What is Evidence-Based Practice?: How To Make EBP Practical October 2010 Brian S. Alper, MD, MSPH Editor-in-Chief, DynaMed Medical Director, EBSCO Publishing.

What is Evidence-Based Practice?:

How To MakeEBP Practical

October 2010Brian S. Alper, MD, MSPHEditor-in-Chief, DynaMed

Medical Director, EBSCO Publishing

Introduction/Disclosures

• Rural family medicine in 1995

• Mission to provide most useful information to healthcare professionals at point of care

• Now working full-time as

– Editor-in-Chief, DynaMed

– Medical Director, EBSCO Publishing

• Define Evidence-Based Practice/Evidence-Based Medicine

• Challenges in practicing EBP

• Strategies for self-support

• Free resources for clinicians

• Subscription-based resources for clinicians

• Strategies for librarians

What does Evidence-Based Medicine mean?

• Ask 4 doctors

• Get 5 opinions

What does Evidence-Based Medicine mean?

• “Medicine is evidence-based and always has been. Everything we do is evidence-based. Making new terminology is not really anything new – it is just practicing good medicine.”

• The Don’t-mess-with-my-mental-framework reaction

• “sound reasoning” and “educated doctor” does not always translate into “best practice” – we used to prescribe flecainide for PVCs after a heart attack.

What does Evidence-Based Medicine mean?

• “Don’t tell me what to do. Who do THEY think they are to tell me how to practice?”

• Reaction to “evidence-based guidelines”, perhaps in the form of reimbursement and care authorization

• May or may not be “evidence-based” in the underlying decision-making.

What does Evidence-Based Medicine mean?

• Cookbook medicine

• Presumption that evidence determines decision-making, so anyone can follow the recipe

• EBM does not replace the need for a clinician to evaluate multiple overlapping considerations and determine the individual guidance for a patient.

• EBM does not replace the need to elicit, understand and incorporate patient values into clinical decision-making.

• Evidence does not “fit” individual patients (inclusion/exclusion criteria, comorbidities, different settings, etc.)

What does Evidence-Based Medicine mean?

• “You need a level 1 randomized trial or you shouldn’t do it”

• The All-or-Nothing reaction

• Not practical – many clinical decisions do not have level 1 randomized trial evidence, but decisions still need to be made.

Evidence-Based Medicine

Definition: Integration of best research evidence with clinical expertise and patient values.

Sackett DL, Straus SE, Richardson WS,Rosenberg W, Haynes RB. Evidence-Based Medicine. How to Practice and Teach EBM. 2nd ed. London: Harcourt Publishers Ltd. 2000. p. 1.

Rule-based vs. Heuristic-based EBM

• August 2010 dialog on Evidence-based health (EBH) listserv

• Heuristic-based EBM

– Practitioners use evidence in sophisticated ways to benefit patients

– Not explicit on how evidence should be applied to decisions

• Rule-based EBM

– Explicit approach to deriving conclusions from evidence

– Useful but not adequate for clinical decision-making

Best Research Evidence

• Comprehensive – evidence only known to be best if all the available evidence is known

• Valid – critical appraisal determines potential for bias

• Systematic – selection and evaluation of evidence by protocol reduces author bias, investigator bias

• Current – every day new evidence could be best

• Synthesized – one study vs. the whole picture

Our Goal in Medicine

• Provide the best care…

• Provide patients the best information to guide health care decisions…

• Improve health outcomes…

• …based on the “truth” – separating medical knowledge from folklore

How do we know medicine?

• WE = society

• MEDICINE = clinical knowledge

• Scientific investigation

• Original research published in journals

• Systematic reviews

• EVIDENCE-BASED MEDICINE

How do we know medicine?

• WE = individual clinicians

• MEDICINE = clinical knowledge

• Consultants • Colleagues

• Lectures • Textbooks

• Rounds • Precepting

• Guidelines • CME

• Experts • Experience

• PRACTICAL choices selected for efficiency

Information Overload

• Thousands of studies published each month to inform primary care practice (BMJ 2009;338:b354)

• 815,941 articles added to MEDLINE in 2008– 2,235 articles per day

• 847,629 articles added to MEDLINE in 2009– 2,322 articles per day

• “Diabetes and guideline” search in MEDLINE finds 455 articles in 2009

How Clinicians Learn

• Human behavior– Fast and easy sources chosen instead of thorough sources

– Familiar sources chosen instead of unfamiliar searching and analysis

• Clinicians’ knowledge comes from– Colleagues

– Specialists

– Lectures

• “Experts” often learn the same way

• This approach does not require evidence

– Textbooks

– Experience

– Google

Using Traditional Textbooks

• Not always written for clinical practice

• May not provide best research evidence(Are opinions well supported,or selectively supported?)

• May be years out-of-date

• Finding specific information within the text can be time-consuming

Using Guidelines

• Not always written for my clinical practice

• May not provide best research evidence(Are opinions well supported,or selectively supported?)

• May be years out-of-date

• Finding specific information within thetext can be time-consuming

• May be unavailable for specific question

Using Journal Articles

• Individual journal articles

– may not relate to specific information need

– may not provide complete picture

• Finding one journal article can be time-consuming, let alone finding all the relevant articles

• Articles are written to promote research findings,not often written for clinical application

• BUT THIS IS OUR EVIDENCE SOURCE

Published information may be wrong or misleading

• Authors trust and cite what is published instead of tracing to original research

• Authors trust and cite conclusions of research instead of evaluating methods and statistics

• Authors re-interpret information to match their biases

• Authors cite what they know instead of comprehensive searching

• Authors select articles that match their biases

• Authors select information (to summarize from articles) that match their biases

• Authors use abstracts instead of full-text articles

• Authors interpret changes in surrogate markers to mean changes inclinical outcomes

The greatest enemyof knowledge is not ignorance; it is the illusion of knowledge.

– Stephen Hawking

“Just-in-Case” vs. “Just-In-Time”

• Apprentice-style

• Memorization

• Soak up information now

• Retrieve information during practice

• Knowledge Mastery

• Find information when you need it

• Adult learning– Problem-oriented

– Clinical application

Defining Evidence-Based for a Clinical ReferenceEvidence-Based = conclusions based on best available evidence

“Evidence-based” requires the following steps:

1. Systematically identifying all applicable evidence

2. Systematically selecting the best available evidence from that identified

3. Systematically evaluating the selected evidence (critical appraisal)

4. Objectively reporting the relevant findings and quality of the evidence

5. Synthesizing multiple evidence reports

6. Deriving overall conclusions and recommendations from the evidence synthesis

7. Changing the conclusions when new evidence alters the best available evidence

6 most important obstacles to answering doctors’ questions with evidence:

– Time required to find information

– Difficulty modifying original question

– Difficulty selecting optimal search strategy

– Failure of resource to cover the topic

– Uncertainty when all relevant evidence found

– Inadequate synthesis of multiple bits of evidence

– BMJ 2002 Mar 23;324(7339):710

Challenge

The Need

• An evidence database must be:

– Fast

– Able to answer most questions

To make EBM feasible in routine practice

Free Resources for Clinicians

• Dr. Alper’s links - http://www.myhq.com/public/a/l/alper/

• PubMed - http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed

• National Guideline Clearinghouse - http://www.guideline.gov/

• TRIP Database - http://www.tripdatabase.com/

Evidence-Based Subscription-Based Resources for Clinicians

• DynaMed www.ebscohost.com/dynamed

– > 3,200 topics

– Updated daily

• Essential Evidence Plus www.essentialevidenceplus.com

– > 700 topics

– Updated 1-4 times per month

• Clinical Evidence clinicalevidence.bmj.com/ceweb/index.jsp

– > 260 topics

– Updated by process tailored to each topic

Here is an example how you can find importantevidence that will change your practice in a

way you would not expect.

If your grandmother broke her wrist, would you suggest she take a vitamin?

Strategies for Librarians to Make EBM Practical

• Teaching others to fish

– Raising awareness of evidence-based resources• Seminars, physicians’ lounge, Grand Rounds

• E-mail, newsletter, website

• Why do they care?

– Raising awareness of evidence concepts• Share new evidence

– DynaMed Weekly Update is a free source you can use

– Share why and how to get more

• Providing the fishing gear

• Facilitating the deep-sea fishing

Strategies for Librarians to Make EBM Practical

• Teaching others to fish

• Providing the fishing gear

– Securing subscriptions and providing links on library portal is straightforward, but where is the point of care?

– Access to information on mobile devices

– Easy access from the physician desktop (not always easiest to start by finding library main page or portal page)

– Electronic health records mean MANY opportunities to access information resources from the workflow (YOU need to be involved)

• Facilitating the deep-sea fishing

Strategies for Librarians to Make EBM Practical

• Teaching others to fish

• Providing the fishing gear

• Facilitating the deep-sea fishing

– You are still the expert for complex searches, for finding (and retrieving) the rare and exotic fish

– Making it easy for clinicians to ask for help

– Sharing examples of what you can do

Questions?:

Brian S. Alper, MD, MSPHEditor-in-Chief, DynaMed

Medical Director, EBSCO Publishing

[email protected]