission of Canada Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) 3 Objectives • Introduce the KATIE program • Raise your awareness about the importance of understanding basic terms that express therapeutic effects A Pervasive Concern Continuing Medical Education often fails to lead to practice change. Weinert et al Curr Opin Crit Care 2008 Green & Seifert. J Am Board Fam Pract 2005 Awareness Acceptance Adop2on 6 The KATIE Program … because sometimes knowledge needs a translator Objective To narrow the knowledge-to-action gap by improving the effectiveness of continuing education and related activities . The KATIE Program prioritizes the learner’s role in achieving this objective.
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8/18/10
1
Evidence Based Medicine, Family Physicians, and
Knowledge Translation (KATIE)
David Gardner PharmD, MSc Michael Allen MD
Dalhousie Refresher February 2010
2
Disclosure
David Gardner Michael Allen Research/ development projects:
Department of Health, NS NSHRF Pfizer
Department of Health, NS Health Canada
Honouraria (expert/ speaker):
AstraZeneca Canadian Pharmacists
Association Mental Health
Commission of Canada
Canadian Optimal Medication Prescribing and Utilization Service (COMPUS)
3
Objectives
• Introduce the KATIE program
• Raise your awareness about the importance of understanding basic terms that express therapeutic effects
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A Pervasive Concern
Continuing Medical Education often fails to lead to practice change.
Weinert et al Curr Opin Crit Care 2008
Green & Seifert. J Am Board Fam Pract 2005
Awareness
Acceptance
Adop2on
6
The KATIE Program … because sometimes knowledge needs a translator
Objective
To narrow the knowledge-to-action gap by improving the effectiveness of continuing education and related activities .
The KATIE Program prioritizes the learner’s role in achieving this objective.
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Knowledge Translation has gone from country peasant to royalty
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Knowledge Translation a.k.a Knowledge-to-Action
Research Phase I-IV
Information dissemination
Information filtering and synthesis
Knowledge exchange
Action planning
Action implementation
Action evaluation
Service providers
individuals
clinics
departments
organizations
Policy makers
Adm
inistrators
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Knowledge Translation a.k.a Knowledge-to-Action
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The KATIE Program … because sometimes knowledge needs a translator
Method
Social marketing to effect a change in learning culture
Targets:
Learners
Presenters/CME developers
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Less of … More of …
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Less of …
More of …
Can you use this in your prac2ce? How?
More of …
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What the KATIE Program IS
• A transformational influence that: – Supports physicians and pharmacists in
making the most of their learning activities – Promotes presenters and learners to focus
on appraising and applying new information
• To be used in any learning situation – Conference – Evening presentation – One-on-one meetings – Readings
• Enduring 14
What the KATIE Program is NOT
• NOT a certification or approval program of CME content or speakers
• NOT an activity that occurs only in formal learning settings
• NOT a course in critical appraisal • NOT a course in statistics This is a KATIE
approved program
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KATIE is a Collaborative Program
Drug Evaluation Unit
O’HALLORAN DESIGN
JOHN SHAW
GRAPHIC DESIGN
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KATIE Program Components and Activities
1. The KATIE Card The appraisal/apply KT aid and reminder
2. Katie on the 52 Crosstown The unorthodox critical appraisal teaching series
3. KATIE @ CME Programs: • An enduring presence of simple messages,
reminder icons
4. KATIE for speakers 5. www.katie.dal.ca
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To enhance CE learning and meaningful dialogue: – learners – presenters
An knowledge-to-action aid and reminder: – Emphasis on
• Critical appraisal (… should …) • Application (… how …)
CE Programs: – Copies available – Content integrated
Aid for presenters 18
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Who
Outcomes
Numbers
Compared to
Believability
Chance
Follow Up
Drop-‐Outs
Risks
Missing
Worth
Str. of Evidence
Big Picture
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Mr. Edwards learns about Torturing Numbers
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The KATIE Program THEMES & ICONS
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When you see this image, what thoughts come to mind?
• A range of values within which we can be 95% sure that the true value lies
• Corresponds to a p-value of 0.05 but provides estimate of precision
• For ratios (odds ratio, hazard ratio, rel risk) – If the CI includes 1, result is not statistically
significant
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95% confidence interval
• For ratios – If the CI includes 1, result is not statistically
significant • Relative risk of MI = 0.80; 95% CI 0.65 to 1.1 Not sig • Relative risk of MI = 0.80; 95% CI 0.65 to 0.90 Sig
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95% confidence interval
• Wide confidence interval – Indicates wide variation in result
– Less confident in result
– Often a result of small sample size
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Think about this RCT …
• Outcomes: non-fatal myocardial infarction and death from coronary heart disease
• Subjects: No history of coronary heart disease (primary prevention).
• Duration: 3.3 years • N: 5100 patients in the control and 5100 patients in the drug
group • The patient characteristics are:
– 80% male – mean age = 63 yrs. – mean blood pressure = 164/95
ASCOT Lancet 2003;361:1149-58
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1. The drug led to a 36% decrease in the incidence of non-fatal MI and CHD death (relative risk reduction).
2. The drug decreased the rate of non-fatal MI and CHD death from 3.0% to 1.9%, an absolute risk reduction of 1.1%.
3. You would have to treat 94 patients for 3.3 years to prevent one non-fatal MI or a death from CHD (number needed to treat).
4. The 95% confidence intervals around the previous result (ie, treat 94 patients for 3.3 years to avoid one non-fatal MI or CHD death) are 60 and 215.
5. At the end of 3.3 years, 97.0% of patients who don't take the drug will remain free of a cardiac event and 98.1% of patients who take the drug will remain free of a cardiac event (inverse absolute RR).
What is your interpretation of the following results? How likely might you be to prescribe the drug based on each one?
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Patients not having MI or dying - Placebo
Patients having MI or CHD death
Patients NOT having MI or CHD death
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Patients not having MI or dying - Drug
Patients having MI or CHD death
Patients NOT having MI or CHD death
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36% relative risk reduction in non-fatal MI and fatal
CHD
Absolute risk reduction 1.1% in non-fatal MI and
fatal CHD NNT=94 (60 to 215)
ASCOT Lancet 2003
48% relative risk reduction in stroke
95% CI 11% to 69%
Absolute risk reduction 1.3% in
stroke NNT 77 (42 to 424)
CARDS Lancet 2004
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Shingles Prevention Study – Results
Outcome Event rate
Placebo Zostavax
Herpes zoster 3.3% 1.6%
PH neuralgia 0.42% 0.14%
RRR ARR
51% 1.7%
66% 0.3%
Time (Yrs)
NNT 95% CI
4 yrs 59 50 – 72
4 yrs 363 263 – 587
Lyle NEJM 2007;357:1799-1809
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Atorvastatin: primary prevention
Outcome Event rate
Placebo Atorv
CHD Death Non-fatal MI 3.0% 1.9%
Stroke 2.8% 1.5%
RRR ARR
35% 1.1%
46% 1.3%
Time (Yrs)
NNT 95% CI
3.3 yrs 94 60-215
3.9 yrs 77 42 – 424
ASCOT Lancet 2003; CARDS Lancet 2004 54
Atorvastatin: primary prevention
Outcome Event rate
Placebo Atorv
CHD Death Non-fatal MI 3.0% 1.9%
Stroke 2.8% 1.5%
RRR ARR
35% 1.1%
46% 1.3%
Time (Yrs)
NNT 95% CI
3.3 yrs 94 60-215
3.9 yrs 77 42 – 424
Outcome (Conditions being studied)
Percent of people in
placebo and drug group having the outcome
Relative risk reduction
(Efficacy or percent of
cases prevented)
Absolute risk
reduction (Event rate in placebo
minus event rate
drug)
Number needed to treat
(Number of people we
must treat to prevent one
outcome event)
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Shingles Prevention Study – Results
Outcome Event rate
Placebo Zostavax
Herpes zoster 3.3% 1.6%
PH neuralgia 0.42% 0.14%
RRR ARR
51% 1.7%
66% 0.3%
Time (Yrs)
NNT 95% CI
3.1 yrs 59 50 – 72
3.1 yrs 363 263 – 587
Lyle NEJM 2007;357:1799-1809
Outcome (Conditions being studied)
Percent of people in
placebo and drug group having the outcome
Relative risk reduction
(Efficacy or percent of
cases prevented)
Absolute risk
reduction (Event rate in placebo
minus event rate
drug)
Number needed to treat
(Number of people we
must treat to prevent one
outcome event)
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ARBs - Reductions in HF Hospitalizations
Pfeffer MA et al. Lancet 2003;363:759-66. Cohn JN et al. N Engl J Med 2001;345:1667-75.