Why Evidence Based Practice Is there any gap between knowledge and practice? Is our practice different from our knowledge? Is our practice relevant to.

Why Evidence Based Practice

Is there any gap between knowledge and practice?

Is our practice different from our knowledge?

Is our practice relevant to the latest scientific findings?

Knowledge Gaps between what is known and what is done

What are the “gaps” between research and practice?

Why do such “gaps” exist?How can we close a specific gap?How can we close all gaps?

Knowledge Gaps between what is known and what is done

What “gaps” between research and practice are you involved in?

The Epidemiology of Ignorancein Health Care

What do we know about what we know?Prevalence & IncidenceAetiology/CausationPrognosisTreatment

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 restIncrease 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...

Many “Leaks” from research & practice

Aware Accept Target Doable Recall Agree Done

ValidResearch

If 80% 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

Knowledge Gaps between what is known and what is done

What “gaps” between research and practice are you involved in?

Why does the “gap” exist?(list several possible causes)

7654321

Aware Accept Target Doable Recall Agree Done

0

Not Organised

Causes1. Too much information2. Too much information3. Too much information

JASPA*(Journal associated score of personal angst)

J: Are you ambivalent about renewing your JOURNAL subscriptions?

A: Do you feel ANGER towards prolific authors?

S: Do you ever use journals to help you SLEEP?

P: Are you surrounded by PILES of PERIODICALS?

A: Do you feel ANXIOUS when journals arrive?

YOUR SCORE? (0 TO 5)

* Modified from: BMJ 1995;311:1666-1668

0 (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions)

Size of Medical Knowledge

NLM MetaThesaurus875,255 concepts2.14 million concept names

Diagnosis Pro9,200 diseases20,000 abnormalities (symptoms, signs, lab,

X-ray,)3,200 drugs (cf FDAs 18,283 products)

1 per day for 25 years

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 p

er Y

ear

5,000?per day

1,500 per day

55 per day

And the information we need is widely scattered

Age AgeingAm J MedBr Heart JBMJ 3CirculationClin CardiolClin Chem ActaEur J Heart FailHypertensionJAMA J Card FailJ HypertensLancet 3N Engl J MedRev Esp CardiolRev Port Cardiol

Studies of BNP in MEDLINE

Natriuretic Peptide 10,110MeSH BNP 2,204PubMed: Clinical Queries broad 799 narrow 82

Our systematic reviewOf BNP accuracy for theDiagnosis of heart failure

20 studies qualified;Found in 16 journals

Organising I: systematic reviews - 20% done for therapy

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New protocols

Existing protocols

New reviews

Updated reviews

Existing reviews, not incl updates

Reviews and protocols for reviews on The Cochrane Database of Systematic Reviews

Issue 1/2005Alderson, 2005

Knowledge Gaps between what is known and what is done

What “gaps” between research and practice are you involved in?

Why does the “gap” exist?What would you do to “fix” the gap?

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Aware Accept Target Doable Recall Agree Done

0

Not Organised

The Prognosis of Ignorance is Poor

Prevention & Treatment

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

Where is your main activity?

“Just in Time” learning:Intern’s information needs

Setting: 64 residents at 2 New Haven hospitalsMethod: Interviewed after 401 consultationsQuestions

Asked 280 questions (2 per 3 patients)Pursued an answer for 80 questions (29%)Not pursued because

Lack of timeForgot the question

Sources of answersTextbooks (31%), articles (21%), consultants (17%)

Green, Am J Med 2000

“Just in Time” learningThe EBM Approach to Education

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

Teaching EBM: a systematic review of 23 controlled studiesIntegrated teaching

Real patientsCurrent problems

Results in betterKnowledgeSkillsAttitudesBehaviour

Coomarasamy, BMJ 2004;329:1017

Implications for practiceInteractive workshops can improve

professional practice. Lectures alone are unlikely to change professional

practice

Treatment of Ignorance

Dissemination and diffusionWhat do we know?

Roger’s work in rural sociologyGreenhalgh 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

You may download this file and some other PDF books about

Evidence Based Practice at the following site

http://rds.sem-ums.ac.ir/fs/files.aspx?id=221. Implementing of Evidence Based Practic.pptx

2. Ethic and evidence based practice (book)

3. Evidence based medicine work book (book)

4. Evidence based practice (book)